Pain from ischemic cardiac or noncardiac origin?

UM Review RN, ASN, RN · Apr 10, 2008

Here's a good article on AMI diagnostics:

http://en.wikipedia.org/wiki/Myocardial_infarction

NoviceRN10 · Apr 10, 2008

Here's a good article on AMI diagnostics:
http://en.wikipedia.org/wiki/Myocardial_infarction

Thank you! That article is full of great information :).

Miami NightNurse · Apr 10, 2008

One thing that can sometimes differentiate between cardiac and non cardiac is to have patient take a deep breath and if it hurts more with deep inspiration it is usually Pulmonary. However and especialy with women I would never rely on that. I would rely on EKG + 3 sets of Cardiac Enzymes all being negative or positive

Daytonite, BSN, RN · Apr 10, 2008

from what I can tell, there is no telltale difference between the actual pain of a MI and other possible causes like gastric issues, or possibly a panic attack or broken rib.

Ah, but there is and it has to do with how you assess it. Use the nursing process. It's not just for writing care plans--it's for problem solving. The puzzle you are trying to solve here is the difference between the origin of ischemic cardiac pain and non-cardiac pain. Step #1 of the nursing process is assessment. That involves, in this instance, learning what these two symptoms are. I just happen to have a couple of books that have that information. Read on.

I went to my book that is used by medical students, Differential Diagnosis in Primary Care, 4th edition, by R. Douglas Collins, to see how the author approached this question since it is a very common symptom and complaint. Basically, it takes the approach of visualizing the anatomical structures of the chest and determining the etiologies of pain for each structure which nets you about 30 to 40 medical conditions! Made me think that I'm glad I'm not a doctor having to make these kinds of decisions! What it does say in relation to the heart is that the origin of cardiac pain comes from two anatomical sources:

the pericardium
the myocardium

There is nothing there about what distinguishes cardiac pain from chest pain caused by a problem in the ribs, esophagus or spine. An MI should always be assumed as being the reason for the pain until it has been ruled out through testing. Here's some interesting information on the rule out tests:

serial EKGs, serum cardiac troponin levels, and cardiac enzymes are done to rule out an MI
coronary insufficiency is diagnosed if nitroglycerin tablet or spray under the tongue relieves the pain; tests for this condition include coronary angiography, 24-hour Holter monitoring, and Single Photon Emission Computed Tomography (SPECT) scan
CT or MRI of the chest will show any dissecting aneurysms
echocardiogram will show if there is pericarditis
chronic chest pain associated with the heart is determined by having the patient do a thallium exercise stress test
ABGs, CXR, lung scan and sometimes pulmonary angiography are done to rule out a pulmonary embolism
CXR to rule out pneumonia
if the pain subsides after having the patient swallow lidocaine viscous, then esophagitis has been ruled out
costochondritis tends to have the symptom of tenderness of the costochondral junctions

From Nurse's 5-Minute Clinical Consult: Signs & Symptoms pages 114-117 on Chest Pain:

Assess for:

onset, radiation, duration, quality, quantity and what, if anything, relieves the pain or aggravates it.

This information will help to determine its cause and give you clues as to the origin of it's location.

Substernal chest pain that radiates to the jaw, neck, arms and back

due to angina pectoris

is often described as

aching, squeezing, pressure, heaviness, and burning. It often subsides within 10 minutes

Pain across the chest that may radiate to the jaw, neck arms, or back

due to an MI

is often described as

tightness or pressure; burning, aching pain, possibly accompanied by shortness of breath, diaphoresis, weakness, anxiety, or nausea; sudden onset; lasts 30 minutes to an hour. (We lovingly referred to the most common symptoms as the 3 Ps of a heart attack--pain, puking and perspiration.)

Here' some of the non-cardiac pain descriptions:

rib fracture
: sharp, severe chest pain aggravated by inspiration, coughing or presswure over the affected area, dyspnea, cough, tenderness, edema at the fracture site and shallow, splinted breathing
acute anxiety
: dull or stabbing pain usually accompanied by hyperventilation or breathlessness; sudden onset; lasting less than a minute or as long as several days
esophageal spasm
: dull, squeezing pain or pressure
hialtal hernia
: sharp, severe pain
peptic ulcer
: burning feeling after eating that is sometimes accompanied by hematemesis or tarry stools; sudden onset; gradually subsides within 15 to 20 minutes
cholecystitis
: (how well I remember this from personal experience!) gripping, sharp pain possibly accompanied by nausea and vomiting, especially following meals. (my pain occurred exactly 6 hours after a meal and felt like a knife stabbing me in the RUQ all the way through to my back)
chest wall syndrome
: continuous or intermittent sharp pain; possibly tender to touch; gradual or sudden onset

And you should learn this because it is getting more attention these days with the rise in women's deaths due to MIs that go undiagnosed. . .atypical chest pain in women of cardiac origin:

back discomfort between the shoulder blades
palpitations
feeling of fullness in the neck
nausea
dizziness
unexplained fatigue
exhaustion or shortness of breath

NoviceRN10 · Apr 10, 2008

Thank you, Daytonite :bow: . I am now thinking the question I'm trying to answer is more simply answered than I thought. Using the nursing process you can systematically narrow down the source of the pain, before you even get to diagnostic tests! I was reading internet articles on MI and I was getting from them that the pain can feel the same, no matter what the source, so that is why I thought you couldn't differentiate without further tests.

Daytonite, BSN, RN · Apr 10, 2008

I gave you the doctors and the nurses approach on how they deal with this. A doc can order tests; we can't. We have to assess (as my oncologist got into a lecture with me over this subject not too long ago - he claims assessment is not the same as examination). So, we have a lot of different elements that we have to be sharp about assessing. Yes, you can assess and go into more depth about a symptom. Assessment is not as easy as some might lead us on to believe. Observation skills take time to master and there is always something more to learn.

Hope that info helps you out. I made sure to include the assessment of pain for the different conditions you mentioned in your post so you could see what made each of them different from each other.

Miami NightNurse · Apr 10, 2008

When I had my MI I had Nausea/Vomiting, Very anxious and squeezing (L)arm pain. I eventually developed (L)sided Chest Pain too but that was near the end of it. For the first few hours I just had the (L)arm pain

UM Review RN, ASN, RN · Apr 11, 2008

One thing that can sometimes differentiate between cardiac and non cardiac is to have patient take a deep breath and if it hurts more with deep inspiration it is usually Pulmonary. However and especialy with women I would never rely on that. I would rely on EKG + 3 sets of Cardiac Enzymes all being negative or positive

Ditto. I've guessed wrong too many times just going by s/s.

When I had my MI I had Nausea/Vomiting, Very anxious and squeezing (L)arm pain. I eventually developed (L)sided Chest Pain too but that was near the end of it. For the first few hours I just had the (L)arm pain

An inferior MI will often cause GI symptoms.