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. Accessed July 20, 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.


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.


Table 1.29-1. The most frequent causes of chest pain and their differential diagnosis




Features of pain

Precipitating, exacerbating, and alleviating factors

Selected accompanying signs or symptoms


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


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


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


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


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



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


Very severe, burning, of sudden onset

Forceful vomiting



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


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


Anterior chest wall



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.

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