Chest Pain

Disorders that affect thoracic or abdominal organs — the heart, pleurae, lungs, esophagus, rib cage,
gallbladder, pancreas, or stomach — are typical causes of chest pain. It can also result from a musculoskeletal or hematologic disorder, anxiety, and drug therapy. Chest pain is an important indicator of several acute and lifethreatening cardiopulmonary and GI disorders.

The onset of chest pain can be sudden or gradual, and its cause may initially be difficult to ascertain. Chest pain can radiate to the arms, neck, jaw, or back. It can be steady or intermittent, mild or acute. And it can range in character from a sharp shooting sensation to a feeling of heaviness, fullness, or even indigestion. Chest pain can be provoked or aggravated by stress, anxiety, exertion, deep breathing, or eating certain foods.

Act Now: Sudden, severe chest pain requires prompt evaluation and treatment because it may herald a lifethreatening disorder. (See Managing severe chest pain, pages 76 and 77.) Standardized algorithms are used to address the treatment regimen of the patient with chest pain. Determine the time of onset and whether it was sudden or gradual. Ask the patient about precipitating, alleviating, or aggravating factors, if the pain radiates, and associated signs and symptoms. Ask him to rate the pain using a standardized pain rating scale. Obtain a 12-lead electrocardiogram (ECG) and a blood sample for serum testing. Administer oxygen through a nasal cannula. Place the patient on a cardiac monitor and establish I.V. access. If test results indicate an acute myocardial infarction (MI), the patient will require emergency percutaneous coronary intervention or fibrinolytic therapy. Be prepared to administer emergency care if the patient experiences cardiopulmonary arrest.

Differential Diagnosis of Chest Pain Cardiovascular
1. 2. 3. 4. 5. 6. 7. 8. 9.

Typical angina pectoris Prinzmetal’s or variant angina Unstable or accelerating angina Acute myocardial infarction Aortic dissection Mitral valve prolapse Pericarditis Dressler’s syndrome Postpericardiotomy syndrome 1

Pulmonary
1. 2. 3. 4. 5.

Pleuritic chest pain Pneumonia Pulmonary embolism Pulmonary hypertension Spontaneous pneumothorax

Gastrointestinal
1. 2. 3. 4. 5.

Reflux esophagitis Esophageal spasm/angina Peptic ulcer Pancreatitis Cholecystitis

Musculoskeletal disorders
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Costochondritis Tietze’s syndrome Rib fracture or trauma Cancer metastsis Sternoclavicular arthritis Painful xiphoid syndrome Fibromyalgia Traumatic muscle pain Shoulder arthritis/bursitis Cervicothoracic nerve root compression Thoracic spine arthritis Throracic outlet syndrome

Miscellaneous
1. 2. 3. 4. 5.

Herpes zoster Anxiety/depressive disorder Panic disorder Cocaine use Post coronary artery bypass pain

Many causes of chest pain arise from the pleura. Pneumonia with pleurisy, empyema, pulmonary infarction, and neoplasms of the pleura must be considered. Tuberculous pleurisy and other infectious agents are not uncommon. On the other hand, conditions of the lung are less likely to cause chest pain unless they involve the pleura: This is certainly true of pneumonia and neoplasms. A pneumothorax, however, is a very common cause of chest pain, especially in young adults.

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Visualize the heart and the pericardium comes to mind. This is a source of chest pain in acute idiopathic pericarditis, rheumatic carditis, and tuberculous and neoplastic pericarditis. The myocardium is the source of the most serious form of chest pain, myocardial infarction, but here again the pain is more severe if the pericardium is involved. Angina pectoris and chronic coronary insufficiency are common causes of chest pain arising from the myocardium. Myocarditis (e.g., viral) causes less severe pain, but inflammation of the myocardium from postinfarction syndrome or postpericardiotomy syndrome can be extremely painful.

Now visualize the other central structures: The esophagus reminds one of reflux esophagitis and hiatal hernia, the mediastinum suggests mediastinitis and substernal thyroiditis or Hodgkin disease (usually not too painful), the aorta suggests dissecting aneurysms, and the thoracic spine suggests spinal cord tumors, osteoarthritis, Pott disease, fractures, herniated discs, as well as the other conditions listed in Table 14.

This chapter would not be complete unless referred pain to the chest was considered. Thus, abdominal conditions such as cholecystitis, pancreatitis, and splenic flexure syndrome may present with chest pain. Conditions of the neck that press the cervical nerves may also cause chest pain, particularly scalenus anticus syndrome, cervical ribs, and herniated discs of the cervical spine:

Neurocirculatory asthenia is associated with atypical chest pain; a psychiatric evaluation will assist in this diagnosis.

Approach to the Diagnosis
A possible myocardial infarction must be the first consideration in all adults with acute chest pain especially if there are significant alterations of the vital signs. Consequently, serial ECGs, serial cardiac enzymes, and hospitalization will often be necessary. Once this condition has been excluded, we can turn our attention to the other possibilities. Arterial blood gases, chest x-ray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may be necessary in some cases. A chest x-ray may be ordered to rule out pneumonia. Acute chest pain related to esophagitis is often relieved by swallowing lidocaine viscus, an extremely useful tool in the differential diagnosis. Relief of the pain with nitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of the costochondral junctions with relief on lidocaine injection into the point of maximum tenderness suggests Tietze syndrome (costochondritis). In cases of chronic chest pain, an exercise tolerance test with thallium scan should be done to rule out coronary insufficiency or myocardial infarct. It may be wise to do immediate coronary angiography if the condition deteriorates so that balloon angiography, bypass surgery, or reperfusion therapy may be initiated. Dissecting aneurysm is revealed by CT scan or MRI of the chest.

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Myocardial infarction
Crushing substernal pain radiating to left arm, shoulder blades, and neck; feeling of impending doom; nausea; shortness of breath; sweating; ST-segment changes on electrocardiogram; elevated serum CK-MB and troponin-I levels

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Other Useful Tests
1. 2. 3. 4. 5. CBC Sedimentation rate (pneumonia, infarction) Sputum smear and culture (pneumonia) Bernstein test (reflux esophagitis) Serum cardiac troponin levels [myocardial infarction (MI)] d-Dimer testing (pulmonary embolism) Esophagoscopy (reflux esophagitis) X-ray of the spine (radiculopathy) Echocardiogram (pericarditis)

6.
7. 8. 9.

10. 24-hour Holter monitoring (coronary insufficiency) 11. Gallbladder sonogram

12. Ambulatory pH monitoring (esophagitis) 9

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