3. Chest pain is one of the most common complaints in the acute care setting.

Major causes of
acute chest pain include cardiac, gastro esophageal, musculoskeletal, pulmonary, and
psychology. The causes of ischemic include coronary artery disease, aortic stenosis, coronary
artery spasm, and hypertrophic cardiomyopathy. On the other hand, the causes of
nonischemic include pericarditis, dissecting aortic aneurysm, and mitral valve prolapse. The
chest pain of aortic stenosis is typically exertional, syncope-related and there is ejection
systolic murmur. Cardiomyopathy results in chest pain with systolic murmur which is louder
if patient carry out valsalva maneuver. Coronary vasospasm causes resting chest pain.
Patients with aortic dissection typically complain of acute severe anterior chest pain that
radiates to the upper back region. The pain usually is alleviated by sitting forward. The pain
from mitral valve prolapse is usually sharp in quality. Late systolic murmur proceeded by
midsystolic click are typical. The causes of noncardiac chest pain are esophageal disorder,
conditions of the upper abdomen, pulmonic, musculoskeletal, herpes zoster, and
psychological. Upper abdominal conditions include acute cholecystitis, acute pancreatitis,
and perforated peptic ulcer. Chest pain associated with pulmonary diseases frequently is
described as pleuritic in nature. Palpation of the chest may reproduce musculoskeletal chest
pain. Herpes zoster can present as acute chest pain. The pain associated with herpes zoster
usually is located in a unilateral dermatomal distribution. Psychological chest pain is
suspected if there is history of emotional disorder.

Chest pain is one of the most common complaints in acute care. Causes of acute chest pain:
cardiac, gastroesophageal, musculoskeletal, and pulmonary. Heart disease is one of the
leading causes of death in the United States (Bernard et al., 2004), therefore cardiac causes
are important in acute chest conditions.

Often, it is worth noting that noncardiac causes can be fatal. Highly developed technology,
careful history and physical examination are still a deep component in patients with. Pain
characteristics, location range, duration, radiation, and quality and accompanying symptoms
are important to explore. This article discusses key clinical signs that can help distinguish the
main causes of acute chest pain with emphasis on history and physical examination
(Braunwald et al., 2001).

CAUSE OF PAIN CARDIAK IN ACUTE

The causes of acute chest pain in the chest include ischemic and non-cinematic conditions
(Table-1). Ischemic causes include coronary heart disease, aortic stenosis, coronary artery
spasm, and hypertrophic cardiomyopathy. Non-anemic causes include pericarditis, aortic
dissection, aortic aneurysm, and mitral valve prolapse. Know the presence of cardiovascular
risk factors such as hypertension, diabetes, hyperlipidemia, smoking, and an important family
history in the history of patients with acute chest pain (Braunwald et al., 2001).

Coronary heart disease

Coronary heart disease can be classified into chronic coronary heart disease, acute coronary
syndrome, and sudden death. Clinical coronary heart disease varies, ranging from
asymptomatic to fatal (Carmel et al., 2009). Angina pectoris is a cardiac chest pain caused by
myocardial oxygen supply insufficiency (Cristina et al., 2010). Patients often express feelings
of heavy or squeezed loads that arise after activity or emotional stress. Complementary
symptoms include diaphoresis, nausea, vomiting, and weakness. Chest pain and diaphoresis
are the two most common symptoms of myocardial infarction (Dharmarajan et al., 2003).
The Levine sign, in which the patient puts his fist on the sternum while attempting to describe
his chest pain is also a sign of ischemic pain (Gillick, 2000; Horne et al., 2000).

Acute coronary syndrome is the terminology used to describe the end result of acute
myocardial ischemia. Acute coronary syndromes consist of unstable angina pectoris, Non-ST
Segment Elevation Myocardial Infarction (NSTEMI), and ST Elevation Myocardial
Infarction (STEMI). Acute coronary syndromes can be life-threatening, therefore effective
diagnosis and management is needed (Carmel et al., 2009).

Based on the study of Dharmarajan et al, evaluating the symptoms of 88 patients with acute
myocardial infarction, 78% of patients reported diaphoresis, 64% reported chest pain, 52%
reported nausea, 47% reported breathlessness. According to Kannel and Abbott (1984) it
should be noted that 25% of myocardial infarction incidents are not recognized by patients,
and this is found in electrocardiographic (ECG) examinations. Unconscious infarction may
be a silent (asymptomatic) infarct or an infarction with atypical symptoms that are different
from angina patients (Kannel and Abbott, 1984).

Many patients are late to the Emergency Department (IGD). This is because the patient has
many symptoms that are not chest pain. Dharmarajan et al. (2003) suggested an average time
delay of 7.3 hours in the first-time myocardial infarction patient. Initial symptoms and the
location of myocardial infarction are correlated with coronary arteries (Kiyici et al., 2001).
There are 3 locations of infarcts, among others, anterior, lateral, and inferior. Chest pain is
the most common symptom without depending on the location of the infarction. Anterior
infarction often causes shortness of breath from left ventricular disorders. Inferior infarction
often causes nausea, vomiting, diaphoresis, and hiccups. The vagus nerve has the role of
inducing nausea and vomiting in inferior infarction patients. Lateral infarction often causes
left arm pain (Braunwald et al., 2001).

Aortic Stenosis

Causes of aortic stenosis include congenital bicuspid valve, aortic sclerosis, rheumatic fever
(Lange and Hillis, 2001). Coronary heart disease often coexists with aortic sclerosis. Chest
pain of aorta stenosis depends on activity. Signs and symptoms of heart failure can also be
found. Syncope is a further symptom and associated with activity. On physical examination
the systolic ejection murmur is most clearly heard in the right second intercostal space that
radiates to the carotid (Carmel et al., 2009). Splitting the second heart sound paradox can also
be found in aortic stenosis. Pattern of late and low amplitude carotid pulse rate. Other signs
are the presence of heaving in the heart apex and thrill in the right second intercostal space
(Braunwald et al., 2001).

Hypertrophy Cardiomyopathy

Interventricular septal hypertrophy in hypertrophy cardiomyopathy causes left ventricular

flow obstruction. The most common symptoms of hypertrophic cardiomyopathy are dyspnea
and chest pain. The reduction in left ventricular filling known as diastolic dysfunction causes
dyspnea (Lange and Hillis, 2001). Syncope also often encountered and influenced activity.
On physical examination, systolic murmur develops harder on Valsalva maneuver, heart
sound (S4), bifid carotid beat, and triple apical pulse due to S4 and midsystolic pressure gap.
Chest pain in hypertrophy-like cardiomyopathy resembles angina (Braunwald et al., 2001).

Coronary vasospasm
Angina Prinzmetal or variant angina is due to coronary vasospasm. This disease is more
common in women under 50 years and usually occurs early in the morning, when just getting
up. Patients experience recurrent ischemic chest pain that is different from typical angina
because it is felt at rest. Coronary spasms can be seen clearly in angiography (Braunwald et
al., 2001).
When patients at low or no risk of atherosclerosis experience nontraumatic chest pain, the
examiner should suspect cocaine consumption. Cocaine can inhibit coronary artery
vasoconstriction and the risk of myocardial infarction depending on the amount of
consumption. Myocardial infarction or myocardial ischaemia caused by cocaine usually
occurs within 1 hour after consumption (Braunwald et al., 2001).

Aortic dissection

Patients with aortic dissection usually complain of severe acute anterior chest pain radiating
backward. Marfan syndrome is one of the causes of dissection of aortic aneurysms (Lange
and Hillis, 2001). Hypertension is common and is a risk factor. Type A dissection occurs in
the ascending aorta, whereas type B occurs in the distal artery of the left subclavian. Physical
examination shows the presence of aortic insufficiency murmurs. Intensity of radial artery
pulses may vary (Carmel et al., 2009).

Pericarditis
Pericarditis can be caused by viral infections, tuberculosis, autoimmune diseases, gamma,
uremia, radiation, and after myocardial infarction (Dressia Syndrome) (Mia et al., 2010).
Cocksackie and echovirus are the commonest causes. Chest pain pericarditis resembles
pleural chest pain. Pain is usually reduced when the patient sits and leans forward and usually
increases when the patient is supine. Fever is a common comorbid symptom. Friction rub is a
major sign of pericarditis (Braunwald et al., 2001).

Mitral Valve Prolapse

Chest pain of the mitral valve prolapse patients is sharp in the apex. Other accompanying
symptoms include dyspnea, fatigue, and palpitations. Patients will feel less pain when lying
on their back. Physical examination shows a final systolic murmur preceded by a clear
midsystolic click on the apex (McGinnis and Foege, 1993). Murmurs get harder when the
patient stands up. Most patients with mitral valve prolapse are thin women (Braunwald et al.,
2001).

NONCARDIAC CAUSE IS ON ACUTE

Acute noncardiac chest pain is common in the general population. A study in China
examined chest pain from 2,209 residents. The results showed chest pain that occurred in
20.6% of the population, and 68% of whom were noncardiac acute chest pain (Michael et al.,
1994). More than half of patients with non-cardiac chest pain feel unconvinced that their
chest pain is not from the heart. In addition, the anxiety of these patients often exceeds
patients with acute chest pain in the heart (Owens, 1986).

CAUSES OF GASTROESOFAGEAL PAIN PAD

According to Fruergaard et al., Gastroesophageal disease is the most common cause of chest
noncardiac pain, reaching 42%. Gastroesophageal diseases that result in acute chest pain
include esophageal perforation, esophageal spasm, esophagitis reflux, peptic ulcer,
pancreatitis, and cholecystitis (Owens, 1986).

Ephthalgia Disorders

Esophageal perforation may be caused by iatrogenic instrument use, severe vomiting, and
esophageal disease (eg, esophagitis or neoplasm). Esophageal erosion occurring at the
endoscope reaches 10-70% of patients with noncardiac chest pain. Esophageal perforation
patients complain of severe, abrupt, and persistent pain from the neck to an aggravated
epigastrium by swallowing. Physical examination indicates a neck swelling and subcutaneous
emphysema is clearly felt as crepitation. This is due to the air seeping into the mediastinum
and surrounding tissues. Pleural effusions can also be found (Braunwald et al., 2001).

Oesophageal spasms are often difficult to distinguish from cardiac ischemic chest pain
because they are also lost or reduced by nitrate. However, chest pain of esophageal spasm is
not affected by activity. Swallowing cold or warm food can trigger spasm (Owens, 1986).

Reflux esophagitis is the leading cause of noncardiac chest pain originating from the
esophagus (Horne et al., 2000). It is often described as a burning sensation, a symptom
associated with heartburn or pyrosis. Pyrosis is triggered by lying down and worsening after
eating. Other accompanying symptoms include chronic cough and dysphagia. Patients also
complain of a bitter taste in the mouth which is the contents of the stomach (Owens, 1986).

Ezephagitis is also associated with infections such as Candida albicans. A history history of
HIV infection or chemotherapy increases assumptions toward Candida esophagitis
(Braunwald et al., 2001). Trush can be not or seen on physical examination. Trush occurs in
the inner cheek mucosa membranes, tongue, palate mole and other oral surfaces and appears
as gray-white pseudomembranes, mostly consisting of pesudomiselium and peeling
epithelium, and there is only minimal erosion of the membrane . Patients also complain of
swallowing pain (odynophagia) (Owens, 1986).

Other causes of esophagitis include several drugs such as nonsteroidal anti-inflammatory and
alendronate. Actually all pills can trigger esophagitis if not accompanied by enough water,
but alendronate get special attention. Alendronate should be drunk with 150-250 cc of water
standing (Rajni, 2009). Chemical osophagitis due to ingestion of caustic substances should
also be considered as a cause (Braunwald et al., 2001).

Top Abdominal Condition

Top abdominal conditions include cholecystitis, acute pancreatitis, and perforation of peptic
ulcer may mimic the signs and symptoms of an inferior myocardial infarction or mychemia.
The upper abdominal condition should be considered as one of the causes of lower chest
pain. The Murphy sign, which is a sign of acute cholecystitis, can be demonstrated by
instructing the patient to take a deep breath while doctors palpate the right subcostal region.
The cessation of inspiration due to pain is a positive result of Murphy's sign. Acute
pancreatitis causes persistent pain in the epigastric region. Alcoholic history, cholinasis, and
hypertriglyceridemia increase suspicion of acute pancreatitis. Peptic ulcer perforation patients
generally suffer from severe epigastric pain. Signs of peritonitis, such as hard stomach-like
boards, may soon be found in patients with peptic ulcer perforation (Braunwald et al., 2001).

CAUSES OF PULMONAL PAIN PAD

Chest pain is often associated with lung disease has the nature of pleural pain. Pleural pain
terminology implies that pain changes according to the respiratory cycle (increased when
inspired and decreases when expiratory). Pleural pain is sharp and unilateral. Pleuritis is the
classic cause of pleural pain. Pleuritis is caused by acute inflammation of the pleura. Pleuritis
is commonly caused by lower respiratory tract infections. Another cause of pleuritis is
autoimmune disease. Pain is sharp and increases when coughing, breathing in, or moving.
Pleural friction rub is usually heard with auscultation. Other lung causes are spontaneous
pneumothorax, pulmonary embolism, pneumonitis, bronchitis, and intrathoracic neoplasms
(Braunwald et al., 2001).

Spotant pneumothorax produces sharp pain that radiates to the ipsilateral shoulder.
Spontaneous pneumothorax may occur in patients with pulmonary disease such as
emphysema. Usually this disease concerns tall, thin men, and smokers. Physical examination
showed a loss of breath and hypersonic sounds from ailing lung (Braunwald et al., 2001).

Pulmonary embolism is suspected in acute dyspnea, pleural chest pain, severe hypoxia, and
risk factors such as recent surgery history, malignancy, prolonged bed rest, or lazy life
attitudes (Ronnie and Tomas, 2008). Most pulmonary embolism is derived from lower
extremity thromboembolism. Stein et al. found the most common symptoms of dyspnea
(73%), pleural pain (28%), hemoptysis (13%). Physical examination showed ronchi (51%)
and tachycardia (30%) (Schlant et al., 1994).

OTHER CAUSE OF chest paint

Musculoskeletal causes

Based on Fruergaard et al, chest wall pain reached 28% of all causes of noncardiac chest pain
in Coronary Care Unit patients. The musculosketal causes (chest wall) of acute chest pain
include co-cytostritis (Tietze Syndrome), caused by inflammation of the costochondral
junction; rib fracture, and myalgia. For patients with chest wall pain, chest palpation can
trigger pain. Passive vertebral movements such as flexion, extension, and rotation of the
thoracic and cervical vertebrae can also cause pain (Smith, 2000).

Fibromialgia is a syndrome of regional muscular pain, fatigue, and sleep disorders

characterized by pain in the palpation of sick areas. The pathophysiology of fibromyalgia
remains unclear, but includes long-term hypersensitivity. This is the form of allodynia (a pain
induced by nonnoxious stimuli), hyperalgesia (a more severe and longer-lasting pain
response) (Wai et al., 2004).
Herpes Zoster

Herpes zoster can cause acute chest pain. The pain caused by herpes zoster resembles a
burning sensation and follows the unilateral dermatomal distribution of the affected part.
Physical examination is not found to be specific because pain usually arises before a
vesicular lesion. This complicates the diagnosis (Yanerys and Leonard, 2010).

Psychological

Panic attacks can cause acute chest pain. Pain may be depressed, stabbed, often accompanied
by shortness of breath and lasts 30 minutes or more. This pain is not related to the activity
and from the history can be obtained history of previous emotional disturbance (Wai et al.,
2004)

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