Chest pain

Chest pain may be a symptom of a number of serious disorders and is, in general, considered a medical emergency. Even though it may be determined that the pain is noncardiac in origin (does not come from a heart problem), this is often a diagnosis of exclusion made after ruling out more serious causes of the pain. Cardiac (heart-related) chest pain is called angina pectoris.

Chest pain is a common presenting problem, as the following numbers illustrate:

• In the US, an estimated 5 million people per year present to the emergency department with chest pain.
• More than 50% of people presenting to emergency facilities with unexplained chest pain will have coronary disease ruled out.
• 1.5 million people are admitted annually for workup of acute coronary syndrome (ACS).
• Approximately 8 billion dollars are used annually to evaluate complaints of chest pain.
• Children with chest pain account for 0.3% to 0.6% of pediatric emergency department visits^[1]

Differential diagnosis

Causes of chest pain range from non-serious to serious to life-threatening.^[2] DiagnosisPro lists more than 440 causes on its website.^[3]

In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%).^[4] Other less common causes include: pneumonia, lung cancer, and aortic aneurysms.^[4]

Chest pain in children differs from adults in that there can be congenital causes and syndromes. In children the most common causes for chest pain are musculoskeletal and unknown.^[5]

Cardiovascular

• Acute coronary syndrome
  • Unstable angina
  • Myocardial infarction ("heart attack")^[6]
• Aortic dissection especially when there is high blood pressure^[7]
• Pericarditis and cardiac tamponade
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Stable angina pectoris - this can be treated medically, and, although it warrants investigation, it is not an emergency in its strictest sense
• Myocarditis
• Mitral valve prolapse syndrome
• Aortic aneurysm

Respiratory

• Bronchitis
• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Pleurisy - an inflammation that can cause painful respiration
• Tuberculosis
• Tracheitis
• Lung malignancy

Gastrointestinal

• Esophageal rupture
• Gastroesophageal reflux disease (GERD) and other causes of heartburn
• Esophagitis
• Hiatus hernia
• Achalasia, nutcracker esophagus, diffuse esophageal spasm and other motility disorders of the esophagus
• Functional dyspepsia

Chest wall

• Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
• Spinal nerve problem
• Fibromyalgia
• Chest wall problems
• Radiculopathy
• Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
• Breast conditions
• Herpes zoster commonly known as shingles
• Tuberculosis
• Osteoarthritis
• Bornholm disease

Psychological

• Panic attack
• Anxiety
• Clinical depression
• Somatization disorder
• Hypochondria

Others

• Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
• Da costa's syndrome
• Carbon monoxide poisoning
• Sarcoidosis
• Lead poisoning
• High abdominal pain may also mimic chest pain
• Prolapsed intervertebral disc
• Thoracic outlet syndrome

Diagnostic approach

History taking

Knowing a patient's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors. Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of acute coronary syndrome.^[8]

Physical examination

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.^[2]

If acute coronary syndrome ("heart attack") is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.

Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialised units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. A rapid diagnosis can be life-saving and often has to be made without the help of medical tests. However, in general, additional tests are required to establish the diagnosis.

Medical tests

On the basis of the above, a number of tests may be ordered:^[9]

• An electrocardiogram (ECG)
• Chest radiograph or chest x rays are frequently performed
• CT scanning is used in the diagnosis of aortic dissection
• V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is suspected)
• Blood tests:
  • Troponin I or T (to indicate myocardial damage)
  • Complete blood count
  • Electrolytes and renal function (creatinine)
  • Liver enzymes
  • Creatine kinase (and CK-MB fraction in many hospitals)
  • D-dimer (when suspicion for pulmonary embolism is present but low)
  • serum lipase or amylase to exclude acute pancreatitis

Management

Aspirin increases survival in people with acute coronary syndrome and it is reasonable for EMS dispatchers to recommend it in people with no recent serious bleeding.^[10]

In people with chest pain supplemental oxygen is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress.^[11][12] Entonox is frequently used by EMS personnel in the prehospital environment.^[13] However, there is little evidence about its effectiveness.^[12][14]

Epidemiology

Chest pain is the presenting symptom in about 12% of emergency department visits in the United States and has a one-year mortality of about 5%.^[15] The rate of ED visits in the US for chest pain increased 13% from 2006-2011.^[16]

References