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INTRODUCTION

There is little correlation between the severity of chest pain and the seriousness of its cause. The range of disorders that cause chest discomfort is shown in Table 37-1.

TABLE 37-1DIFFERENTIAL DIAGNOSES OF PATIENTS ADMITTED TO HOSPITAL WITH ACUTE CHEST PAIN RULED NOT MYOCARDIAL INFARCTION

POTENTIALLY SERIOUS CAUSES

The differential diagnosis of chest pain is shown in Figs. 37-1 and 37-2. It is useful to characterize the chest pain as (1) new, acute, and ongoing; (2) recurrent, episodic; and (3) persistent, e.g., for days at a time.

FIGURE 37-1

Differential diagnosis of recurrent chest pain. *If myocardial ischemia suspected, also consider aortic valve disease (Chap. 123) and hypertrophic obstructive cardiomyopathy (Chap. 124) if systolic murmur present.

FIGURE 37-2

Differential diagnosis of acute chest pain.

Myocardial Ischemia Angina Pectoris

Substernal pressure, squeezing, constriction, with radiation typically to left arm; usually on exertion, especially after meals or with emotional arousal. Characteristically relieved by rest and nitroglycerin.

Acute Myocardial Infarction

Similar to angina but usually more severe, of longer duration (≥30 min), and not immediately relieved by rest or nitroglycerin (Chaps. 128 and 129). S3 and S4 common.

Pulmonary Embolism

May be substernal or lateral, pleuritic in nature, and associated with hemoptysis, tachycardia, and hypoxemia (Chap. 142).

Aortic Dissection

Very severe, in center of chest, a sharp “ripping” quality, radiates to back, not affected by changes in position (Chap. 134). May be associated with weak or absent peripheral pulses.

Mediastinal Emphysema

Sharp, intense, localized to substernal region; often associated with audible crepitus.

Acute Pericarditis

Usually steady, crushing, substernal; often has pleuritic component aggravated by cough, deep inspiration, supine position, and relieved by sitting upright; one-, two-, or three-component pericardial friction rub often audible (Chap. 125).

Pleurisy

Due to inflammation; less commonly tumor and pneumothorax. Usually unilateral, knifelike, superficial, aggravated by cough and respiration.

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