Chest discomfort is a common challenge for clinicians in the office or emergency department. The differential diagnosis includes conditions affecting organs throughout the thorax and abdomen, with prognostic implications that vary from benign to life-threatening (Table 12-1). Failure to recognize potentially serious conditions such as acute ischemic heart disease, aortic dissection, tension pneumothorax, or pulmonary embolism can lead to serious complications, including death. Conversely, overly conservative management of low-risk patients leads to unnecessary hospital admissions, tests, procedures, and anxiety.
Table 12-1 Diagnoses among Chest Pain Patients Without Myocardial Infarction |Favorite Table|Download (.pdf)
Table 12-1 Diagnoses among Chest Pain Patients Without Myocardial Infarction
Esophageal motility disorders
Ischemic heart disease
Chest wall syndromes
Causes of Chest Discomfort
Myocardial Ischemia and Injury
Myocardial ischemia occurs when the oxygen supply to the heart is insufficient to meet metabolic needs. This mismatch can result from a decrease in oxygen supply, a rise in demand, or both. The most common underlying cause of myocardial ischemia is obstruction of coronary arteries by atherosclerosis; in the presence of such obstruction, transient ischemic episodes are usually precipitated by an increase in oxygen demand as a result of physical exertion. However, ischemia can also result from psychological stress, fever, or large meals or from compromised oxygen delivery due to anemia, hypoxia, or hypotension. Ventricular hypertrophy due to valvular heart disease, hypertrophic cardiomyopathy, or hypertension can predispose the myocardium to ischemia because of impaired penetration of blood flow from epicardial coronary arteries to the endocardium.
(See also Chap. 243) The chest discomfort of myocardial ischemia is a visceral discomfort that is usually described as a heaviness, pressure, or squeezing (Table 12-2). Other common adjectives for anginal pain are burning and aching. Some patients deny any “pain” but may admit to dyspnea or a vague sense of anxiety. The word “sharp” is sometimes used by patients to describe intensity rather than quality.
Table 12-2 Typical Clinical Features of Major Causes of Acute Chest Discomfort |Favorite Table|Download (.pdf)
Table 12-2 Typical Clinical Features of Major Causes of Acute Chest Discomfort
|Angina||More than 2 and less than 10 min||Pressure, tightness, squeezing, heaviness, burning||Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or arms—frequently on left|
Precipitated by exertion, exposure to cold, psychologic stress
S4 gallop or mitral regurgitationmurmur during pain
|Unstable angina||10–20 min||Similar to angina but often more severe||Similar ...|