Chest pain and a slow pulse in a 56-year-old: a live emergency case

Why chest pain with a slow pulse matters

Chest pain and a slow pulse together are dangerous: the heart's rhythm may be failing because of whatever is causing the pain. You may have to stabilise him and make treatment decisions far from specialist help, so reading the pattern early is the core skill.

What to ask in the history

• Onset, character, radiation and duration of the pain
• Sweating, nausea, vomiting, faintness, breathlessness
• Previous chest pain or heart problems
• Risk factors: smoking, diabetes, blood pressure, cholesterol, family history
• Medicines that slow the heart
• Exposure to pesticides on the farm
• Anything that would make blood-thinning or clot-dissolving drugs unsafe: recent bleeding, surgery, stroke

Red flags

• A very slow pulse, or pauses
• Low blood pressure, faintness, confusion
• Ongoing pain
• Breathlessness or crackles in the chest
• A new murmur

What to examine

• Airway, breathing, circulation; full observations
• Pulse rate and rhythm; blood pressure in both arms
• Jugular venous pressure, heart sounds, chest
• Signs of poor perfusion
• Pupils, sweating and secretions

First investigations

• 12-lead ECG at once, repeated
• Continuous cardiac monitoring
• Troponin
• Potassium and other electrolytes, glucose
• Full blood count, kidney function, clotting
• Echocardiogram if available
• Cholinesterase if poisoning is a possibility and the test is available

Differential diagnosis of chest pain with a slow pulse

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Treating the slow pulse and missing what is causing it.
• Waiting for a troponin when the ECG already tells you what to do.
• Giving drugs that lower the heart rate or blood pressure further.