* suspicious signs , apart from an obvious clinical picture:
– history of coronary heart disease.
– pains that last for several seconds at least.
– pain dependent on breathing.
– Pain not reproducible by palpation and mobilization of the rib cage.
– associated digestive symptoms.
– risk factors for thromboembolic disease.
* signs of gravity :
– sweating, nausea, dyspnea, fever, polypnea.
Hypotension, thrombophlebitis, aortic insufficiency murmur, right heart failure, blood pressure asymmetry and peripheral pulses, focal pulmonary signs, abdominal defense.
* benign causes :
– parietal pain exacerbated by palpation or mobilization of the thoracic cavity:
– intercostal neuralgia, herpes zoster, primary fibromyalgia.
Osteoarthritis or sternocostal sprain.
– contusion, fracture, osteoporotic fracture, Tietze syndrome, Cyriax, bone cancer.
– pain in young neurotic subject:
– pain of psychic origin: anxious state .
– chest pain and vertebral pain :
– disc conflict in the dorsal or cervical vertebrae.
– vertebral compression.
– gastro-oesophageal reflux, spastic colitis.
– esophageal spasm:
– in the elderly person.
– Retrosternal spastic or constrictive pain radiating in the back, sensitive trinitro, during the meal or after ingestion of cold water.
– dysphagia and gastroesophageal reflux sometimes associated.
– treatment: trinitrine, Spasfon.
* serious causes:
– trinitrino-sensitive pain:
– intense pain, lasting more than half an hour, sensitive or not to trinitrin:
– myocardial infarction.
– pain with dorsal or descending lumbar irradiation, peripheral pulse asymmetry and breath of aortic insufficiency:
– aortic dissection.
– pain aggravated by inspiration, respiro-dependent:
– acute pericarditis.
– pain with dyspnea and signs or risk factors for thromboembolic disease:
– pulmonary embolism.
– lateralized pain + fever + expectorant cough + dyspnea:
Acute acute lobar pneumonia .
– low chest pain + digestive disorders:
Acute pancreatitis, peptic ulcer, cholecystitis.
– infarction inferior.
* scope, SpO², temperature.
* ECG before and after trinitrin:
– except if certain non-cardiac origin.
– a normal ECG is not incompatible with unstable angina or even an IDM.
– to repeat regularly in case of doubt.
* chest x-ray, ASP.
* CPK, CPK-MB , troponin or myoglobin, to be redone in case of doubt.
* possibly, D-dimers.
* treatment of the cause .
* if suspicion of a coronary event:
– trinitrin in the absence of hypotension, effective in 2-3 minutes unless IDM.
* if suspected of esophageal colic:
– sublingual trinitrine which calms the pain in about ten minutes.
– oral pain relievers.
– or Nubain: ½ or 1 ampoule SC, IV or Morphine: 1 mg / 10 kg to be diluted in 10 ml, to inject ml / ml IV, until sedation of the pain.
– do not do intramuscular .
* if doubt diagnosis, suspicious signs or signs of gravity:
– venous route, oxygen therapy mask.