Skip to Main Content

Chapter 1-03: Approaches and Chief Complaints in Cardiology

CHEST PAIN

Approach to chest pain

  • Take a focused history: Ask about the character and quality of pain, provoking and relieving factors, duration and frequency.

  • Perform a targeted exam: Vitals (including BP in both arms and legs), cardiac and chest wall exam, pulmonary exam, abdominal exam.

  • Differential diagnosis:

    • - Think about the five “cannot-miss” causes of chest pain: 1) ACS; 2) PE; 3) Aortic dissection; 4) Tension pneumothorax; 5) Esophageal rupture.

    • - Then can consider a broader differential diagnosis by organ system (Table 1.5)

  • Initial diagnostics:

    • - ECG: Look for ST changes (ACS, pericarditis, demand), RV strain (PE), Q waves (evidence of prior ischemia)

    • - CXR: Look for pneumonia, rib fractures, pneumothorax, widened mediastinum (can occur due to aortic dissection)

    • - D-dimer: Use age-adjusted cutoff for patients >50 yr (age × 10 = upper limit cutoff); normal d-dimer can:

      • Rule out PE in low to intermediate clinical probability situations

      • Rule out aortic dissection in low risk patients (i.e., no connective tissue disease; no new murmur; no chest, abdominal, or back pain that is abrupt, severe, or ripping)

  • CT scan: Timing of contrast differs slightly depending on whether the imaging focuses on the systemic or pulmonary arteries

    • - CTA (CT angiography with arterial contrast) is used if most concerned for aortic dissection

    • - CTPA (CT pulmonary angiography) is used if most concerned for PE

TABLE 1.5Etiologies of Chest Pain by System
View Table||Download (.pdf)
TABLE 1.5 Etiologies of Chest Pain by System

System

Etiologies of Chest Pain

Cardiac

Angina: Pain due to myocardial tissue ischemia (aka supply/demand mismatch)

  • Examples: ACS (STEMI, NSTEMI, unstable angina), stable angina, demand ischemia, vasospasm, spontanous coronary artery dissection (SCAD), myocardial infarction with non-obstructive coronary arteries (MINOCA)

  • Characteristics: Especially concerning if “typical” features (i.e., substernal, exertional, improves with rest/nitroglycerin)

Pericarditis: Pleuritic, sharp, retrosternal, relieved with sitting forward, +friction rub throughout the cardiac cycle

Advanced heart failure or pulmonary hypertension (PAH): Pressure, often exertional dyspnea, syncope (with advanced PAH)

Vascular

Aortic dissection: Sudden onset tearing pain, radiates to the back, unequal pulses and discordant blood pressures in arms and/or legs, often occurs in the setting of hypertension or connective tissue disorders

Pulmonary embolism (PE): Sudden onset, pleuritic, often associated with dyspnea

Pulmonary

Pneumonia/pleuritis: Lateral to midline, brief, often associated with dyspnea, cough, sputum production, fever

Tracheobronchitis: Midline, burning discomfort, associated with coughing

Pneumothorax: Sudden, pleuritic pain, dyspnea, decreased breath sounds. Spontaneous or associated with instrumentation (e.g., central line placement)

GI

Peptic ulcer disease: Burning, epigastric, relieved with food or antacids

GERD: Burning, epigastric, worsened when lying flat after a meal

Esophageal spasm: Pressure, tightness, retrosternal, mimics angina, often relieved by nitroglycerin (likely due to relaxant effect of nitrites on smooth muscle with resultant change in esophageal motility)

Biliary disease: RUQ pain, may occur after meals

Pancreatitis: Prolonged/intense epigastric/back pain, presence of certain risk factors (e.g., heavy alcohol use)

Neuromuscular

Costochondritis: Rare ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close