chest pain

Etiology

• Cardiovascular
  • myocardial ischemia*
    • pressure or squeezing pain
    • radiation to left arm
    • precipitated by exertion#
      • exercise
      • meals
      • emotion
      • straining on defecation
    • relieved by rest & nitroglycerin#
  • Prinzmetal's angina (coronary vasospasm)
    • chest pain at night or at rest
    • cocaine or amphetamines may induce coronary vasospasm in young patients with normal coronary arteries
  • myocardial infarction*
    • STEMI & NSTEMI
    • stress cardiomyopathy (broken heart syndrome)
      • post-menopausal women with severe emotional or physical stress
      • STEMI with normal coronary angiography
  • acute pericarditis
    • steady, crushing, substernal pain
    • pleuritic pain component aggravated by cough or deep inspiration
    • positional, relieved by sitting up, worse when supine
    • pericardial tamponade*
  • valvular heart disease
    • mitral valve prolapse
    • aortic stenosis
  • aortic dissection*
    • very severe pain, midline, radiation to back
    • ripping, tearing pain
    • not affected by changes in position
    • weak or absent peripheral pulses
    • especially Marfan syndrome
  • coronary artery dissection
    • peripartum chest pain
  • hypertrophic cardiomyopathy
• Pulmonary
  • pulmonary embolism*
    • pleuritic chest pain
    • hemoptysis
    • hypoxia, dyspnea
    • tachycardia
    • risk factors for venous thromboembolism
  • pneumothorax
    • tall, thin, young, male, smoker
    • sudden pleuritic chest pain, dyspnea
  • mediastinal emphysema
    • chest wall trauma, bronchoscopy, esophagoscopy
    • sharp, intense, substernal pain
    • audible crepitus
  • pleurisy
    • secondary to inflammation, less commonly tumor or pneumothorax*
    • generally sharp, unilateral, superficial
    • aggravated by cough & respirations
  • pneumonia
  • tracheobronchitis
  • lung cancer
• Esophageal pain:
  • esophagitis, GERD, esophageal spasms
  • esophageal rupture* & mediastinitis
  • additional symptoms of dysphagia, vomiting
  • may be relieved by antacids
• Rheumatologic (musculoskeletal)
  • costochondral pain
    • pain reproduced by pressure over painful area
  • chest wall pain
    • muscle or ligament strain from exercise
    • rib fracture
    • local tenderness
  • fibromyalgia
  • Tietze's syndrome (costochondritis)
  • arthritis: rheumatoid, osteoarthritis
• spinal disease
  • subacromial bursitis
• Neurologic
  • cervical or thoracic spine nerve root compression
  • intercostal neuritis (Herpes)
• Referred pain from abdominal disorders
  • peptic ulcer
  • hiatal hernia
  • pancreatitis
  • biliary colic due to cholecystitis or choledocholithiasis
  • colonic distension
• Inflammation or tumor of the breast
• Psychiatric disorders
  • panic disorder
  • anxiety
  • phobias, especially agoraphobia
  • depression
  • somatization
  • conversion
  • malingering
  • Munchausen's syndrome
  • hyperventilation
• idiopathic
  • most patients presenting with chest pain for the 1st time do not receive a diagnosis within 6 months

* potentially lethal conditions

# relief of pain with nitroglycerin NOT helpful in establishing etiology

History

• duration, location, radiation, character, intensity, rate of onset, relationship to activity, relief by nitroglycerin, rest, or antiacids, changes in frequency or severity of chest pain, occurrence during rest or sleeping, diaphoresis, nausea/vomiting, dyspnea at rest or on exertion, orthopnea, edema, palpitation, hemoptysis, dysphagia, cough, sputum, paresthesia, syncope, fever/chills, use of cocaine effect of: inspiration, cough, position, arm, chest or neck movement, eating, NSAIDs, alcohol, exertion

Clinical manifestations

• non cardiac chest pain may coexist with coronary artery disease
• features associated with likelihood of cardiac ischemia
  • exertional chest pain*
  • radiation of pain to either of both arms or shoulder pain
  • diaphoresis
  • nausea/vomiting
  • pressure-like pain
• features associated with a low risk of cardiac ischemia
  • age < 40 years
  • no new ST segment changes on EKG
  • pain reproduced by palpation
  • radiation of the pain to the back, abdomen or legs
  • pleuritic chest pain
  • a pain that is stabbing or sharp in nature
  • positional chest pain
  • inframammary chest pain
  • not associated with exertion
• findings helpful in establishing diagnosis
  • 4th heart sound
  • systolic click
  • murmur
  • friction rub with pericarditis
  • pain relief with change in position with pericarditis
  • cardiac risk factors: smoking, hypertension, diabetes, hyperlipidemia
  • chest pain occurring after meals or upon reclining suggests of gastroesophageal reflux
  • cough or respiratory tract symptoms suggestive of pulmonary disease
  • pain exacerbated by upper body movements in rheumatologic disease
  • pain characteristics suggesting aortic dissection
    • tearing or ripping sensation
    • pain starting at maximum intensity
    • radiation to back, abdomen or legs
  • pain, pressure, or tightness in the chest, shoulders, arms, neck,back, upper abdomen, or jaw, dyspnea & fatigue should all be considered equivalents of angina pectoris

* accuracy of most chest pain characteritics in the diagnosis of acute myocardial infarction (AMI) is low

• the association with exertion is a stronger indicator of AMI than association with dyspnea, pressure, or stress

Laboratory

• complete blood count (CBC)
• markers of myocardial infarction
  • emergency department or inpatient setting
  • sensitivity of negative markers is 98.8% for rule out MI increased to 99.6% for a 2nd set of markers 6 hours later
  • high-sensitivity cardiac troponins preferred standard
    • high-sensitivity cardiac troponin T in serum may reduce risk of major cardiac events in patients discharged from the emergency department
  • obtain cardiac troponin initially & after 1 hour
    • if cardiac troponin level does not significantly change after 1 hour admit/hold for observation*
• erythrocyte sedimentation rate if indicated
• rheumatoid factor if indicated

* if high-risk, treat as acute coronary syndrome

Diagnostic procedures

• electrocardiogram (EGG)
  • would seem indicated in all patients presenting to the emergency department with chest pain
  • likelihood of an acute coronary syndrome in patients with chest pain & a normal ECG is the same whether or not chest pain was present when the ECG was obtained
• percutaneous coronary intervention when ECG or biomarker testing is positive
• stress tests
  • graded exercise test with or without thallium or sestamibi scintigraphy
  • dipyridamole thallium test
  • exercise echocardiography
  • stress testing not beneficial in low-risk patients
• coronary CT angiography with better outcomes than stress testing
• psychometric testing if indicated

* non-invasive testing for acute chest pain in the ED (coronary CT angiography, treadmill test, stress echocardiography) is associated with longer hospital stays, but no better clinical outcomes beyond ECG & serum troponin-I

Radiology

• chest radiograph
• echocardiogram rarely appropriate
• coronary computed tomography angiography
  • suspected NSTEMI
  • cost-effective in 60 year old patients with non-acute chest pain & low to intermediate probability of coronary artery disease
  • not beneficial in low-risk patients
• triple-rule-out CT
  • evaluates coronary arteries, thoracic aorta, & pulmonary arteries
  • better sensitivity for pulmonary embolism, aortic aneurysm, & pneumonia than CT angiography
    • higher radiation dose (mean, 4.84 mSv higher)
    • larger contrast bolus (mean, 38.0 mL higher)

Complications

• patients presenting with chest pain for the 1st time who do not receive a diagnosis within 6 months are at increased cardiovascular risk in subsequent years

Differential diagnosis

• 6 potentially lethal conditions
  • acute coronary syndrome
  • aortic dissection
  • pericarditis with pericardial tamponade
  • pulmonary embolism
  • pneumothorax
  • esophageal rupture
• see etiology & also chest pain syndrome

Management

• general
  • directed at underlying etiology
  • shared decision-making
• a normal physical exam, electrocardiogram, & laboratory results do not rule out coronary artery disease
• identification of emergency room patients with chest pain eligibile for early discharge
  • TIMI risk score = 0
  • no new ischemic changes on electrocardiogram
    • no left bundle branch block
    • no cardiac pacemaker
  • normal laboratory markers of myocardial infarction (at least two measurements 3 hours apart)
    • serum troponin-I
    • serum creatine kinse MB
    • serum myoglobin
  • normal vital signs
  • hospital admission & cardiac stress testing not indicated
• exercise testing before discharge
  • not yet feasible in all hospitals
  • may increase downstream testing & treatment without reducing hospitalization for myocardial infarction
  • may not improve outcomes
• patients with coronary artery disease should be followed periodically for an indefinite period to assess progression of disease
• most patients with chest pain & angiographically normal coronary arteries continue to complain of chest pain
• proton pump inhibitor for unexplained chest pain effective in a minority of patients (NNT = 8) but recommended as empiric therapy for non-cardiac chest pain
• remove cardiac monitor if patient is pain-free with normal or nonspecific electrocardiogram
  • false alarms lead to alert fatigue & negatively impact patient safety & satisfaction
• several scoring systems & web-based tools described
  • emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP)
    • uses age, sex, patient history, presenting signs & symptoms, electrocardiogram, serum troponin I or serum troponin T at 0 & 2 hours
    • score range: -10 to 34
    • score < 16 in a stable patient with a nonischemic ECG & nonelevated serum troponin I or serum troponin T is considered low risk
  • Heart score performs well (free online calculator)
  • for low-risk chest pain in the emergency department (normal ECG & initial serum troponin-I) shared decision-making usinga web-based tool can help reduce admissions for cardiac testing

Notes

• rate of MI is 2% within 6 months of emergency department visit for chest pain
• rate of MI does not differ according to whether or not a cardiac stress test is done
  • patients having a cardiac stress test are more likely to undergo coronary angiography
• non-cardiac chest pain rather than atypical chest pain is the preferred descriptor if heart disease is not suspected

More general terms

• pain [odyn-]

More specific terms

• angina pectoris
• pleuritis (pleurisy)
• pleurodynia
• sternalgia (sternodynia)
• xiphoidynia (xiphoidalgia)

Additional terms

• chest pain syndromes
• Women's Heart Attack Signs/Symptoms

Patient information

chest pain patient information