Chest pain

Chest pain

ICD-10	R07
ICD-9	786.5
MedlinePlus	003079

Chest pain may be a symptom of a number of serious conditions and is, in general, considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.

• In the US, an estimated 5 million patients per year present to the Emergency Department with chest pain.
• More than 50% of patients presenting to emergency facilities with unexplained chest pain will have coronary disease ruled out.
• 1.5 million patients are admitted annually for workup of acute coronary syndrome (ACS).
• Approximately 8 billion dollars are used annually to evaluate complaints of chest pain.

Differential diagnosis

Causes of chest pain range from non-serious to serious to life-threatening.^[1] DiagnosisPro lists more than 440 causes on its website.^[2]

In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%).^[3] Other less common causes include: pneumonia, lung cancer, and aortic aneurysms.^[3]

In children the most common causes for chest pain are musculoskeletal and unknown.^[4]

Cardiovascular

• Acute coronary syndrome
  • Unstable Angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction.
  • Myocardial infarction ("heart attack")^[5]
• Aortic dissection
• Pericarditis and cardiac tamponade
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Stable angina pectoris - this can be treated medically, and, although it warrants investigation, it is not an emergency in its strictest sense
• Myocarditis
• Mitral valve prolapse syndrome
• Aortic aneurysm

Respiratory

• Bronchitis
• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Pleurisy - an inflammation that can cause painful respiration
• Tuberculosis
• Tracheitis
• Lung malignancy

Gastrointestinal

• Eosinophilic Esophogitus
• Gastroesophageal reflux disease (GERD) and other causes of heartburn
• Hiatus hernia
• Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus
• Functional dyspepsia

Chest wall

• Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
• Spinal nerve problem
• Fibromyalgia
• Chest wall problems
• Radiculopathy
• Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
• Breast conditions
• Herpes zoster commonly known as shingles
• Tuberculosis
• Osteoarthritis
• Bornholm disease

Psychological

• Panic attack
• Anxiety
• Clinical depression
• Somatization disorder
• Hypochondria

Others

• Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
• Da costa's syndrome
• Carbon monoxide poisoning
• Sarcoidosis
• Lead poisoning
• High abdominal pain may also mimic chest pain
• Prolapsed intervertebral disc
• Thoracic outlet syndrome

Diagnostic approach

History taking

Knowing a patient's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors.

Physical examination

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.^[1]

If acute coronary syndrome ("unstable angina") is suspected, many people are admitted briefly for observation, sequential ECGs, and determination of cardiac enzymes over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk. Features of the pain suggestive of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to the neck, jaw or left arm; sweating; nausea; palpitations; pain felt upon exertion; dizziness; shortness of breath; and a "sense of impending doom."

Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialised units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. A rapid diagnosis can be life-saving and often has to be made without the help of medical tests. However, in general, additional tests are required to establish the diagnosis.

Medical tests

On the basis of the above, a number of tests may be ordered:^[6]

• An electrocardiogram (ECG)
• CT scanning may be used in unexplained chest pain when other tests are inconclusive.
• V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is suspected)
• X-rays of the chest and abdomen. Routine X-rays, however, are not needed.
• Blood tests:
  • Troponin I or T (to indicate myocardial damage)
  • Complete blood count
  • Electrolytes and renal function (creatinine)
  • Liver enzymes
  • Creatine kinase (and CK-MB fraction in many hospitals)
  • D-dimer (when suspicion for pulmonary embolism is present but low)
  • serum lipase or amylase to exclude acute pancreatitis

Management

Aspirin increases survival in patients with acute coronary syndrome and it is reasonable for EMS dispatchers to recommend it in people with no recent serious bleeding.^[7]

In people with chest pain supplemental oxygen is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress.^[8][9] Entonox is frequently used by EMS personnel in the prehospital environment.^[10] However, there is little evidence about its effectiveness.^[9][11]

Epidemiology

Chest pain is the presenting symptom in about 12% of emergency department visits in the United States and has a one-year mortality of about 5%.^[12] The rate of ED visits in the US for chest pain increased 13% from 2006-2011.^[13]

References

Pain and nociception By region/system HEENT Headache Neck Odynophagia (swallowing) Otalgia (ear) Toothache Chest pain Cardiovascular system Angina pectoris Respiratory system Sore throat Pleurodynia Breast Mastodynia (Breast) Musculoskeletal Arthralgia (joint) Bone pain Myalgia (muscle) Muscle soreness: Acute / Delayed onset Neurologic Congenital insensitivity to pain HSAN Type I II congenital sensory neuropathy III familial dysautonomia IV congenital insensitivity to pain with anhidrosis V congenital insensitivity to pain with partial anhidrosis Neuralgia Pain asymbolia Pain disorder Paroxysmal extreme pain disorder Allodynia Chronic pain Hyperalgesia Hypoalgesia Hyperpathia Phantom pain Referred pain Abdominal pain Urogenital Dysuria Pelvic pain Dyspareunia Testicular pain Gastrointestinal Proctalgia Back Upper Lower Tests Cold pressor test Dolorimeter Hot plate test Tail flick test Related concepts Anterolateral system Pain management Anesthesia Cordotomy Pain scale Pain threshold Pain tolerance Posteromarginal nucleus Substance P Suffering OPQRST Philosophy of pain Cancer pain Drug-seeking behavior Index of the central nervous system Description Anatomy meninges cortex association fibers commissural fibers lateral ventricles basal ganglia diencephalon mesencephalon pons cerebellum medulla spinal cord tracts Physiology neutrotransmission enzymes intermediates Development Disease Cerebral palsy Meningitis Demyelinating diseases Seizures and epilepsy Headache Stroke Sleep Congenital Injury Neoplasms and cancer Other paralytic syndromes ALS Symptoms and signs head and neck eponymous lesions Tests CSF Treatment Procedures Drugs general anesthetics analgesics addiction epilepsy cholinergics migraine Parkinson's vertigo other Index of the peripheral nervous system Description Anatomy Nerves cranial trigeminal cervical brachial lumbosacral plexus somatosensory spinal autonomic Physiology reflexes proteins neurotransmitters transporters Development neurotrophins Disease Autonomic Congenital Injury Neoplasms and cancer Other Symptoms and signs eponymous Treatment Procedures Local anesthetics

Symptoms and signs: respiratory system (R04–R07, 786) Medical examination and history taking Auscultation Respiratory sounds Stridor Wheeze Crackles Rhonchi Hamman's sign Pleural friction rub Fremitus Bronchophony Elicited findings Pectoriloquy: Whispered pectoriloquy Egophony Abnormalities of breathing Respiratory distress Respiratory arrest Cyanosis Rate Apnea Dyspnea Hyperventilation Hypoventilation Hyperpnea Tachypnea Hypopnea Bradypnea Orthopnea/Platypnea Trepopnea Pattern Biot's respiration Cheyne–Stokes respiration Kussmaul breathing Asphyxia Breath holding Other Chest pain Precordial catch syndrome Pleurisy Clubbing Cough Sputum Hemoptysis Epistaxis Silhouette sign Post-nasal drip Mouth breathing Snoring Hiccup Index of the respiratory system Description Anatomy nose larynx lower thorax Physiology Development Disease Congenital Neoplasms and cancer Chest trauma Infection common cold pneumonia tuberculosis Other Symptoms and signs eponymous Treatment Procedures mechanical ventilation Drugs nasal throat obstructive airway diseases cough and cold histaminergics pulmonary arterial hypertension other Surgery