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ThePatientWithChestPain
W.StevenPray,PhD,DPh
USPharmacist.200732(2)

Introduction
Pharmacistsareinauniquepositionwithinthehealthcarecommunity.Patientsfeelfreetoquestionpharmacists
aboutvarioussymptomstheyortheirfamilymembersareexperiencing.Manycomplaintsaretrivialandeasilytreated
withnonprescriptionproducts,butsomearepossiblemanifestationsofseriousdisease.Chestpain(usuallyinthe
substernalarea)isoneofthelatter,asitmayindicatecardiacpathology,andheartdiseaseistheleadingcauseof
deathintheUnitedStates. [1]
Prevalence

Chestpainisexperiencedby25%ofpeopleintheU.S. [2]Atleast1%to2%ofvisitstophysiciansarecausedby
concernaboutchestpain. [1,3]Chestpainisresponsiblefor5.5to5.8millionvisitstoemergencyroomseachyear. [4]
Despitethepotentialgravityofthissymptom,perhaps77%ofpatientswhoexperienceitrefusetomakean
appointmentwithaphysician. [5]
CardiacVersusNoncardiacChestPain

Chestpainhasanextensivedifferentialdiagnosis.Thetypicalpatientwiththefirstboutofchestpainimmediately
fearstheonsetofcardiacpathology,suchasischemiccardiacdisease,butonly11%to39%ofthesepatientsare
eventuallyfoundtohavecoronaryarterydisease. [2]Furthermore,onlyabout45%to50%ofpatientsvisitingemergency
roomsforchestpainactuallyhavecardiacrelatedchestpain. [2,3]Thebalanceofpatients(50%to55%)experience
noncardiacchestpain. [5]
Therelativerisksofeithercardiacornoncardiacchestpainaremarkedlydifferentwhenpatientspresentingto
emergencydepartmentsandthoseseeninoutpatientprimarycareareexaminedseparately.Inemergencycare
patients,overhalfofthosewithchestpainreceiveadiagnosisofmyocardialinfarction,angina,pulmonaryembolism,
andheartfailure. [1]Inoutpatientprimarycare,ontheotherhand,themostcommoncauseisgastroesophagealreflux
disease(GERD),followedbymusculoskeletalconditions,othergastrointestinalconditions,psychiatricconditions(e.g.,
panicdisorder),pulmonarydisease,orstablecoronaryarterydisease. [1,6]Someoftheconditionscausingchestpain
arelessseriousbutstillrequirephysiciandiagnosis(e.g.,GERDuncontrolledbynonprescriptionproducts,panic
disorder,pepticulcerdisease,chestwallpain).Othersposegreaterrisktothepatient'slife,suchasstableorunstable
coronaryarterydisease,pulmonaryembolism,andpneumonia.Virtuallyallrequirephysicianreferral.Thesole
exceptionmightbeheartburnorgastroesophagealreflux,potentiallyselftreatablewithomeprazole,H2antagonists,or
antacids,assumingallFDArequiredlabelsarefollowedclosely.
ChestPainRequiringEmergencyCare

Severalpotentialcausesofchestpainrequireemergencycare, [7]whichareincludedhereinordertostressthatall
requireanimmediatephysicianvisit.Onesuchdiagnosisisacutecoronarysyndrome,includingacutemyocardial
infarctionandunstableanginabothrequireanelectrocardiogramfordiagnosis.Typicalanginalpainhasthree
characteristics:Itissubsternal,itisbroughtonbyexertion,anditisrelievedbyeitherrestornitroyglycerin. [1]Anginal
painisalsobrief,withadurationoffiveto15minutes. [4]Amyocardialinfarctionismorelikelyifthepatienthas
diaphoresis,painradiatingtobotharms,andlowbloodpressure. [1]Alternatively,thepatientmayhaveahypertension
inducedaorticdissection,inwhichthereisatearinanaorticwall.Thechestpainofaorticdissectionisaripping,
tearing,orknifelikepainthatbeginssuddenlyatpeakintensity,alongwithneurologicalorpulseabnormalities. [1,4]
aorticdissectionmaybetreatedwithmedicationorsurgery,dependingonthenatureofthetear.
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Chestpaincanbecausedbyacutepericarditis,perhapsfollowingaviralillness.Inthiscondition,chestpainradiatesto
theback,neck,orshouldersandoftenworsenswhenthepatientinhales.Itimprovesifthepatientsitsuprightorleans
forward.Thepainistraditionallyaccompaniedbydyspneaandfever.
Pulmonaryembolismmaycauseasuddenonsetofpleuriticchestpain. [4,7]Additionalmanifestationsarefatigue,
dyspnea,fainting,spittingupblood,andcardiacarrest.AnEKGhelpsconfirmthediagnosis.
Pneumothoraxisapotentialcauseofpleuritic,sharp,andsuddenchestpain,usuallyaccompaniedbyshortnessof
breath. [7]Patientsoftenhaveahistoryofcigaretteuseorhavechronicobstructivepulmonarydisease. [8]
Severechestpaincanoccurfollowingperforationoftheesophagus,mostofteninpatientsages63to71. 7Additional
manifestationsincludevomiting,shortnessofbreath,dyspnea,cough,fever,andabdominalpain.AchestXray,
endoscopy,orotheremergencydiagnosticprocedureisneededtoconfirmperforationpromptconfirmationcanbe
lifesaving.
Approximately5.6millionindividualseachyearintheU.S.contractcommunityacquiredpneumonia,anotherpotential
diagnosisforthosewithchestpain. [9]Pneumoniapainmaybepleuritic,sharp,dull,orsubsternal. [7]Other
manifestationsaredyspnea,fever(over100.4F),malaise,fatigue,cough(productiveornonproductive),alteredbreath
sounds,wheezing,andrales. [4,7]AchestXray,CATscan,orbronchoscopycanconfirmthisdiagnosis,allowingthe
cliniciantobeginantibacterialtherapy.

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Figure1.

NonemergencyChestPain

Thereareothercausesofchestpainthatrequirephysiciancare,althoughanimmediatevisittotheemergencyroomis
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notnecessary.Theseincludepanicdisorder,depression,variousgastrointestinaldiseases,chestwallsyndrome,and
nerverootcompression. [6,7]Panicdisordercausesabroadsetofsymptomssuchaspalpitations,diaphoresis,tremor,
dyspnea,choking,nausea,dizziness,fearoflosingcontrolordying,tinglingoftheextremities,hotflashes,andchills.
Somegastrointestinalconditionsthatcancausechestpainarereflux,spasmoftheesophagus,pancreatitis,and
pepticulcer.Iftheproblemisduetoreflux,thepatientwillalsodescribethepostprandialsensationoffoodmoving
upwardfromthestomach. [1,4]Chestwallpainisoftenacute,localized,andsharp,worseningwithmovementoradeep
breath,anddyspneaisoftenpresent. [1]Patientswithchestwallpainmayhaveahistoryofrheumatoidarthritisor
osteoarthritis. [1]Ifthecervical/thoracicnerverootsbecomecompressed,theycauseananginalikepainthatisworseif
thepatientmovestheneck,coughs,orsneezes.
ChestPaininYoungAthletes

Pharmacistsareoccasionallyapproachedbyaworriedyoungathleteorhisorherparent(s).Inatypicalscenario,the
youthhasexperiencedsubsternalchestpainduringanathleticevent. [10]Thefamilyisunderstandablybewildered,
sincepriortotheepisode,theyouthappearedtobeatthepeakofability,inexcellentshape,andwithnoapparent
healthproblems.Undoubtedly,thepatientwasclearedforexercisebyaphysician.Thefamilymaybeinthemidstof
recriminationsandguiltforallowingtheyouthtoengageinsportsinthefirstplace,supposingthattheyouthhasnow
developedaseriouscardiacconditionasaresult.

Figure2.

Theprognosisisactuallyquitefavorable,becauseonlyaboutadozenyoungathletesdieeachyearfromundetected
cardiacdisease.Inthosewhodo,theprobablecausesarerareconditions,suchashypertrophiccardiomyopathyor
congenitalcoronaryarteryanomalies. [10]Thelowriskofseriouspathologyislargelymisunderstoodbythelaypublic,
asthefewunfortunatesuddendeathsinyoungathletesseemtogarnerwidespreadpublicity.Firstandforemost,the
pharmacistmusturgethefamilytovisitaphysician.Themostfrequentdiagnosisisexerciseinducedasthma,andthe
mostcommonvenueforitsoccurrenceisacold,dryambientenvironment,suchasahockeyrink.Thepatientmay
havealsoexperiencedgastroesophagealreflux,aproblemforthoseengaginginsportswithpronouncedvertical
movement,suchasrunningandjumping.Thecausemayalsobethewellknown"stitch"intheside.Thisisacommon
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painlocatedoverthelowerleftribcageitmaybecausedbystrainoraspasmofthemusclessupportingthe
diaphragm.
CocaineInducedChestPain

Chestpainistheleadingmedicalcomplaintamongcocaineabusers.Inurbanareas,itisthoughttoberesponsiblefor
14%to25%ofchestpainepisodestheestimateinsuburbanareasisonly7%. [11]However,patientsarenotlikelyto
revealahistoryofillicitdrugabusetothepharmacistorphysician.
Conclusion

Pharmacistsarelikelytobeapproachedbypatientswhocomplainofchestpain.Thedifferentialdiagnosisofchest
painisextensive,includingmanylethaldiagnoses.Invirtuallyeverycase,theprudentpharmacistwillencouragethe
patienttoseekemergencymedicalcare.
References

1. CayleyWEJr.Diagnosingthecauseofchestpain.AmFamPhysician.200572:20122021.
2. KachintornU.Howdowedefinenoncardiacchestpain?JGastroenterolHepatol.200520Suppl:S2S5.
3. ShepsDS,CreedF,ClouseRE.Chestpaininpatientswithcardiacandnoncardiacdisease.PsychosomMed.
200466:861867.
4. ReigleJ.Evaluatingthepatientwithchestpain:Thevalueofacomprehensivehistory.JCardiovascNurs.
200520:226231.
5. EslickGD,CoulshedDS,Talley.Diagnosisandtreatmentofnoncardiacchestpain.NatClinPract
GastroenterolHepatol.20052:463472.
6. FassR,DickmanR.Noncardiacchestpain:Anupdate.NeurogastroenterolMotil.200618:408417.
7. RingstromE,FreedmanJ.Approachtoundifferentiatedchestpainintheemergencydepartment:Areviewof
recentmedicalliteratureandpublishedpracticeguidelines.MtSinaiMed.200673:499505.
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obstructivepulmonarydisease.AmJMed.2006119(Suppl1):3845.
9. LutfiyyaMN,HenleyE,ChangLF,etal.Diagnosisandtreatmentofcommunityacquiredpneumonia.AmFam
Physician.200673:442450.
10. RowlandTW.Evaluatingcardiacsymptomsintheathlete:Isitsafetoplay?ClinJSportMed.200515:417
420.
11. JonesJH,WeirWB.Cocaineinducedchestpain.ClinLabMed.200626:127146.
12. CavaJR,SaygerPL.Chestpaininchildrenandadolescents.PediatrClinNorthAm.200451:15531568.
ReprintAddress
Tocommentonthisarticle,contacteditor@uspharmacist.com.
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