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