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:
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:
Burning: Gastroesophageal reflux disease
Radiation
Shoulder/arms/neck/jaw:
Back: Aortic dissection
Exacerbating factors
Exercise, emotion:
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
- No correlation with exertion or emotion
- Well-localised
- Location continually varies
- Lasts for less than 30 seconds
Cardiac investigations
- ECG
- Blood markers:
- Troponin I and T – marker for myocardial infarction
- Brain natriuretic peptide (BNP) – marker for heart failure
- Chest x-ray
- Echocardiography: used to assess ventricular function, valves, structural heart disease and pericardial effusions.
- CT/MRI scan
- Coronary angiography: assess coronary arteries and chamber pressures
- Radionuclide imaging: uses gamma-emitting radionuclides to study heart function. Can assess ventricular function and blood supply
- Pericardiocentesis
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