Chest Pain

Chapter: Chest Pain
McMaster Section Editor(s): Akbar A. Panju
Section Editor(s) in Interna Szczeklika: Andrzej Budaj, Wiktoria Leśniak
McMaster Author(s): Maryan Graiss, Nicholas Valettas
Author(s) in Interna Szczeklika: Wojciech Szczeklik, Miłosz Jankowski
Additional Information

Causes and PathogenesisTop

Chest pain may originate from all structures of the chest except the pulmonary parenchyma:

1) Cardiovascular: Angina pectoris, myocardial infarction, pericarditis, aortic dissection.

2) Other organs located in the chest: Pleural irritation (pneumonia, pulmonary infarction, pneumothorax, pulmonary embolism); disorders of the esophagus, trachea, bronchi, or mediastinum.

3) Chest wall: Neuralgia, musculoskeletal pain, breast disorders, skin disorders.

4) Abdominal organs: Gastroesophageal reflux disease, peptic ulcer disease, cholelithiasis, pancreatitis.

5) Psychogenic pain (Da Costa syndrome).

Pathogenesis and characteristics of the most common causes of chest pain: Table 1.1-1.

DiagnosisTop

Assess the vital signs (respiratory rate, pulse, blood pressure). Take a history and perform physical examination to determine the nature and probable cause of pain. Always perform electrocardiography (ECG). Other investigations depend on the suspected cause.

TablesTop

 

Table 1.1-1. The most frequent causes of chest pain and their differential diagnosis

Cause

Pathogenesis

Location

Features of pain

Precipitating, exacerbating, and alleviating factors

Selected accompanying symptoms

Angina pectoris

Transient myocardial ischemia

Retrosternal, may be referred to neck, jaw, arms, elbows, epigastrium

Crushing, burning, squeezing; persists for 2-10 min

 

Exercise, stress, cold air, heavy meals; resolves soon after stopping activity or use of nitroglycerin

Dyspnea

MI or unstable angina

Prolonged myocardial ischemia, myocardial necrosis

As above

As above but usually more severe; persists for >30 min in MI, <20 min in angina pectoris

Not resolving after use of nitroglycerin or stopping activity

Dyspnea, excessive sweating, fatigue, nausea, vomiting

Pericarditis

Irritation of pericardial layers or part of pleura adjacent to pericardium

Retrosternal or over apex, may be referred to neck and left shoulder

Sharp, stabbing, varying intensity

Exacerbated by deep inspiration, trunk turning, supine position, cough; reduced when sitting and leaning forward

Features of underlying condition, pericardial rub, dyspnea

Aortic dissection

Distension of aortic wall

Anterior chest wall, may be referred to interscapular or lumbar area

Extremely severe, tearing, of sudden onset

High BP

Murmur of mitral regurgitation, asymmetric BP in extremities, new-onset neurologic deficits

Pleuritic pain

Inflammatory infiltration of pleura, irritation of pleura in pulmonary infarction, pneumothorax

Usually unilateral, may be referred to interscapular area

Sharp, stabbing

Exacerbated by deep inspiration, cough, trunk movement; reduced after lying down on the side of pain

Features of underlying condition, usually dyspnea, tachypnea

Neuralgia

Neuritis (eg, in herpes zoster), nerve compression by spinal lesions

Unilateral in herpes zoster, may be bilateral when caused by spinal lesions

Sharp, shooting

Exacerbated by palpation along nerve, sometimes with very light touch (allodynia)

Rash typical of herpes zoster, tenderness of thoracic vertebrae

GERD

Esophagitis

Retrosternal, may be referred to back

Usually burning or squeezing

Heavy meals, leaning forward, lying down

Upper abdominal pain, dyspepsia

Esophageal rupture

Disruption of esophageal wall

Retrosternal

Very severe, burning, of sudden onset

Forceful vomiting

Vomiting

Cholelithiasis

Increased pressure in gallbladder

Right hypochondrium or epigastrium, may be referred to right shoulder

Severe pain with gradually increasing intensity, resolves slowly, persists for minutes to hours

Fatty meals; alleviated by lying down still

Nausea, vomiting, loss of appetite

Peptic ulcer disease

Gastric or duodenal mucosal injury

Epigastrium, sometimes in lower chest

Dull, rarely sharp or burning

Exacerbated by meals (gastric ulcer) or fasting; meals alleviate symptoms in patients with duodenal ulcer

Dyspepsia

Bone and joint pain

Inflammation of sternocostal and sternoclavicular joints, trauma, other

Local, anterior chest wall

Sharp or squeezing

Chest wall movement, particularly cough

Tenderness (often reproducible on palpation)

Neurotic pain

Unclear

Anterior chest wall

Variable

Stress

Dyspnea, palpitations, anxiety

BP, blood pressure; GERD, gastroesophageal reflux disease; MI, myocardial infarction.

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