Chest pain

In medicine, chest pain is a symptom of a number of conditions and is generally considered a medical emergency, unless the patient is a known angina pectoris sufferer and the symptoms are familiar (appearing at exertion and resolving at rest, known as "stable angina"). When the chest pain is not attributed to heart disease, it is termed non-cardiac chest pain.

Additional recommended knowledge

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Essential Laboratory Skills Guide

Causes

Cardiopulmonary

Important cardiovascular and pulmonary causes of chest pain:

• "Stable" Angina Pectoris - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense
• Acute coronary syndrome
  • "Unstable" Angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction
  • Myocardial infarction ("heart attack")
• Aortic dissection
• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.

Other causes

Other causes of chest pain include:

• Upper gastrointestinal ailments, for example:
  • gastroesophageal reflux disease (GERD) and other causes of heartburn
  • Hiatus hernia (which may not accompany GERD)
  • Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus
• Problems of outer chest structures
  • Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease, often called costochondritis
  • Spinal nerve problem
  • Fibromyalgia
  • Chest wall problems and breast conditions
  • Herpes zoster
• Psychological
  • Panic attack
  • Anxiety
  • Clinical depression
  • Somatization disorder
  • Hypochondria
• Others
  • Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
  • Da costa's syndrome
  • Bornholm disease - a viral disease that can mimic many other conditions
  • Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
  • Stooped posture (kyphosis) - re: The Posture Theory - postural compression of the chest causes occasional sharp stabbing pains between the ribs, and chest muscle cramps

High abdominal pain may also mimick chest pain.

Analysis

As in all medicine, a careful medical history and physical examination is essential in separating dangerous and trivial causes of disease, and the management of chest pain is often done on specialised units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection). Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.

An emergency medicine doctor will also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking, diabetes and other risk factors.

Features of the pain suggest of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; the pain coming upon exertion; dizziness; shortness of breath and a "sense of impending doom."

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

• X-rays of the chest and/or abdomen (CT scanning may be better but is often not available)
• An electrocardiogram (ECG)
• V/Q scintigraphy or CT Pulmonary angiogram(when a pulmonary embolism is suspected)
• Blood tests:
  • Complete blood count
  • Electrolytes and renal function (creatinine)
  • Liver enzymes
  • Creatine kinase (and CK-MB fraction in many hospitals)
  • Troponin I or T (to indicate myocardial damage)
  • D-dimer (when suspicion for pulmonary embolism is present but low)

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 ("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.

References

• Chun A, McGee S (2004). "Bedside diagnosis of coronary artery disease: a systematic review.". Am J Med 117 (5): 334-43. PMID 15336583.
• 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. Full text (PDF)
• Butler K, Swencki S (2006). "Chest pain: a clinical assessment.". Radiol Clin North Am 44 (2): 165-79, vii. PMID 16500201.
• Haro L, Decker W, Boie E, Wright R (2006). "Initial approach to the patient who has chest pain.". Cardiol Clin 24 (1): 1-17, v. PMID 16326253.
• Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain.". Clin Med 6 (5): 445-9. PMID 17080889.