Chest pain overview: Difference between revisions
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==Overview== | ==Overview== | ||
[[Chest pain]] is [[ | |||
After [[injuries]], [[chest pain]] is the second most common cause of seeking medical attention in [[emergency department]] ([[ED]]) in the [[United States]] and responsible for >6.5 million visits, which is 4.7% of all [[ED ]] visits. [[Chest pain]] also is the cause of nearly 4 million [[outpatient]] visits every year in the [[United States]]. [[Chest pain]] remains a diagnostic challenge in the [[ED]] and [[outpatiet]] setting and needs thorough [[clinical]] evaluation. Causes of [[chest pain]] include [[noncardiac]],and cardiac in which noncardiac [[chest pain]] is responsible for more than half of [[ED]] visits and only 5.1% will have an [[acute coronary syndrome]]. [[Coronary artery disease]] ([[CAD]]) is the leading cause of [[death]] for [[men]] and [[women]]. Distinguishing between serious and benign causes of [[chest pain]] is important. [[Chest pain]] is the most [[symptom]] of [[CAD]] in both [[men]] and [[women]]. | |||
==Historical Perspective== | ==Historical Perspective== | ||
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==Classification== | ==Classification== | ||
Chest pain | [[Chest pain]] traditionally has been classified into [[typical]] and atypical types. [[Chest pain]] that is more likely associated with [[ischemia]] includes substernal [[chest discomfort]] aggravated by [[exertion]] or [[emotional stress]] and relieved by [[rest]] or [[nitroglycerin]]. [[Ischemic chest discomfort]] can be described based on [[quality]], [[location]], [[radiation]], and provoking and relieving factors. Using the term of [[atypical chest pain]] is problematic. Although the term of atypical [[chest pain]] was intended to describe [[angina]] without typical [[chest]] [[symptoms]], it is more often used to consider that the [[symptom]] is [[noncardiac]] in origin. Then, it is discouraged using the term of atypical [[chest pain]]. Notably, [[chest pain]] is a broadly term to define referred [[pain]] in the [[shoulders]], [[arms]], [[jaw]], [[neck]], and upper [[abdomen]]. So, using the terms of [[cardiac]], possible [[cardiac]], and [[noncardiac]] are encouraged to describe the suspected causes of [[chest pain]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
The cardiovascular system, respiratory system, part of the gastrointestinal system, and the great vessels give off afferent visceral input via common thoracic autonomic ganglia. Painful stimuli in any of the aforementioned systems are usually sensed as originating from the chest. However, due to the fact that afferent nerve fibers overlap in the dorsal ganglia, pain in the thorax may be experienced at any point between the umbilicus and the ear, as well as in the upper limbs. | The [[cardiovascular]] system, respiratory system, part of the [[gastrointestinal]] system, and the great [[vessels]] give off afferent visceral input via common [[thoracic]] [[autonomic ganglia]]. Painful stimuli in any of the aforementioned systems are usually sensed as originating from the [[chest]]. However, due to the fact that [[afferent nerve]] fibers overlap in the dorsal ganglia, pain in the [[thorax]] may be experienced at any point between the [[umbilicus]] and the [[ear]], as well as in the upper [[limbs]]. | ||
==Causes== | ==Causes== | ||
There are many organ systems, that when affected, can lead to the symptoms of chest pain. The most common organs involved are the [[heart]], [[lungs]], and the [[digestive system]]. [[Psychiatric disorders]], can also lead to the perception of chest pain. The most important facet of diagnosis is distinguishing the life-threatening causes of chest pain, to the more benign causes. | There are many [[organ]] systems, that when affected, can lead to the symptoms of [[chest pain]].The most common organs involved are the [[heart]], [[lungs]], and the [[digestive system]]. [[Psychiatric disorders]], can also lead to the perception of [[chest pain]]. The most important facet of diagnosis is distinguishing the life-threatening causes of [[chest pain]], to the more benign causes. [[Life-threatening]] causes of chest pain include [[myocardial infarction]], [[aortic dissection]], [[pulmonary embolism]], [[tension pneumothorax]], and [[esophageal rupture]]. Other common causes of chest pain include [[GERD]], chest wall tenderness, [[achalasia]], [[pneumonia]], and [[anxiety]]. | ||
==Differentiating Chest pain from Other Diseases== | ==Differentiating Chest pain from Other Diseases== | ||
There are several life-threatening causes of chest pain which need to be evaluated for first, which include; [[myocardial infarction]], [[aortic dissection]], [[esophageal rupture]], [[pulmonary embolism]], and [[tension pneumothorax]]. The other possible causes of chest pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history. | There are several life-threatening causes of chest pain which need to be evaluated for first, which include; [[myocardial infarction]], [[aortic dissection]], [[esophageal rupture]], [[pulmonary embolism]], and [[tension pneumothorax]]. The other possible causes of chest pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
There is a significant difference in the [[epidemiology]] of [[chest pain]] in the [[outpatient]] and [[emergency]] settings. The [[incidence]]<nowiki/>of chest pain is approximately 1,500 per 100,000 individuals worldwide. According to a study conducted in Belgium, the prevalence of [[chest pain]] is approximately 2000-5000 per 100,000 individuals worldwide. The incidence of patients presenting with chest pain increases with age and men are more likely to present with chest pain than women. | There is a significant difference in the [[epidemiology]] of [[chest pain]] in the [[outpatient]] and [[emergency]] settings. The [[incidence]]<nowiki/> of [[chest pain]] is approximately 1,500 per 100,000 individuals worldwide. According to a study conducted in Belgium, the prevalence of [[chest pain]] is approximately 2000-5000 per 100,000 individuals worldwide. The incidence of patients presenting with chest pain increases with age and men are more likely to present with chest pain than women. | ||
==Risk Factors== | ==Risk Factors== | ||
Common risk factors in the development of chest pain may be associated with the cardiac, respiratory, or gastrointestinal systems. Other risk factors include smoking, obesity, drug abuse, and psychiatric disorders. | Common [[risk factors]] in the development of chest pain may be associated with the [[cardiac]], [[Respiratory system|respiratory]], or [[Gastrointestinal tract|gastrointestinal]] systems. Other [[risk factors]] include [[smoking]], [[obesity]], [[drug abuse]], and [[psychiatric disorders]]. | ||
==Screening== | ==Screening== | ||
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==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
Common complications of chest pain include [[arrythmia]], [[heart failure]] and Death. Depending on the etiology at the time of presentation, the prognosis may vary. However, the prognosis is generally regarded as good | [[Angina pectoris]] is defined as a retrosternal [[chest discomfort]] that increases gradually in intensity (over several [[minutes]]). Percipitant factors are [[physical]] or [[emotional]] [[stress]]. In [[ACS]], [[chest pain]] may occur during [[rest]]. [[Chest pain]] is characterized by [[radiation]] ([[ left arm]], [[neck]], [[jaw]]) and its associated [[symptoms]] ([[ dyspnea]], [[nausea]], [[lightheadedness]]). When actively treated or spontaneously resolving, it disappears over a few [[minutes]]. Relief with [[nitroglycerin]] is not necessarily a diagnostic criterion of [[myocardial ischemia]], especially because other causes such as [[esophageal spasm]] may have respons to [[nitroglycerin]]. Associated [[symptoms]] such as [[shortness of breath]], [[nausea]] or [[vomiting]], [[lightheadedness]], [[confusion]], [[presyncope]] or [[syncope]], or [[vague]] [[abdominal]] symptoms are more frequently seen among [[patient]]s with [[diabetes]], [[women]], and the [[elderly]]. A detailed assessment of [[cardiovascular]] [[risk factors]], review of [[systems]], [[past medical history]], and [[family]] and [[social history]] should be done in [[patients]] with [[chest pain]]. It is pivotal to identify and triage the [[patients]] presented with [[chest pain]] within 10 minutes of arrival to the [[hospital]]. [[Patients]] diagnosed with [[STEMI]] should be scheduled for primary [[PCI]]. Early recognition of [[STEMI]] may improve [[outcomes]]. [[Stable angina]] and non-cardiac [[chest pain]] should be evaluated in [[outpaient]] setting. | ||
Common [[complications]] of chest pain include [[arrythmia]], [[heart failure]] and Death. Depending on the etiology at the time of presentation, the [[prognosis]] may vary. However, the [[prognosis]] is generally regarded as good. | |||
==Chest Pain in Pregnancy== | ==[[Chest Pain]] in [[Pregnancy]]== | ||
Causes of chest pain in pregnancy are similar to those in the general population. Acute life-threatening causes include [[ST elevation myocardial infarction in pregnancy|myocardial infarction]], [[aortic dissection]], [[tension pneumothorax]], as well as thromboembolic diseases that are more common in pregnancy | Causes of chest pain in pregnancy are similar to those in the general population. Acute life-threatening causes include [[ST elevation myocardial infarction in pregnancy|myocardial infarction]], [[aortic dissection]], [[tension pneumothorax]], as well as [[thromboembolic]] diseases that are more common in [[pregnancy]] such as [[pulmonary embolism]] and [[amniotic fluid embolism]]. Occasionally, [[chest pain]] in [[pregnant]] [[women]] is caused by physiological changes in [[pregnancy]], namely [[chest expansion]] and [[breast]] tenderness. | ||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Study of Choice=== | ===Diagnostic Study of Choice=== | ||
[[Chest pain]] or [[chest pain]] equivalent may be referred as [[chest pain]]. Diagnosis of nontraumatic [[chest pain]] is frequent challenge for [[physicians]]. Initial evaluation is considered for life-threatening [[conditions]] such as [[ACS]], [[aortic dissection]], and [[pulmonary embolism ]], as well as nonvascular syndromes (eg, [[esophageal rupture]], [[tension pneumothorax]]). So, therapy for those with less critical illnesses is reasonable. Although there are several life-threatening causes, [[chest pain]] usually reflects a more benign [[condition]]. The initial work-up is taking [[ECG]], but exact [[history]], [[physical examination]], [[biomarkers]], and other tests are necessary. There is no association between the intensity of [[symptoms]] and [[seriousness]] of [[disease]] and general similarity of [[symptoms]] among different causes of [[chest pain]]. A [[comprehensive]] [[history]] with all characteristics of [[chest pain]] including nature; 2) onset and duration, 3) location and radiation, 4) precipitating factors, 5) relieving factors, and 6) associated [[symptoms]] should be obtained to identify the underlying causes of [[chest pain]]. | |||
===History and Symptoms=== | ===History and Symptoms=== | ||
The | The patient's history must be thoroughly investigated to exclude the life-threatening causes of [[chest pain]], such as the [[cardiovascular]] ones: [[acute coronary syndrome]], [[aortic dissection]], [[pulmonary embolism]] but also the non-cardiac such as [[tension pneumothorax]] and [[esophageal rupture]]. [[Chest pain]] in [[myocardial ischemia]] presented as deep, difficult to localization, and diffuse. Point tenderness is less likely to be [[symptom]] of [[myocardial ischemia]]. [[Chest pain]] characterized by [[duration]], [[provoking factors]], [[relieving factors]], [[age]], [[cardiac risk factors]]. [[Patient]] [[history]] is the most important basis of defining [[myocardial ischemia]]. Because of complexity of [[cardiac symptoms]] and variable expression of [[chest pain]], [[ischemic chest pain]] may be present as non-[[cardiac]] [[chest pain]].[[Characteristic]] of [[chest pain]] with high likelihood of [[myocardial ischemia]] including: central, [[pressure]], [[squeezing]], [[gripping]], [[heaviness]], [[tighness]], [[exertional]], [[stress related]], [[retrosternal]], [[left-sided]], [[dull]], [[aching]], [[Characteristic]] of [[chest pain]] with less likelihood of [[myocardial ischemia]] include [[right-sided]], [[tearing]], [[ripping]], [[burning]], [[sharp]], [[fleeting]], [[shifting]], [[pleuritic]], [[positional]]. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Physical examination should focus on evaluating for the life-threatening causes of chest pain first. A complete physical exam should be done, which includes a thorough cardiac, lung, and abdominal exam. | [[Physical examination]] should focus on evaluating for the life-threatening causes of chest pain first. A complete physical exam should be done, which includes a thorough [[cardiac]], [[lung]], and [[abdominal]] exam. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
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===Electrocardiogram=== | ===Electrocardiogram=== | ||
The key findings to look for on an [[ECG]] is the [[ST elevation]] which is characteristic of [[myocardial infarction]]. However, The major challenge is the differential between [[NSTE-ACS]] and non-cardiac [[chest pain]]. Diffuse [[ST elevation]] may point to the [[diagnosis]] of [[pericarditis]]. A serial [[ECG]] should be obtained to evaluate for continued or progression of [[myocardial]] injury over time. | |||
The key findings to look for on | |||
===X-ray=== | ===X-ray=== | ||
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===Echocardiography and Ultrasound=== | ===Echocardiography and Ultrasound=== | ||
[[Transthoracic echocardiography]] ([[TTE]]) can be helpful for diagnosis the causes of acute [[chest pain]] such as acute [[aortic dissection]], [[pericardial effusion]], [[stress cardiomyopathy]], and [[ hypertrophic cardiomyopathy]]. In addition, [[TTE]] does provide information for patients with acute [[chest pain]] and suspected [[ACS]] about left and [[right ventricular function]] and [[regional wall motion abnormalities]]. [[Stress echocardiography]] can be used to define [[ischemia]] severity and for risk stratification purposes when ≥2 contiguous segments of [[wall motion abnormalities]] in [[coronary territories]] are visualized. | |||
===CT scan=== | ===CT scan=== | ||
[[CT angiography]] | [[Coronary CT angiography]] ([[CCTA]]) can be helpful to diagnose the extent and severity of [[nonobstructive]] and [[obstructive]] [[CAD]], as well as high-risk features of [[atherosclerotic plaque]] (positive [[remodeling]], [[low attenuation plaque]]). [[ Fractional flow reserve]] with [[CT]] ([[FFR-CT]]) provides additional information about [[ischemia]] related to [[lesion]]. Dosimetry is low for [[CCTA]], with effective doses for most patients in the 3 to 5 mSv range. | ||
===MRI=== | ===MRI=== | ||
[[Cardiovascular magnetic resonance imaging]] ([[CMR]]) is helpful to accurately determin global and regional left and [[right ventricular]] function, localized [[myocardial ischemia]] and [[infarction]], and detection of [[myocardial viability]]. [[Myocardial edema]] and [[microvascular obstruction]] can be determined by [[CMR]] to differentiate acute versus chronic [[MI]], as well as other causes of acute [[chest pain]], including [[myocarditis]]. | |||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
After ruling out of [[ACS]], rest/stress [[positron emission tomography]] ([[PET]]) or [[single-photon emission computed tomography]] ([[SPECT]]) [[myocardial perfusion imag-ing]] ([[MPI]]) are helpful for detection of [[perfusion]] abnormalities, measures of [[left ventricular]] function, and high-risk findings, such as [[transient ischemic dilation]]. For [[PET]], calculation of [[myocardial blood flow reserve]] ([[MBFR]], the ratio of peak [[hyperemia]] to [[resting myocardial blood flow]]) adds diagnostic and [[prognostic]] information over [[MPI]]. [[Radiation]] exposure dose is ∼3 mSv for rest/stress [[PET]] with [[Rb]]-82 and ∼10 mSv for [[Tc-99m SPECT]]. | |||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
[[Invasive Coronary Angiography]] ([[ICA]]) is used to determine the presence and severity of a luminal obstruction of an [[epicardial coronary artery]], including its [[location]], [[length]], and [[diameter]], as well as [[coronary blood flow]]. [[ICA]] provides the characterization of high-grade obstructive stenosis and possibility for percutaneous or [[surgical revascularization]]. ([[IFR]] and [[FFR]]) provide [[physiologic]] characteristic of stenosis. [[Radiation]] exposure to the [[patient]] during an [[interventional procedure]] varied 4 to 10 mSv and is dependent on [[procedural duration]] and complexity. The spatial resolution of [[ICA]] is 0.3 mm, so, visualization of [[arterioles]] (diameter of 0.1 mm) that regulate [[ myocardial blood flow]] is impossible. [[Coronary vascular functional]] studies can be performed during [[coronary angiography]]. In normal [[ coronary angiography]] there may be evident abnormal [[coronary vascular function]]. Assessment of [[coronary microcirculation]] and [[coronary vasomotion]] by [[coronary function testing]] are reasonable. | |||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
A correct diagnosis of the underlying cause of the chest pain should be obtained prior to deciding on an appropriate treatment strategy. The most dangerous causes should be evaluated first. If [[myocardial infarction]] or ischemia is suspected, the immediate pharmacotherapies | A correct diagnosis of the underlying cause of the [[chest pain]] should be obtained prior to deciding on an appropriate treatment strategy. The most dangerous causes should be evaluated first. If [[myocardial infarction]] or [[ischemia]] is suspected, the immediate pharmacotherapies including [[morphine]], [[oxygen]], [[nitrate]], [[aspirin]], [[ACE inhibitors]] should be initiated. | ||
===Interventions=== | ===Interventions=== | ||
Common indications of [[coronary angiography]] in high risk [[ACS]] [[patients]] include new [[ischemic]] changes on the [[ECG]], [[troponin]]-confirmed acute [[myocardial injury]], new-onset [[left ventricular systolic dysfunction ]] ([[ejection fraction]] <40%), and newly diagnosed moderate-severe [[ischemia]] on [[stress]] imaging. For high-risk [[patients]] presented with documented [[AMI]] and normal [[epicardial coronary arteries]] on [[CCTA]] or invasive [[ coronary angiography]], or nonobstructive [[CAD]], [[CMR]] and [[echocardiography]] are useful for evaluation of [[nonischemic cardiomyopathy]] or [[myocarditis]]. Among high risk [[patients]], [[invasive coronary angiography]] provides a comprehensive assessment of the extent and severity of obstructive [[CAD]]. The determination of the severity of anatomic [[CAD]] is critical to guide the use of [[coronary revascularization]]. Approximately 6% to 15% of [[troponin]]-positive [[ACS]] occurs in the absence of obstructive [[CAD]]. Additional testing may be helpful to determine the strategy of treatment. Evidence supports that [[CMR]] can identify [[wall motion abnormalities]] and [[myocardial edema]] and distinguish [[infarct]]-related [[scar]] from non-[[CAD]] causes such as [[myocarditis]] and [[nonischemic cardiomyopathy]]. Performing [[CMR]] within 2 weeks of [[ACS]], can be useful to identify [[MI ]] with nonobstructive [[CAD]] ([[MINOCA]]) from other causes. The term obstructive [[CAD]] indicates [[CAD]] with ≥50% stenosis. Nonobstructive [[CAD]] is used if [[CAD]] <50% stenosis. High risk [[CAD]] is defined in the presence of obstructive [[stenosis]] with [[left main]] stenosis ≥50% or anatomically significant 3-vessel disease (≥70% stenosis). | |||
===Surgery=== | ===Surgery=== | ||
Common causes of acute [[chest pain]] in the months after [[CABG]] include [[musculoskeletal]] pain from [[sternotomy]]( the most common cause), [[myocardial ischemia]] from acute [[graft stenosis]] or [[occlusion]], [[pericarditis]], [[pulmonary embolism]], [[sternal]] [[wound]] [[infection]] , nonunion. [[Post-sternotomy pain syndrome]] is defined as discomfort after [[thoracic]] [[surgery]], persisting for at least 2 months, and without apparent cause. The [[incidence]] of [[post-sternotomy pain syndrome]] is varied 7%-66% with a higher [[prevalence]] in [[women]] compared with [[men]] within the first 3 months of [[thoracic surgery]] but, after 3 months, [[postoperative]] [[sex]] difference in [[prevalence]] was not seen. Causes of [[ Graft]] failure within the first year post-[[CABG]] using [[saphenous venous grafts]] are technical issues, [[intimal hyperplasia]], [[thrombosis]]. [[Internal mammary artery graft]] failure within the first-year post-[[CABG]] is most commonly attributable to issues with the [[anastomotic site]] of the [[graft]]. Causes of acute [[chest pain]] several years after [[CABG]] include [[graft]] stenosis, occlusion or progression of [[disease]] in a non-bypassed [[vessel]]. One year after [[CABG]], about 10%-20% of [[saphenous vein grafts]] fail. By 10 years, about half of [[saphenous vein grafts]] are patent. The [[internal mammary artery]] has patency rates of 90% to 95% 10 to 15 years after [[CABG]]. The use of [[radial artery grafts]] for [[CABG]] has a higher patency rate at 5 years of follow-up, compared with the use of [[saphenous vein grafts]]. | |||
===Primary Prevention=== | ===Primary Prevention=== | ||
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===Secondary Prevention=== | ===Secondary Prevention=== | ||
[[Secondary prevention]] of [[chest pain]] depends on the cause for instance, risk factor modification remains essential part of the [[secondary prevention]] strategy in [[chronic stable angina]]. [[Secondary prevention]] of [[chest pain]] caused by [[GERD]] is avoiding [[food ]] that worsens the symptoms, [[smoking]] cessation, [[weight loss]], eating frequent [[meals]], and head raising of the bed while [[sleeping]]. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Latest revision as of 09:22, 8 November 2022
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Chest pain Microchapters |
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Chest pain overview On the Web |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3],Nuha Al-Howthi, MD[4]
Overview
After injuries, chest pain is the second most common cause of seeking medical attention in emergency department (ED) in the United States and responsible for >6.5 million visits, which is 4.7% of all ED visits. Chest pain also is the cause of nearly 4 million outpatient visits every year in the United States. Chest pain remains a diagnostic challenge in the ED and outpatiet setting and needs thorough clinical evaluation. Causes of chest pain include noncardiac,and cardiac in which noncardiac chest pain is responsible for more than half of ED visits and only 5.1% will have an acute coronary syndrome. Coronary artery disease (CAD) is the leading cause of death for men and women. Distinguishing between serious and benign causes of chest pain is important. Chest pain is the most symptom of CAD in both men and women.
Historical Perspective
The first recorded description of chest pain was given by Benivieni, a Florentine physician in the early 1500s. The first concise account of angina pectoris was given by the then Earl of Clarendon when he described his father's illness. Angina pectoris was described by a medical practitioner when Dr. William Heberden read his paper to the College of Physicians in London on 21 July 1768.
Classification
Chest pain traditionally has been classified into typical and atypical types. Chest pain that is more likely associated with ischemia includes substernal chest discomfort aggravated by exertion or emotional stress and relieved by rest or nitroglycerin. Ischemic chest discomfort can be described based on quality, location, radiation, and provoking and relieving factors. Using the term of atypical chest pain is problematic. Although the term of atypical chest pain was intended to describe angina without typical chest symptoms, it is more often used to consider that the symptom is noncardiac in origin. Then, it is discouraged using the term of atypical chest pain. Notably, chest pain is a broadly term to define referred pain in the shoulders, arms, jaw, neck, and upper abdomen. So, using the terms of cardiac, possible cardiac, and noncardiac are encouraged to describe the suspected causes of chest pain.
Pathophysiology
The cardiovascular system, respiratory system, part of the gastrointestinal system, and the great vessels give off afferent visceral input via common thoracic autonomic ganglia. Painful stimuli in any of the aforementioned systems are usually sensed as originating from the chest. However, due to the fact that afferent nerve fibers overlap in the dorsal ganglia, pain in the thorax may be experienced at any point between the umbilicus and the ear, as well as in the upper limbs.
Causes
There are many organ systems, that when affected, can lead to the symptoms of chest pain.The most common organs involved are the heart, lungs, and the digestive system. Psychiatric disorders, can also lead to the perception of chest pain. The most important facet of diagnosis is distinguishing the life-threatening causes of chest pain, to the more benign causes. Life-threatening causes of chest pain include myocardial infarction, aortic dissection, pulmonary embolism, tension pneumothorax, and esophageal rupture. Other common causes of chest pain include GERD, chest wall tenderness, achalasia, pneumonia, and anxiety.
Differentiating Chest pain from Other Diseases
There are several life-threatening causes of chest pain which need to be evaluated for first, which include; myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. The other possible causes of chest pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.
Epidemiology and Demographics
There is a significant difference in the epidemiology of chest pain in the outpatient and emergency settings. The incidence of chest pain is approximately 1,500 per 100,000 individuals worldwide. According to a study conducted in Belgium, the prevalence of chest pain is approximately 2000-5000 per 100,000 individuals worldwide. The incidence of patients presenting with chest pain increases with age and men are more likely to present with chest pain than women.
Risk Factors
Common risk factors in the development of chest pain may be associated with the cardiac, respiratory, or gastrointestinal systems. Other risk factors include smoking, obesity, drug abuse, and psychiatric disorders.
Screening
There is insufficient evidence to recommend routine screening for chest pain
Natural History, Complications, and Prognosis
Angina pectoris is defined as a retrosternal chest discomfort that increases gradually in intensity (over several minutes). Percipitant factors are physical or emotional stress. In ACS, chest pain may occur during rest. Chest pain is characterized by radiation (left arm, neck, jaw) and its associated symptoms (dyspnea, nausea, lightheadedness). When actively treated or spontaneously resolving, it disappears over a few minutes. Relief with nitroglycerin is not necessarily a diagnostic criterion of myocardial ischemia, especially because other causes such as esophageal spasm may have respons to nitroglycerin. Associated symptoms such as shortness of breath, nausea or vomiting, lightheadedness, confusion, presyncope or syncope, or vague abdominal symptoms are more frequently seen among patients with diabetes, women, and the elderly. A detailed assessment of cardiovascular risk factors, review of systems, past medical history, and family and social history should be done in patients with chest pain. It is pivotal to identify and triage the patients presented with chest pain within 10 minutes of arrival to the hospital. Patients diagnosed with STEMI should be scheduled for primary PCI. Early recognition of STEMI may improve outcomes. Stable angina and non-cardiac chest pain should be evaluated in outpaient setting. Common complications of chest pain include arrythmia, heart failure and Death. Depending on the etiology at the time of presentation, the prognosis may vary. However, the prognosis is generally regarded as good.
Chest Pain in Pregnancy
Causes of chest pain in pregnancy are similar to those in the general population. Acute life-threatening causes include myocardial infarction, aortic dissection, tension pneumothorax, as well as thromboembolic diseases that are more common in pregnancy such as pulmonary embolism and amniotic fluid embolism. Occasionally, chest pain in pregnant women is caused by physiological changes in pregnancy, namely chest expansion and breast tenderness.
Diagnosis
Diagnostic Study of Choice
Chest pain or chest pain equivalent may be referred as chest pain. Diagnosis of nontraumatic chest pain is frequent challenge for physicians. Initial evaluation is considered for life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism , as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax). So, therapy for those with less critical illnesses is reasonable. Although there are several life-threatening causes, chest pain usually reflects a more benign condition. The initial work-up is taking ECG, but exact history, physical examination, biomarkers, and other tests are necessary. There is no association between the intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain. A comprehensive history with all characteristics of chest pain including nature; 2) onset and duration, 3) location and radiation, 4) precipitating factors, 5) relieving factors, and 6) associated symptoms should be obtained to identify the underlying causes of chest pain.
History and Symptoms
The patient's history must be thoroughly investigated to exclude the life-threatening causes of chest pain, such as the cardiovascular ones: acute coronary syndrome, aortic dissection, pulmonary embolism but also the non-cardiac such as tension pneumothorax and esophageal rupture. Chest pain in myocardial ischemia presented as deep, difficult to localization, and diffuse. Point tenderness is less likely to be symptom of myocardial ischemia. Chest pain characterized by duration, provoking factors, relieving factors, age, cardiac risk factors. Patient history is the most important basis of defining myocardial ischemia. Because of complexity of cardiac symptoms and variable expression of chest pain, ischemic chest pain may be present as non-cardiac chest pain.Characteristic of chest pain with high likelihood of myocardial ischemia including: central, pressure, squeezing, gripping, heaviness, tighness, exertional, stress related, retrosternal, left-sided, dull, aching, Characteristic of chest pain with less likelihood of myocardial ischemia include right-sided, tearing, ripping, burning, sharp, fleeting, shifting, pleuritic, positional.
Physical Examination
Physical examination should focus on evaluating for the life-threatening causes of chest pain first. A complete physical exam should be done, which includes a thorough cardiac, lung, and abdominal exam.
Laboratory Findings
Serial troponins and CK-MB should be ordered. Additional laboratory tests include serum electrolytes, a complete blood count, renal function tests, and liver function tests.
Electrocardiogram
The key findings to look for on an ECG is the ST elevation which is characteristic of myocardial infarction. However, The major challenge is the differential between NSTE-ACS and non-cardiac chest pain. Diffuse ST elevation may point to the diagnosis of pericarditis. A serial ECG should be obtained to evaluate for continued or progression of myocardial injury over time.
X-ray
Chest X-ray can be useful in the initial evaluation of the patient to ascertain if there is cardiomegaly, pulmonary edema and aortic dissection. CT scanning may be better for visualizing the etiology of chest pain depending on the patient history and their symptoms.
Echocardiography and Ultrasound
Transthoracic echocardiography (TTE) can be helpful for diagnosis the causes of acute chest pain such as acute aortic dissection, pericardial effusion, stress cardiomyopathy, and hypertrophic cardiomyopathy. In addition, TTE does provide information for patients with acute chest pain and suspected ACS about left and right ventricular function and regional wall motion abnormalities. Stress echocardiography can be used to define ischemia severity and for risk stratification purposes when ≥2 contiguous segments of wall motion abnormalities in coronary territories are visualized.
CT scan
Coronary CT angiography (CCTA) can be helpful to diagnose the extent and severity of nonobstructive and obstructive CAD, as well as high-risk features of atherosclerotic plaque (positive remodeling, low attenuation plaque). Fractional flow reserve with CT (FFR-CT) provides additional information about ischemia related to lesion. Dosimetry is low for CCTA, with effective doses for most patients in the 3 to 5 mSv range.
MRI
Cardiovascular magnetic resonance imaging (CMR) is helpful to accurately determin global and regional left and right ventricular function, localized myocardial ischemia and infarction, and detection of myocardial viability. Myocardial edema and microvascular obstruction can be determined by CMR to differentiate acute versus chronic MI, as well as other causes of acute chest pain, including myocarditis.
Other Imaging Findings
After ruling out of ACS, rest/stress positron emission tomography (PET) or single-photon emission computed tomography (SPECT) myocardial perfusion imag-ing (MPI) are helpful for detection of perfusion abnormalities, measures of left ventricular function, and high-risk findings, such as transient ischemic dilation. For PET, calculation of myocardial blood flow reserve (MBFR, the ratio of peak hyperemia to resting myocardial blood flow) adds diagnostic and prognostic information over MPI. Radiation exposure dose is ∼3 mSv for rest/stress PET with Rb-82 and ∼10 mSv for Tc-99m SPECT.
Other Diagnostic Studies
Invasive Coronary Angiography (ICA) is used to determine the presence and severity of a luminal obstruction of an epicardial coronary artery, including its location, length, and diameter, as well as coronary blood flow. ICA provides the characterization of high-grade obstructive stenosis and possibility for percutaneous or surgical revascularization. (IFR and FFR) provide physiologic characteristic of stenosis. Radiation exposure to the patient during an interventional procedure varied 4 to 10 mSv and is dependent on procedural duration and complexity. The spatial resolution of ICA is 0.3 mm, so, visualization of arterioles (diameter of 0.1 mm) that regulate myocardial blood flow is impossible. Coronary vascular functional studies can be performed during coronary angiography. In normal coronary angiography there may be evident abnormal coronary vascular function. Assessment of coronary microcirculation and coronary vasomotion by coronary function testing are reasonable.
Treatment
Medical Therapy
A correct diagnosis of the underlying cause of the chest pain should be obtained prior to deciding on an appropriate treatment strategy. The most dangerous causes should be evaluated first. If myocardial infarction or ischemia is suspected, the immediate pharmacotherapies including morphine, oxygen, nitrate, aspirin, ACE inhibitors should be initiated.
Interventions
Common indications of coronary angiography in high risk ACS patients include new ischemic changes on the ECG, troponin-confirmed acute myocardial injury, new-onset left ventricular systolic dysfunction (ejection fraction <40%), and newly diagnosed moderate-severe ischemia on stress imaging. For high-risk patients presented with documented AMI and normal epicardial coronary arteries on CCTA or invasive coronary angiography, or nonobstructive CAD, CMR and echocardiography are useful for evaluation of nonischemic cardiomyopathy or myocarditis. Among high risk patients, invasive coronary angiography provides a comprehensive assessment of the extent and severity of obstructive CAD. The determination of the severity of anatomic CAD is critical to guide the use of coronary revascularization. Approximately 6% to 15% of troponin-positive ACS occurs in the absence of obstructive CAD. Additional testing may be helpful to determine the strategy of treatment. Evidence supports that CMR can identify wall motion abnormalities and myocardial edema and distinguish infarct-related scar from non-CAD causes such as myocarditis and nonischemic cardiomyopathy. Performing CMR within 2 weeks of ACS, can be useful to identify MI with nonobstructive CAD (MINOCA) from other causes. The term obstructive CAD indicates CAD with ≥50% stenosis. Nonobstructive CAD is used if CAD <50% stenosis. High risk CAD is defined in the presence of obstructive stenosis with left main stenosis ≥50% or anatomically significant 3-vessel disease (≥70% stenosis).
Surgery
Common causes of acute chest pain in the months after CABG include musculoskeletal pain from sternotomy( the most common cause), myocardial ischemia from acute graft stenosis or occlusion, pericarditis, pulmonary embolism, sternal wound infection , nonunion. Post-sternotomy pain syndrome is defined as discomfort after thoracic surgery, persisting for at least 2 months, and without apparent cause. The incidence of post-sternotomy pain syndrome is varied 7%-66% with a higher prevalence in women compared with men within the first 3 months of thoracic surgery but, after 3 months, postoperative sex difference in prevalence was not seen. Causes of Graft failure within the first year post-CABG using saphenous venous grafts are technical issues, intimal hyperplasia, thrombosis. Internal mammary artery graft failure within the first-year post-CABG is most commonly attributable to issues with the anastomotic site of the graft. Causes of acute chest pain several years after CABG include graft stenosis, occlusion or progression of disease in a non-bypassed vessel. One year after CABG, about 10%-20% of saphenous vein grafts fail. By 10 years, about half of saphenous vein grafts are patent. The internal mammary artery has patency rates of 90% to 95% 10 to 15 years after CABG. The use of radial artery grafts for CABG has a higher patency rate at 5 years of follow-up, compared with the use of saphenous vein grafts.
Primary Prevention
Make healthy lifestyle choices to prevent chest pain from heart disease: Achieve and maintain normal weight, Control high blood pressure, high cholesterol, and diabetes, avoid cigarette smoking and secondhand smoke, eat a diet low in saturated and hydrogenated fats and cholesterol, and high in starches, fiber, fruits, and vegetables, get at least 30 minutes of moderate intensity exercise on most days of the week, Reduce stress.
Secondary Prevention
Secondary prevention of chest pain depends on the cause for instance, risk factor modification remains essential part of the secondary prevention strategy in chronic stable angina. Secondary prevention of chest pain caused by GERD is avoiding food that worsens the symptoms, smoking cessation, weight loss, eating frequent meals, and head raising of the bed while sleeping.