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 33-1.
TABLE 33-1Diagnoses of Pts Admitted to Hospital with Acute Chest Pain Ruled Not Myocardial Infarction ||Download (.pdf) TABLE 33-1 Diagnoses of Pts Admitted to Hospital with Acute Chest Pain Ruled Not Myocardial Infarction
|DIAGNOSIS ||PERCENTAGE |
| Gastroesophageal reflux |
| Esophageal motility disorders |
| Peptic ulcer |
| Gallstones |
|Ischemic heart disease ||31 |
|Chest wall syndromes ||28 |
|Pericarditis ||4 |
|Pleuritis/pneumonia ||2 |
|Pulmonary embolism ||2 |
|Lung cancer ||1.5 |
|Aortic aneurysm ||1 |
|Aortic stenosis ||1 |
|Herpes zoster ||1 |
POTENTIALLY SERIOUS CAUSES
The differential diagnosis of chest pain is shown in Figs. 33-1 and 33-2. It is useful to characterize the chest pain as (1) new, acute, and ongoing; (2) recurrent, episodic; and (3) persistent, e.g., for hours or days at a time.
Differential diagnosis of recurrent chest pain. *If myocardial ischemia suspected, also consider aortic valve disease (Chap. 116) and hypertrophic obstructive cardiomyopathy (Chap. 117) if systolic murmur present. TNG, trinitroglycerin.
Differential diagnosis of serious conditions that cause acute chest pain. CK, creatine phosphokinase.
Myocardial Ischemia: Angina Pectoris
Substernal pressure, squeezing, constriction, with radiation often to left arm; usually on exertion, especially after meals or with emotional arousal. Characteristically relieved by rest and nitroglycerin.
Acute Myocardial Infarction or Unstable Angina
Similar to angina but more severe, of longer duration (≥30 min), and not immediately relieved by rest or nitroglycerin (Chaps. 121 and 122). S3 and/or S4 may be present.
May be substernal or lateral, pleuritic in nature, and associated with hemoptysis, tachycardia, and hypoxemia (Chap. 135).
May impinge on neighboring structures and cause deep, persistent chest pain, dysphagia, hoarseness, or cough (Chap. 127).
Very severe, in center of chest, a sharp “ripping” quality, radiates to back, not affected by changes in position (Chap. 127). May be associated with weak or absent peripheral pulses.
Sharp, intense, localized to substernal region; often associated with audible crepitus.
Usually steady, crushing, substernal; ...