What are the potential causes and treatments for symptoms of tachycardia, chest pain, and cough?

Evaluation and Management of Tachycardia, Chest Pain, and Cough

Immediate Life-Threatening Conditions to Exclude First

The combination of tachycardia, chest pain, and cough requires immediate evaluation for life-threatening cardiac and pulmonary emergencies before considering benign causes. 1, 2

Critical Diagnoses Requiring Urgent Intervention

• Acute coronary syndrome (ACS) must be excluded immediately with ECG at first medical contact, as chest pain with tachycardia can signal myocardial ischemia requiring prompt catheterization 2
• Pericardial effusion with tamponade presents with tachycardia, jugular venous distension, and can manifest as cough even without dyspnea; pulsus paradoxus and hypotension indicate tamponade requiring urgent pericardiocentesis 1, 3
• Pulmonary embolism causes acute chest pain, tachycardia, and cough; this diagnosis must be considered in any patient with this triad 4
• Pneumothorax presents with acute chest pain and tachycardia, particularly in younger patients 4
• Aortic dissection with pericardial involvement causes chest pain and tachycardia; pericardiocentesis is contraindicated due to risk of intensified bleeding 1

Initial Diagnostic Approach

• Obtain ECG immediately to assess for ST-elevation myocardial infarction (STEMI), STEMI-equivalents, or arrhythmias causing tachycardia 2
• Chest radiograph should be performed to evaluate for pneumonia, pneumothorax, pleural effusion, or cardiomegaly suggesting heart failure 1, 5
• Vital signs assessment including temperature ≥38°C, respiratory rate >24/min, and blood pressure to identify hemodynamic instability 5, 6

Cardiac Causes

Tachycardia-Induced Cardiomyopathy

• Persistent tachyarrhythmia can cause left ventricular dysfunction presenting as chronic cough without typical heart failure symptoms, even in young patients without underlying heart disease 7
• Heart rate control alone can reverse cardiomyopathy and resolve symptoms in most patients with tachycardia-induced cardiomyopathy 7
• Consider this diagnosis when chronic cough occurs with persistent tachycardia, regardless of patient age 7

Pericardial Disease

• Pericardial effusion can present with cough as the sole manifestation, even without chest pain or dyspnea, particularly following cardiac procedures 3
• Onset of dyspnea, cough, chest pain, and tachycardia occurs when pericardial fluid exceeds 500 ml 1
• Echocardiography is essential to diagnose pericardial effusion and assess for tamponade physiology 1, 3
• Ibuprofen is the agent of choice for post-procedural pericarditis, as it increases coronary flow 1

Pulmonary Causes

Community-Acquired Pneumonia

Pneumonia is the most important pulmonary cause to identify, as it requires specific antibiotic therapy and can be life-threatening if untreated. 5

Diagnostic Criteria

• Cough with dyspnea or pleuritic pain combined with fever ≥38°C, chills, and tachypnea (respiratory rate >24/min) strongly suggests pneumonia 5, 6
• Absence of nasal discharge (rhinorrhea) significantly increases pneumonia probability 5, 6
• Focal crackles, diminished breath sounds, or consolidation on chest examination are the most diagnostically significant findings 6, 8

Laboratory Testing

• C-reactive protein (CRP) >30 mg/L with suggestive symptoms strongly increases pneumonia probability 5, 8
• CRP <10 mg/L or 10-50 mg/L without dyspnea and daily fever makes pneumonia less likely 5, 8
• Measuring CRP strengthens both diagnosis and exclusion of pneumonia 5, 8

When Chest X-Ray is Normal

• Normal chest X-ray does not rule out pneumonia, as radiographic changes may not develop until 2 days after symptom onset 6
• CT chest detects pneumonia in 27-33% of patients with negative chest X-rays and clinical suspicion 6
• Lung ultrasound has 81-96% sensitivity compared to 64% for chest X-ray 6

Treatment

• Empiric antibiotic treatment according to local guidelines is recommended for patients with radiographic evidence or high clinical suspicion of pneumonia 5, 6
• Initiate antibiotics even without radiographic confirmation if vital signs are abnormal, focal chest findings are present, and CRP >30 mg/L 6

Malignant Pericardial or Pleural Effusion

• Neoplastic pericarditis from lung cancer, breast cancer, or lymphoma causes chest pain, tachycardia, and cough when fluid exceeds 500 ml 1
• Malignant pleural effusions cause chest pain and cough; large effusions should be drained in controlled fashion (≤1-1.5 L at one time or 500 ml/hour) to avoid re-expansion pulmonary edema 1
• Pericardiocentesis is class I indication for cardiac tamponade in neoplastic pericardial effusion 1

Lung Cancer

• Cough is present in >65% of patients at lung cancer diagnosis, often accompanied by dyspnea 1
• Smokers with new cough or changing cough character persisting for months should undergo bronchoscopy even with normal chest radiograph 1
• Hemoptysis (even small volume or streaks) with cough and tachycardia should prompt consideration of lung cancer 1

Pulmonary Embolism

• Acute chest pain with tachycardia and cough represents a classic triad requiring immediate evaluation for pulmonary embolism 4
• Pleuritic chest pain (pain related to breathing) is characteristic of pulmonary embolism 4

Common Benign Causes of Chronic Cough

When Life-Threatening Causes Are Excluded

For immunocompetent nonsmokers with normal or insignificant chest radiograph, the three most common causes are upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD) in descending order of prevalence. 1

Sequential Empiric Treatment Approach

• Begin with treatment for UACS using first-generation antihistamine/decongestant combination 1
• If cough persists, add empiric asthma therapy with inhaled corticosteroids and bronchodilators 1
• If still unresolved, add GERD treatment with proton pump inhibitors 1
• Cough is often multifactorial; resolution may require treating two or all three conditions simultaneously 1

Important Medication History

• ACE inhibitors cause cough in a significant proportion of patients; discontinue regardless of temporal relationship 1
• Cough resolution usually occurs within days to 2 weeks of stopping ACE inhibitor, but median time is 26 days 1

Smoking-Related Cough

• Cigarette smoking causes chronic bronchitis with productive cough 1
• Smoking cessation is almost always effective; majority resolve within 4 weeks 1

Algorithmic Approach Summary

1. Immediate assessment: ECG, vital signs, chest radiograph to exclude life-threatening conditions (ACS, tamponade, pneumothorax, pulmonary embolism) 1, 5, 2

2. If pneumonia suspected: Check CRP; if >30 mg/L with clinical findings, initiate empiric antibiotics per local guidelines 5, 6, 8

3. If cardiac cause suspected: Echocardiography for pericardial effusion or ventricular dysfunction; treat tachyarrhythmia with rate control 1, 3, 7

4. If malignancy suspected: CT chest, bronchoscopy for smokers with persistent cough, or pericardial/pleural fluid analysis 1

5. If chronic cough with normal workup: Sequential empiric treatment for UACS, then asthma, then GERD; discontinue ACE inhibitors if applicable 1

Critical Pitfalls to Avoid

• Do not assume young age or absence of heart disease excludes cardiac causes; tachycardia-induced cardiomyopathy occurs in previously healthy young patients 7
• Do not rule out pneumonia based on normal chest X-ray alone; consider CT or lung ultrasound if clinical suspicion is high 6
• Do not perform pericardiocentesis in aortic dissection with pericardial effusion, as this increases bleeding risk 1
• Do not drain large pleural effusions rapidly; limit to 1-1.5 L at one time or 500 ml/hour to prevent re-expansion pulmonary edema 1
• Do not delay bronchoscopy in smokers with persistent cough and hemoptysis even when chest radiograph is normal 1