Chest pain is one of the common reasons for patients’ visits to the emergency department. It is defined as an unpleasant sensation localized to the chest, which can present as squeezing burning, clawing, and tearing sensation among others. etc1. The evaluation of non traumatic chest discomfort is inherently challenging owing to the broad variety of possible causes, a minority of which are life-threatening conditions that should not be missed1.
Chest discomfort is the second most common reason for visits to the ED, resulting in 6 to 7 million emergency visits each year in the USA8, 12. More than 60% of patients with this presentation are hospitalized for further testing, and the rest undergo additional investigation in the ED1. Fewer than 25% of evaluated patients are eventually diagnosed with acute coronary syndrome (ACS), with rates of 5–15% in most series of unselected populations1. In the remainder, the most common diagnoses are gastrointestinal causes, and fewer than 10% are other life-threatening cardiopulmonary conditions1.
Once a patient presents with such complaint, the first priority is to consider potentially life-threatening causes. These include acute coronary syndromes, aortic dissection, pulmonary embolism (PE), ruptured aortic aneurysm, and tension pneumothorax2. Thus, early diagnosis and intervention are important. In patients with non-life-threatening chest pain, it may be only after a complete workup, including a comprehensive history, physical examination, and some further investigations, that a diagnosis is reached.
In a large proportion of patients with transient acute chest discomfort, ACS or another acute cardiopulmonary cause is excluded but the cause is not determined. Therefore, the resources and time devoted to the evaluation of chest discomfort in the absence of a severe cause are substantial. Nevertheless, a disconcerting 2–6% of patients with chest discomfort of presumed non-ischemic etiology who are discharged from the ED, are later deemed to have had a missed myocardial infarction (MI) 1. 25% percent of ECG normal cases were shown in one study to have myocardial infarction. So if the clinical picture suggests myocardial infarction better to do cardiac enzymes and further workup like echocardiography. And also patients with acute myocardial infarction who are mistakenly discharged from the emergency department have short term mortality rates of about 25 percent, at least twice what would be expected if they were admitted 13,14.
The diagnostic approach to chest pain, which is ‘a “risk avoidance” and a “rule out coronary heart disease” strategy, might improve with better knowledge of the wide spectrum of etiology of non-cardiac chest pain. These conditions include musculoskeletal syndromes, pulmonary disease, psychological disorders (panic attacks, anxiety, or somatization) and disorders of abdominal viscera3. A confident diagnosis of musculoskeletal chest pain can be challenging because no clear reference standard exists.
When previous literatures of chest pain from various countries were reviewed, It was observed. In 2012–2013 there were 237,832 emergency admissions to hospitals in England with chest pain representing 4.5% of all emergency admissions5, 9.A prospective observational study that was conducted in western, French-speaking Switzerland between March and June 2001, it showed that chest pain is a common symptom in primary care, as about 1.5% of the population visit a general practitioner (GP) for such reason over a one-year period. The causes of chest pain in 651 patients after 12 months: musculoskeletal chest pain (49%), cardiovascular (16%), psychogenic (11%), respiratory (10%), digestive (8%) and miscellaneous (2%) 6.
In a retrospective study done in Pretoria South Africa by Mimi geyser et al in 2016 about chest pain prevalence causes and disposition in emergency department of Pretoria hospital found the prevalence of chest pain to be 1.66%, the most common cause was respiratory illness (36.19%) and pneumonia was the most common diagnosis (24.40%). Musculoskeletal problems (21.90%) and cardiovascular disease (21.43%) were next in line and in cardiovascular causes ischemic heart disease was the most common. Similar to the study done in the USA patients with cardiovascular disease tend to be older than the average age, with a mean age of 55.07 (SD 16.04) years. Patients with psychological disorders were younger than average, with a mean age of 29.86 (SD 6.79) years. The mean age for patients with respiratory disease was 43.21 (SD 16.58) years and for musculoskeletal problems 35.74 (SD 10.83) years7.
In the sub Saharan African, according to a systematic review that included seven observation studies with 92,378 participants from 5 countries (South Africa, Sudan, Nigeria, Senegal, and Kenya) showed acute myocardial infarction prevalence rate to be in the range of 0.1–10.4%15
In our setting, there is no data regarding the prevalence of chest pain in the emergency department. But the incidence of myocardial infarction was found to be alarming in a study done in Halibet National Referral Hospital in Asmara between 1997 and 2001that showed that the incidence of acute Myocardial infarction was 4.35 per 1000 admissions.10. And a retrospective study conducted in Orotta National Referral Hospital Intensive Care Unit (ONRH-ICU) in Asmara for ten years (2005–2015) by Elias...et al showed majority of patients 79% presented with STEMI which is one of the top killers’ worldwide11.