Chest Pain
Chest pain is a frequent symptom and may be a manifestation of cardiovascular or noncardiovascular disease. Full characterization of the pain with regard to quality, quantity, frequency, location, duration, radiation, aggravating or alleviating factors and associated symptoms may help to distinguish among various causes. Always ask about describing the discomfort in their chest, “squeezing,” “tightening,” “pressing,” “burning.” All patients presenting to a hospital with severe or persistent chest pain should have a full set of vital signs, an ECG, and a CXR.
Etiologies and signs/symptoms/diagnosis
** The life-threatening causes that must be considered and ruled out in all patients with severe, persistent chest pain.
Cardiac Causes
- Angina/Myocardial infarction **
- Substernal pressure +/- radiation to neck, jaw, Left arm
- Duration usually > 1 minute and < 12 hours for angina
- Associated with dyspnea, diaphoresis, nausea/vomiting
- Worsened with exertion, relieved with rest or nitroglycerin
- Infarction is same as angina except increased intensity and duration
- ECG: look for ST elevations or depressions, T wave inversions
- Pericarditis/Myocarditis **
- Sharp pain radiation to trapezius
- Aggravated by respiration
- Relieved by sitting forward
- Listen for pericardial friction rub
- ECG: look for diffuse ST elevations and PR depressions
- Aortic Dissection **
- Sudden onset of tearing chest pain, knife-life pain
- Radiation to back
- Usually severely hypertensive (can become hypotensive)
- Asymmetric blood pressure in arms and asymmetric pulses bilaterally
- Widened mediastinum on CXR, new aortic insufficiency murmur
Pulmonary Causes
- Pneumonia **
- A very common cause of chest pain in our settings
- Pleuritic in nature
- Associated with dyspnea, cough, fever, sputum production
- Presents with fever, tachycardia, crackles on physical exam
- CXR should show an infiltrate
- Pneumothorax **
- Sharp, pleuritic pain +/- shortness of breath
- Unilateral hyperresonance and decreased breath sounds on one side
- Confirmed by CXR
- Pulmonary embolism **
- Pleuritic, sudden onset
- Associated with tachypnea, tachycardia, hypoxemia
- ECG can show T wave inversions V1-V4, RAD, S1Q3T3
- Pulmonary hypertension
- Dyspnea, exertional pressure
- Hypoxemia
- Loud P2 sound on heart exam, right sided S3 &S4
GI causes
- Esophageal reflux
- Substernal burning, worsened with lying down
- Acid taste in mouth
- Peptic ulcer disease
- Epigastric pain
- Hematemesis or melena
- EGD with H. pylori test
- Biliary disease
- With RUQ pain, nausea/vomiting
- Aggravated by fatty foods
- Needs RUQ ultrasound, liver tests
- Pancreatitis
- Epigastric or back discomfort
- Increased amylase and lipase, has risk factors
Musculoskeletal and other Causes
- Costochondritis
- Localized sharp or dull pain
- Tenderness to palpation
- Herpes zoster
- Intense unilateral pain often preceeds rash
- Dermatomal rash and sensory findings
- Cervical spine disease or arthritis
- Precipitated by motion
- Lasts seconds to hours
- X-rays to confirm
Chest pain Clinical Cases
Case 1
26 yo female with no past medical history comes in complaining of chest pain x 2 weeks. She described the pain as sharp, lasting a few seconds at a time and is intermittent. On your physical exam, her BP is 120/80 and HR 72. She has a regular rate and rhythm with no murmurs. When you palpate her chest, she said she feels pain where you palpate.
1. What is the most likely etiology for her pain?
-costochondritis
2. Is there any test that you would want to get at this point to help diagnosis and why?
-ECG to rule look for pericarditis
-CXR to rule out pneumothorax and rib fractures
Case 2
55 yo male with longstanding, poorly controlled HTN presents with chest pain to the hospital. He describes the pain as the strongest chest pain he has ever felt and it radiates to his back. No associated palpitations or nausea. He does say he feels a little short of breath because the pain is so severe. He has never had pain like this before.
1. What diagnosis are you most worried about with this description of chest pain?
-aortic dissection
2. Which physical exam findings are you looking for?
-asymmetric blood pressures and pulses in both arms
3. What tests do you want to order and why?
-ECG to look for myocardial infarction/ischemia
-CXR to look for mediastinal widening
You take his blood pressure and find that it is 180/100 in his right arm and 140/80 in his left arm. His pulse in the right radial artery is stronger then the left radial artery. His ECG shows sinus tachycardia with rate of 110. You ordered a chest xray.
1. What finding will you see on chest xray to confirm your diagnosis?
-widening of the mediastinum
2. What medications do you want to give him?
-beta blockers
Case 3
58 yo female with history of HTN is admitted to the hospital with chest pain. She further describes the pain as burning and points to her epigastric area and chest area. She denies radiation of pain, denies nausea/vomiting, denies dyspnea and palpitations. The patient says the pain is worse when she is lying down and 30 minutes after she eats.
1. What is the most likely etiology of her pain?
-gastroesophageal reflex disease
2. What tests do you want to order, if any?
-no tests necessary initially
-if pain does not improve with medical therapy, consider EGD and H. pylori testing to look for peptic ulcer disease
3. How would you like to treat this patient?
-antacids, H2 blockers, or proton pump inhibitors
-counsel her on lifestyle modifications: avoid spicy and fried foods, avoid cigarettes, avoid alcohol, avoid laying down for at least one hour after eating
