Chest Pain

 Chest pain originates from one of the

organs in the chest (heart, lung, or
esophagus) or from the components of
the chest wall (skin, muscle or bone).
Or organs close to the chest, such as
the gall bladder or stomach.

Severity doesn’t indicate

seriousness.
WHAT LIES IN THE CHEST?
 SKIN
 MUSCLES
 BONES
 JOINTS
 HEART AND VESSELS
 LUNGS AND AIRWAYS
 ESOPHAGUS
 NERVES
 [ETIOLOGIES]
Chest diseases ：
 1 ． Musculoskeletal of Chest :
 Trauma 、 inflammation 、 tumor
 Costochondritis 、 fracture 、
 intercostal neuritis ， herpes
zoster （ shingles ）
 2 ． Cardiovascular diseases ：
 CHD ： MI ， Angina pectoris ；
 Myocarditis 、 pericarditis ；
 AD aortic dissection 。
 3 ． Pulmonary diseases ：
 Pleuritis 、 mesothelioma 、 pneumothorax ；
 pneumonia 、 lung cancer

 4. Psychosocial pain
 Somatization, Anxiety ， Hyperventilation

 5.Misc ：
 Mediastinum dieases 、 esophagogastric
diseases 、 hepatobilitary diseases 。
 [Mechanism]
 Irritants ：
desatruation 、 inflammation 、 tumor
invasion 、 organic impairment
 afferent fiber of sensory nerve
 pain center in cerebrum
 chest pain

 referred chest pain ：

involve with non-chest
area
Mechanism of referred pain
(radiating pain)


 Life-threatening Causes of Chest Pain:
 acute myocardial infarction /Angina.
 Aortic dissection.
 Pulmonary embolism.
 Tension pneumothorax.
 Perforated viscera.
 Chest Pain That Are Not Immediately Life-
Threatening:
 Anxiety with somatization
Pneumonia/pleuritis
GERD/Esophagitis.
Costochondritis.
Herpes zoster.
 Life threatening causes:

P is Pericarditis （ pericardial tamponade ） .

A is as Acute myocardial infarction.
P is Pneumothorax
P is Pulmonary embolism
A is Aneurysm.

YOU have to exclude LIFE-THREATENING etiologies.

Though NON life threatening etiologies are
much more common.
 [Key points for DDx]

1 ． HISTORY WITH SPECIFIC AGE

 Young people ：
pneumothorax, pleuritis,
valvular heart diease
 Age >40y/o ： heart
attack,cancer
 2 、 Oneset ：
 Acute/sudden ： AMI, Pneumothorax, AD,PE
 Gradual ： TB, cancer, GI, HZ

3 、 Location (site)
 Chest wall ： HZ 、 costochondritis 。
 Retrosternal: Angina/AMI with referred pain to left upper
limb. Esophageal, mediastinal
 Lateral : Pleuritic pain aggrevating with inspiration.
Pneumonia, Pneumothorax, pleurisy
 Back pain (interscapular) ： AD radiating to
abdomen
4. Radiation
Neck  esophageal spasm
Back (interscapular) AD
Neck, jaw, shoulder, Lt arm Heat
attack
Right shoulder  liver diz or diaphram
involved diz
5 ． Characteristic:

Sharp pericarditis, HZ
Squeezing heavy pressure MI, Angina
Stabbing  pericarditis PE
Pluritic  PE, Pneumonia
Tearing AD
Burning GERD
6 ． Duration
< 15 min ( 2- 10) min  Angina
Upto 30 min  MI
Upto 60 min  E.spasm
Few hours  PE, pnumothorax
Hours to days  pericarditis pleuritis
Continuous  HZ, Cancer
Periodic ／ Paroxysmal GI spasm, neurogenic

NOTE: <1 min or > 30 is less likely to be cardiac.

7 ． Aggravating & Relieving
Exertion, cold, stress, meals  cardiac
ischemia
Swallowing, postprandial,  GI reflux
Deep breathing, movement  Pleuritic,
pericarditis
Deep breathing  PE,pneumothorax
Resting  Anxiety, somatiztion
Post-vomiting  esophageal tearing

NOTE: HZ is not aggravated by anything

Relieving factors
Rest or nitroglycerin(GTN)  angina
Sitting up, leaning forward  pericarditis
Antacid or food  GI causes
GTN  E.spasm

.
 [Associated symptoms]
Cough, fever, sputum:PNA
Dyspnea : PNA, Pleural effusion,peumothorax,heart
Sweating & shock: AMI, PE, AD
Nausea, vomiting,swollen: GI, esophagus
Hemoptysis: TB,PNA,CA,PE
Heartburn, regurgitation: esophagitis
Palpitations: heart attack or failure
Psychiatric symptoms:Anxiety,depression, panic attack
Approach to chest pain
 Judging the severity,and treating the
unstable
 History taking and physical exam
performing
 Targeting examation
 Uncovering the problems and treating
immediately.
 Observation
CHEST PAIN ASSESSMENT
 HISTORY
 EXAMINATION
 ECG
 CARDIAC ENZYMES
 CXR
 OTHERS SPECIFICS
ST Depression or Dynamic T
wave Inversions
ST-Segment Elevation MI
Aortic dissection
Pleural effusion
Pneumothorax
 TEITZE`S SYNDROME
IDIOPATHIC COSTOCHONDRITIS
 LOCALIZED PAIN/TENDERNESS AT
COSTOCHONDRAL JUNCTION
 ENHANCED BY EMOTION,COUGHING,SNEEZING
 2nd.RIB MOST AFFECTED
HERPES ZOSTER （ shingle
s）
Next: cough