Chest Pain

How to Cite This Chapter: Valettas N, Graiss M, Szczeklik W, Jankowski M. Chest Pain. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.I.1.6. Accessed November 21, 2024.

Last Updated: December 30, 2021

Last Reviewed: December 30, 2021

Chapter Information

Causes and PathogenesisTop

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

1) Cardiovascular: Coronary artery disease (stable ischemic heart disease and acute coronary syndromes); pericarditis or myopericarditis; selected cardiomyopathies, with hypertrophic and Takotsubo cardiomyopathies being the most common; valvular heart disease; aortic dissection; pulmonary hypertension.

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.

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 1.29-1. The most frequent causes of chest pain and their differential diagnosis
Cause	Pathogenesis	Location	Features of pain	Precipitating, exacerbating, and alleviating factors	Selected accompanying signs or symptoms
SIHD	Transient myocardial ischemia	Retrosternal, may be referred to neck, jaw, scapulae, 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
Acute coronary syndromes including NSTEACS and STEACS	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/myopericarditis	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
Hypertrophic cardiomyopathy	Supply/demand mismatch due to decreased coronary flow, LVH, LVOTO	As in SIHD	As in SIHD	Physical activity, dehydration, tachyarrhythmias, nitrates, and other preload- or afterload-reducing agents	Dyspnea, presyncope or frank syncope, SCD
Takotsubo cardiomyopathy	Unknown but presumed due to catecholamine-induced cardiotoxicity	Similar as in ACS	Similar as in ACS	Emotional or physical stress; strong female preponderance	Dyspnea, heart failure, cardiogenic shock
Valvular heart disease (AS/AI)	Myocardial oxygen supply/demand mismatch	Similar as in SIHD	Similar as in SIHD	Physical activity, resolves with rest	Exertional dyspnea, exertional presyncope/syncope in AS, signs of heart failure
PH	Impaired coronary perfusion to a dilated and hypertrophied RV	Similar as in SIHD	Similar as in SIHD	Similar to SIHD	Dyspnea, fatigue, signs of right heart failure, signs and symptoms of underlying cause of PH
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
AI, aortic insufficiency; AS, aortic stenosis; BP, blood pressure; GERD, gastroesophageal reflux disease; LVH, left ventricular hypertrophy; LVOTO, left ventricular outflow tract obstruction; MI, myocardial infarction; NSTEACS, non–ST-segment elevation acute coronary syndrome; PH, pulmonary hypertension; RV, right ventricle; SCD, sudden cardiac death; SIHD, stable ischemic heart disease; STEACS, ST-segment elevation acute coronary syndrome.

CAUSES AND PATHOGENESIS
DIAGNOSIS
TABLES

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Chest Pain

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