Chest pain

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Chest pain from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Chest Pain in Pregnancy

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

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Surgery

Primary Prevention

Secondary Prevention

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Future or Investigational Therapies

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Chest Discomfort or chest pain is one of the commonest symptoms presented in the emergency department. It can be a manifestation of a benign condition like gastroesophageal reflux diseases to life threatening conditions like myocardial infarction, aortic dissection, tension pneumothorax, or pulmonary embolism. Thus, it requires careful consideration on the physician's part not to miss important diagnosis and also not to over-treat a simple condition. Several life threatening disorders should be excluded upon presentation. The frequency of non-acute myocardial infarction conditions in a decreasing order is: gastroesophageal disease commonest followed by ischemic heart disease, and chest wall syndromes [1]. Other less frequent diagnoses included pulmonary embolism, pleuritis/pneumonia, lung cancer, aortic stenosis, aortic aneurysm and herpes zoster. The first diagnostic study to be ordered within 10 minutes is the 12 lead electrocardiogram. A full medical history may assist in the prompt management of the patient with chest pain.

Chest pain that suggest cardiac ischemia as the underlying cause

Chest pain that are not characteristic of myocardial ischemia

  • Muscular pain; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
  • Pleura related pain (pleuritic pain); a sharp or knifelike pain brought on by respiratory movements as deep breathing orcough
  • Primary or sole location of discomfort in the middle or lower abdominal region
  • Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costo chondral junction
  • Pain reproduced with movement or palpation of the chest wall or arms
  • Very brief episodes of pain that last a few seconds or less
  • Pain that radiates into the lower extremities


The relief of chest pain by administration of sublingual nitroglycerin in outpatient setting is not diagnostic of coronary artery disease. For instance, esophageal pain can be relieved by administration of nitroglycerin. Likewise, the relief of chest pain by the administration of liquid or chewable antacids and anti reflux drugs does not exclude coronary artery disease as the underlying etiology of the pain.

5 Life Threatening Diseases to Exclude Immediately

Differential Diagnosis of Chest Pain

Cardiovascular Acute Aortic DissectionAcute Coronary Syndrome • (unstable angina) • (non ST elevation MI) • (ST elevation MI) • Aortic AneurysmAortic StenosisArryhthmiasBland-White-Garland SyndromeChronic Stable AnginaCor pulmonaleCoronary Heart Disease Dressler's syndrome (postpericardiotomy)Hypertrophic CardiomyopathyMitral valve prolapseMyocardial infarctionMyocarditisPericardial tamponadePericarditisTakotsubos cardiomyopathyStress cardiomyopathy
Chemical / poisoning Carbon monoxide poisoning • Lead poisoning
Dermatologic Herpes zoster
Drug Side Effect Drugs to treat migraine headache
Ear Nose Throat Retropharyngeal abscess
Endocrine AcromegalyHyperthyroidismHypothyroidism
Environmental No underlying causes •
Gastroenterologic AchalasiaAbdominal distensionBarret’s esophagusCarcinomaCholecystitisCholelithiasisDiverticulitisDuodenitisEsophageal ruptureEsophageal spasmEsophagitisForeign bodyGastritisGastroesophageal reflux (GERD) • Hiatus HerniaImpacted stoneLiver abscessMallory-Weiss SyndromeNeoplasmNutcracker's esophagusPancreatitisPeptic ulcer diseasePerforated ulcerPlummer-Vinson SyndromePneumoperitoneumSplenic enlargementSplenic infarction • Subdiaphragmatic abcsess • Subphrenic abscessWhipple's Disease
Genetic No underlying causes •
Hematologic Sickle cell anemia
Iatrogenic No underlying causes •
Infectious Disease Bornholm diseaseHepatitisHIV infectionHerpes Zoster
Musculoskeletal / Ortho Bechterew's DiseaseBone tumor • Chest wall pain syndrome • Costochondritis • Chosto condral tendinitis • Chosto sternal tendinitis • Tietze's syndrome • CS/TS osteochondrosis • FibromyalgiaFractured ribIntercostal muscle spasm • Interstitial fibrosis • Intercostal neuralgiaMuscle strain or spasm • Myofascial pain •MyostitisNeuritisRadiculitisPeriostitisPrecordial catch syndromeShoulder bursitisShoulder tendinitisSoft tissue sarcoma or tumor • Sternoclavicular arthritis • Strain of pectoralis muscle • Thoracic Outlet SyndromeTrauma • Vertebrogenic thoracic pain
Neurologic Tabes dorsalis
Nutritional / Metabolic No underlying causes •
Oncologic Liver cancerMesotheliomaMetastatic tumorNeurofibromaPheochromocytoma
Opthalmologic No underlying causes •
Overdose / Toxicity No underlying causes •
Psychiatric Anxiety disordersAffective disorders (e.g., depression) • Da costa's syndrome • Thought disorders (e.g., fixed delusions) • Hyperventilation syndromeHypochondriaFactitious disorders (e.g. Münchausen syndromeFabricated or induced illness • Hospital addiction syndrome • Panic attackSomatoform disordersSomatization disorder
Pulmonary AsthmaBronchial carcinomaBronchiectasisBronchogenic carcinomaCarcinomatousPleural EffusionChronic Obstructive Pulmonary Disease (COPD) • EmpyemaHemothoraxLung AbscessLung CancerLymphomaMediastinitisPleuritisPleurodyniaPneumomediastinumPneumoniaPneumothoraxPulmonary EmbolismPulmonary InfarctionTension pneumothoraxThymoma • Tracheoesophageal abscess • Tuberculosis
Renal / Electrolyte No underlying causes •
Rheum / Immune / Allergy Familial mediterranean fever
Substance abuse Cocaine
Trauma Chest wall injuries •
Miscellaneous • Collagen vascular disease with pleuritis • Conn's Syndrome • Degenerative changes of cervical spine •PeritonitisPott's DiseaseXiphodynia

Diagnosis

History and Symptoms

Thorough history including: Onset, duration, type of pain, location, exacerbating factors, alleviating factors, radiation. Risk factors for coronary artery disease: family history smokinghyperlipidemiadiabetes

Clinical features of different conditions presenting with acute chest discomfort

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated symptoms
Stable Angina Sudden (acute) 2-10 minutes Heaviness, tightness, squeezing Retrosternal Exertion, emotions, cold Rest, nitroglycerine Radiation to neck, jaw, shoulders, or arms (commonly on left) Sweating, Nausea, Palpitations, Pain with exertion, Dizziness, Shortness of breath, a sense of impending doom
Unstable Angina Acute 10-20 minutes same as stable angina but often more severe same as stable angina same as stable angina but occurs with lower levels of exertion and even at rest same as stable angina same as stable angina same as stable angina
Myocardial Infarction Acute commonly > 20 minutes same as stable angina but often more severe same as stable angina same as stable angina but occurs with lower levels of exertion and even at rest Usually unrelieved by nitroglycerine and rest same as stable angina same as stable angina

Physical Examination

Heart: Cardiovascular examination including assessment of murmurs, gallops or rubs,carotid bruit and heart sounds

Extremities: Evidence of lower limb tenderness or pain

Other: Rectal examination is required to assess for occult bleeding

Laboratory Findings

On the basis of the above, a number of tests may be ordered:

  • X-rays of the chest and/or abdomen:
  • Echocardiography or Ultrasound:
  • MRI and CT:
  • Other Imaging Findings:
  • Other Diagnostic Studies:

Interpretation

  • In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analyses are not sensitive enough (Chun & McGee 2004).
  • The physician's typical approach is to rule-out the most dangerous causes of chest pain first (e.g., heart attack, blood clot in the lung, aneurysm). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made.
  • Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient.
  • If acute coronary syndrome (e.g.unstable angina) is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (CK-MB, troponin or myoglobin). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.

Treatment

Immediate Management:

  • Special attention to: airway, breathing, and circulation
  • Treat all underlying etiologies as clinically indicated
  • Supplemental O2 should be administered to patients with suspected coronary artery disease

Acute Pharmacotherapies:

Surgery and Device Based Therapy:

Sources

  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [7]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [8]


References

  1. Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal. 17 (7): 1028–34. PMID 8809520. Retrieved 2012-05-02. Unknown parameter |month= ignored (help)
  2. Chun AA, McGee SR (2004). "Bedside diagnosis of coronary artery disease: a systematic review". Am. J. Med. 117 (5): 334–43. doi:10.1016/j.amjmed.2004.03.021. PMID 15336583. Unknown parameter |month= ignored (help)
  3. Ringstrom E, Freedman J (2006). "Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines". Mt. Sinai J. Med. 73 (2): 499–505. PMID 16568192. Unknown parameter |month= ignored (help)
  4. Butler KH, Swencki SA (2006). "Chest pain: a clinical assessment". Radiol. Clin. North Am. 44 (2): 165–79, vii. doi:10.1016/j.rcl.2005.11.002. PMID 16500201. Unknown parameter |month= ignored (help)
  5. Haro LH, Decker WW, Boie ET, Wright RS (2006). "Initial approach to the patient who has chest pain". Cardiol Clin. 24 (1): 1–17, v. doi:10.1016/j.ccl.2005.09.007. PMID 16326253. Unknown parameter |month= ignored (help)
  6. Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain". Clin Med. 6 (5): 445–9. PMID 17080889.
  7. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter |month= ignored (help)
  8. Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter |month= ignored (help)


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