Published January 8, 2024
Chest pain is a common and multifaceted symptom that can indicate various underlying health issues, ranging from mild to severe. Given the diagnostic reliance on a patient's history, any instance of chest pain warrants attention and chest pain management. Due to the varying nature of the causes of chest pain, determining the cause can be difficult. In the below blog, we will explore valuable diagnostic insights and approaches to effectively diagnose and treat the common chief complaint of chest pain
Pain Assessment Simplified: OLDCART Method
In the realm of chest pain management, nurse practitioners (NPs) and physician assistants (PAs) actively engage in understanding and addressing pain.
The OLDCART mnemonic stands as a crucial tool in chest pain diagnosis, streamlining the assessment process by systematically capturing key details such as onset, location, duration, characteristics, aggravating and relieving factors, and treatments, enabling more accurate and effective diagnostic decisions. For example, OLDCART can be used to further probe into a patient’s shortness of breath.
- O- Onset: When does the shortness of breath become noticeable to you?
- L- Location: Where do you feel the symptoms?
- D- Duration: How long does the shortness of breath last?
- C- Characteristics: Does it feel more difficult to take a breath in or do you feel like you don’t have enough breath?
- A- Aggravating factors: What makes the shortness of breath worse?
- R- Relieving factors: What makes the shortness of breath better?
- T- Treatment: Have you done anything to help your shortness of breath, like taking medication?
Explore the crucial role of OLDCART in chest pain diagnosis in this clip from “My Chest Hurts,” a course from Primary Care Bootcamp for NPs and PAs.
Primary Care Case Study: Chest Pain
To review strategies to diagnose chest pain, we will look at a case study. Tom is a 62-year-old man with a medical history notable for hypertension, hyperlipidemia treated with statins, pre-diabetes, and a significant smoking habit that he kicked five years ago. He presents today with a chief complaint of heartburn.
History of Present Illness:
- Despite working long days as a contractor, Tom feels well
- Acknowledges shortness of breath with exertion, which he attributes to 20 years of being a smoker
- No orthopnea or paroxysmal nocturnal dyspnea (PND)
- No lower leg swelling
- No chest pain, except for the heartburn
- Total cholesterol of 120 mg/dl, triglycerides of 100 mg/dl, HDL of 38 mg/dl and LDL of 72 mg/dl
Diagnostic Tests, Considerations, and Planning:
- Labs: complete blood count (CBC), basic metabolic panel (BMP), B-type natriuretic peptide (BNP)
- A low-dose chest computed tomography (CT) scan
- Electrocardiogram (EKG) and chest-X-ray
- Stress tests and pulmonary function tests
Test Results
Tom’s labs and EKG were unremarkable, but the exercise stress test told a different story, showing significant ST depression – a sign of ischemia. This led to a referral to an outpatient cardiologist, who, after angiography, discovered obstructive atherosclerosis, a slow build-up of plaque restricting blood flow to the heart muscle. Tom's left anterior descending artery (LAD) had a narrowing that was fixed with a stent during a percutaneous coronary intervention (PCI) procedure, and he's now doing well.
Reducing the risk of future cardiac events hinges on effective risk factor modification. This involves maintaining control over cholesterol, diabetes, and blood pressure, alongside crucial lifestyle changes such as quitting smoking.
Identifying Red Flags when Diagnosing Chest Pain
When evaluating a patient, it is essential to consider the following, as these accompanying symptoms can also lead to more serious consequences.
- Chest pain at rest
- Difficulty breathing
- Feeling faint
- Fast or slow pulse
When these symptoms are present, knowing the next step is crucial. It may involve a telephone consultation with a cardiologist or a swift move to the emergency department. For further guidance, consider the following steps:
- Emergency Department: When symptoms are unstable or rapidly escalating.
- Outpatient cardiology or consult with a cardiologist: In the case of abnormal stress testing indicating ischemia.
- Outpatient Cardiology: If the patient exhibits normal stress testing but experiences persistent symptoms, as it could be balanced ischemia, or if uncertainty persists.
Acute Coronary Syndrome
While exploring chest pain management, it is also essential to consider acute coronary syndrome (ACS). ACS is characterized by a sudden reduction in blood flow to the heart.
There are three main types of ACS:
- Non-ST-elevation myocardial infarction (NSTEMI)
- ST-elevation myocardial infarction (STEMI)
- Unstable angina
All three types of ACS demand immediate attention and an urgent transfer to the emergency department. A crucial aspect of ACS lies in assessing symptoms at rest versus symptoms with exertion. It’s also essential to consider the reproducibility of pain, particularly in response to breathing or palpation, which may help identify musculoskeletal etiologies. By recognizing the presenting signs, common symptoms and physical exam characteristics of ACS and what distinguishes it from other causes of chest pain, clinicians can be better equipped to manage chest pain in the primary care setting.
A nuanced approach to chest pain, which considers underlying conditions, the history of present illness, and physical exam findings, is essential to providing comprehensive management. By prioritizing swift responses to red-flag symptoms and integrating practical insights into clinical assessments, clinicians are better equipped to navigate the complexities of patient care in the realm of chest pain.
We’ve just skimmed the surface of chest pain management in this overview. To learn more, enroll in Primary Care Bootcamp for NPs and PAs, an on-demand curriculum with over 40 courses that review topics and strategies to help APPs confidently and compassionately provide care.
Dr. St. Hilare is a double-board certified Nurse Practitioner at a community hospital in North Central Massachusetts . She graduated with her Doctorate in Nursing Practice from UMass Amherst in 2015. She has then worked as a Cardiac NP primarily in the outpatient setting. Prior to this, she worked for 4 years as a critical care nurse practitioner. She has a passion for heart failure management and primary prevention of heart disease.