Chest Pain

Key Features

Essentials of Diagnosis

• Inquire about

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

  • Shortness of breath

• Vital signs

• Chest and cardiac examination

• 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

Clinical Findings

Symptoms

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

• Pain reaching maximum intensity in seconds is uncommon

• 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

  • Usually relieved by rest

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

• 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

• 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 breathing, 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 ...