Chest pain

Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.

Differential diagnosis

Causes of chest pain range from non-serious to serious to life threatening.^[1] DiagnosisPro lists more than 440 causes on its website.^[2]

Cardiovascular

• Acute coronary syndrome
  • Unstable Angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction.
  • Myocardial infarction ("heart attack")^[3]
• Aortic dissection
• Pericarditis and cardiac tamponade
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Stable angina pectoris - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense

Pulmonary

• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Pleurisy - an inflammation which can cause painful respiration

GI

• Gastroesophageal reflux disease (GERD) and other causes of heartburn
• Hiatus hernia
• Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus
• Functional dyspepsia

Chest wall

• Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
• Spinal nerve problem
• Fibromyalgia
• Chest wall problems
• Radiculopathy
• Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
• Breast conditions
• Herpes zoster commonly known as shingles
• Tuberculosis

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
• Carbon monoxide poisoning
• Sarcoidosis
• Lead poisoning
• High abdominal pain may also mimic chest pain

Diagnostic approach

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax and cardiac tamponade. By elimination or confirmation the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.^[1]

If acute coronary syndrome ("unstable angina") is suspected, many people are admitted briefly for observation, sequential ECGs, and determination of cardiac enzymes over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.

As in all medicine, a careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be 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.

A focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking, diabetes and other risk factors is useful.

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). Routine X-rays and CT may however not be needed.^[4]
• 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)
  • serum amylase to exclude acute pancreatitis

Management

In people with chest pain supplemental oxygen is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress.^[5][6] Entonox is frequently used by EMS personnel in the prehospital environment.^[7] There is however little evidence about its effectiveness.^[8][9]

Epidemiology

Chest pain is the presenting symptom in about 12% of emergency department visits in the United States and has a one year mortality of about 5%.^[10]

References