Chest Pain

Essentials of Diagnosis

• Inquire about

  • Pain onset, character, location/size, duration, periodicity, and exacerbating factors

  • Shortness of breath

• Vital signs

• Chest and cardiac examinations

• Electrocardiogram

• Biomarkers of myocardial necrosis

General Considerations

• Can occur as a result of

  • Cardiovascular, pulmonary, pleural, or musculoskeletal disease

  • Esophageal or other gastrointestinal disorders

  • Herpes zoster

  • Cocaine use

  • Anxiety states

• Conditions that confer a strong risk for coronary artery disease

  • Diabetes mellitus

  • Systemic lupus erythematosus

  • Rheumatoid arthritis

  • Reduced estimated glomerular filtration rate (eGFR)

  • HIV

• Because pulmonary embolism can present with a wide variety of symptoms, consideration of this diagnosis and rigorous risk factor assessment for venous thromboembolism (VTE) is critical

• Classic VTE risk factors include

  • Cancer

  • Trauma

  • Recent surgery

  • Prolonged immobilization

  • Pregnancy

  • Oral contraceptives

  • Family history

  • Prior history of VTE

• Other conditions associated with increased risk of pulmonary embolism include heart failure and chronic obstructive pulmonary disease

• Sickle cell anemia can cause acute chest syndrome

• Carbon monoxide poisoning may trigger coronary artery spasm

Symptoms

• Myocardial ischemia is usually described as dull, aching sensation of "pressure," "tightness," "squeezing," or "gas," rather than as a sharp or spasmodic pain

• Ischemic symptoms usually subside within 5–20 minutes but may last longer

• Progressive symptoms or symptoms at rest may represent unstable angina

• Prolonged chest pain episodes might represent myocardial infarction, although up to one-third of patients with acute myocardial infarction do not report chest pain

• Pain due to myocardial ischemia is

  • Commonly accompanied by a sense of anxiety or uneasiness

  • Usually retrosternal or left precordial

• Because the heart lacks somatic innervation, precise localization of pain due to cardiac ischemia is difficult; the pain is commonly referred to the

  • Throat

  • Lower jaw

  • Shoulders

  • Inner arms

  • Upper abdomen

  • Back

• Ischemic pain

  • May be precipitated or exacerbated by exertion, cold temperature, meals, stress, or combinations of these factors

  • Is usually relieved by rest

• Atypical presentations of acute coronary syndrome (ACS) are more common in the elderly, women, and persons with diabetes mellitus

• Other symptoms that are associated with ACS

  • Shortness of breath

  • Dizziness

  • Anxiety, such as a feeling of impending doom

  • Vagal symptoms, such as nausea and diaphoresis

• In the elderly, fatigue is a common presenting complaint of ACS

• Women are more likely than men to

  • Present with three or more associated symptoms (eg, epigastric symptoms, palpitations, and pain or discomfort in the jaw, neck, arms, or between the shoulder blades; 61.9% for women versus 54.8% for men)

  • Perceive symptoms as due to stress/anxiety (20.9% versus 11.8%) but less likely to attribute symptoms to muscle pain (15.4% versus 21.2%)

  • Present without chest pain

• Hypertrophy of either ventricle or aortic stenosis may also give rise to chest pain with less typical features

• Pericarditis may produce pain that is greater when supine than upright and may increase with respiration, coughing, or swallowing

• Aortic dissection

  • Classically produces an abrupt onset of tearing pain of great intensity that often radiates to the back

  • Anterior aortic dissection can also lead to myocardial or cerebrovascular ischemia

• Rupture of the thoracic esophagus iatrogenically or secondary to vomiting is another cause of chest pain

Physical Examination

• Vital sign measurement (including pulse oximetry) and cardiopulmonary examination are the first steps for assessing this symptom's urgency

• Although chest pain that is reproducible or worsened with palpation strongly suggests a musculoskeletal cause, up to 15% of patients with ACS will have reproducible chest wall tenderness

• Pointing with one finger to indicate the location of the pain has been shown to be highly correlated with nonischemic chest pain

• Aortic dissection

  • Can result in differential arm blood pressures (> 20 mm Hg), pulse amplitude deficits, and new diastolic murmurs

  • Systolic blood pressure < 100 mm Hg is present in up to 25% of patients

• Cardiac friction rub

  • Represents pericarditis until proven otherwise

  • Can best be heard with the patient sitting forward at end-expiration

• Tamponade should be excluded in all patients with a clinical diagnosis of pericarditis by assessing pulsus paradoxus and inspection of jugular venous pulsations

• Subcutaneous emphysema is common following cervical esophageal perforation but present in only about one-third of thoracic perforations

Imaging Studies

• Chest radiography

  • Often useful in the evaluation of chest pain

  • Always indicated when cough or shortness of breath accompanies chest pain

  • Findings of pneumomediastinum or new pleural effusion are consistent with esophageal perforation

• CT is the study of choice at most centers for the diagnosis of esophageal perforation as well as for aortic dissection (helical CT)

• CT angiography (with helical or multidetector CT imaging)

  • Has replaced ventilation-perfusion scanning as the preferred diagnostic test for pulmonary emboli

  • Has approximately 90–95% sensitivity and 95% specificity for detecting pulmonary emboli

• Multidetector CT angiography

  • Enables diagnosis (or exclusion) of coronary artery disease, ACS, and pulmonary emboli (so-called "triple rule-out")

  • Involves both radiation and contrast exposure, however

Diagnostic Studies

• Studies of high-sensitivity cardiac troponin suggest that it may be the best cardiac biomarker

• Copeptin and heart fatty acid binding protein may also have a role in increasing diagnostic sensitivity

• ECG

  • Warranted in the initial evaluation of most patients with acute chest pain to help exclude ACS

    • ST segment elevation is the strongest predictor of acute myocardial infarction; however, up to 20% of patients with ACS can have a normal ECG

    • Can also provide evidence for alternative diagnoses, such as pericarditis and pulmonary emboli

• A negative D-dimer test is helpful for excluding pulmonary emboli in patients with low clinical probability of VTE

• Should be guided by the underlying etiology

• A meta-analysis of 15 trials suggested psychological (especially cognitive-behavioral) interventions may have modest to moderate benefit in noncardiac chest pain

• But whether tricyclic and SSRI antidepressants have benefit is unclear

• Hypnotherapy may have some benefit

When to Refer

• Refer patients with poorly controlled, noncardiac chest pain to a pain specialist

• Refer patients with sickle cell chest pain to a hematologist

When to Admit

• Failure to adequately exclude life-threatening causes of chest pain, particularly myocardial infarction, dissecting aortic aneurysm, pulmonary emboli, and esophageal rupture

• High risk of pulmonary embolism and a positive sensitive D-dimer test

• TIMI score of > 1, HEART score > 3, abnormal electrocardiogram and abnormal 0- and 2-hour troponin tests

• Pain control for rib fracture that impairs gas exchange