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Chest Pain Overview

by | 20 May, 2020

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Introduction

Chest pain is a non-specific symptom that can arise from any thoracic organ and a few abdominal regions. It may also be a discomfort rather than a pain.

Causes

By frequency

The main causes in over 60 year olds: Young patients are less likely to suffer from myocardial ischaemia. Instead, consider:
  • Pulmonary embolus e.g. pregnancy, combined oral contraceptive pill
  • Pneumothorax e.g. tall, male
  • Cocaine-induced coronary spasm
Rare causes include:
  • Myopericarditis
  • Cholecystitis
  • Pancreatitis
  • Aortic dissection
  • Coronary vasospasm (secondary to cocaine use)
  • Oesophageal spasm
  • Boerhaave’s perforation

By anatomical location

Cardiac: Pulmonary:
  • Pulmonary embolus
  • Pleurisy
  • Pneumothorax
Gastrointestinal tract:
  • Oesophagitis
  • Peptic ulcer disease
  • Cholecystitis
  • Pancreatitis
  • Oesophageal spasm
  • Boerhaave’s perforation
Musculoskeletal e.g. muscle sprain from coughing Thoracic aorta:
  • Dissection
  • Aneurysm
Anxiety

Red flag diseases

  • Acute coronary syndrome – sudden, central crushing chest pain that radiates to arms, neck or jaw.
  • Pulmonary embolus – sudden onset pleuritic chest pain and dyspnoea
  • Pneumothorax – sudden onset pleuritic chest pain and dyspnoea. Produces hyperresonance to percussion and reduced breath sounds on auscultation
  • Aortic dissection – sudden tearing chest pain radiating to the back
  • Boerhaave’s perforation – sudden onset severe chest pain after vomiting

Features of chest pain

Site

Most cardiac causes present as central chest pain. Most pulmonary causes present as lateral/peripheral chest pain, usually pleuritic in nature (worse on inspiration).

Localisation

Cardiac pain is usually poorly localised and diffuse. Pleurisy, pericarditis and pulmonary infarction are well-localised. Musculoskeletal pain is well-localised with tenderness on palpation.

Character

Constricting:
  • Angina
  • Anxiety
  • Oesophagitis
Sharp:
  • Pleuritis
  • Pericarditis
Burning: Gastroesophageal reflux disease

Radiation

Shoulder/arms/neck/jaw:
  • Cardiac
  • Aortic
  • Oesophageal
Back: Aortic dissection

Exacerbating factors

Exercise, emotion:
  • Cardiac
  • Anxiety
Food/hot drinks/alcohol/lying down: oesophagitis Breathing, lying down: pericarditis Pain after exercise: musculoskeletal

Relieving factors

Antacids: Oesophagitis GTN use:
  • Cardiac
  • Oesophageal (has a slower response to GTN than cardiac)
Leaning forwards: pericarditis

Associated symptoms

Dyspnoea:
  • Cardiac
  • Pulmonary embolus
  • Pleurisy
  • Anxiety
Nausea and vomiting:
  • Acute coronary syndrome
  • Boerhaave’s perforation
  • Pancreatitis
  • Cholecystitis
Sense of impending doom: Myocardial infarction Fever:
  • Infection
  • Myocardial infarction
  • Pulmonary embolus
Cough and wheeze: Respiratory causes Tenderness: Musculoskeletal

Features suggesting non-cardiac pain

  1. No correlation with exertion or emotion
  2. Well-localised
  3. Location continually varies
  4. Lasts for less than 30 seconds

Cardiac investigations

  1. ECG
  2. Blood markers:
    1. Troponin I and T – marker for myocardial infarction
    2. Brain natriuretic peptide (BNP) – marker for heart failure
  3. Chest x-ray
  4. Echocardiography: used to assess ventricular function, valves, structural heart disease and pericardial effusions.
  5. CT/MRI scan
  6. Coronary angiography: assess coronary arteries and chamber pressures
  7. Radionuclide imaging: uses gamma-emitting radionuclides to study heart function. Can assess ventricular function and blood supply
  8. Pericardiocentesis

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