Chest pain

Chest pain is a common symptom and can occur due to a variety of disorders. Acute chest pain is a common cause of admission to the emergency department. Most cases are not life-threatening, but it’s important to rule out life-threatening causes.

Evaluation

Everyone who is admitted with acute chest pain get:

• Blood test checking for troponins, D-dimer, amylase, + other general tests
• ECG

Further examinations are based on the examining physician’s differential diagnosis based on the patient’s clinical features. These may include:

• Echocardiography
• Imaging
• Arterial blood gas

Types

Clinically, we distinguish three types of chest pain based on the pain characteristics; typical angina, atypical angina, and non-anginal chest pain. There are three features which are important here:

• The pain has typical anginal characteristics: constricting discomfort in the front of the chest or in the neck, jaw, shoulder, or arm
• The pain is provoked by physical or emotional stress
• The pain is relieved by rest or nitroglycerine

Typical angina, called angina pectoris, has all three features. If only 2 features are present, the chest pain is called atypical angina. If only 1 or none of the above apply, it’s called non-anginal chest pain.

As few as 10 – 15% of patients with CCS present with typical angina.

Differential diagnosis of acute chest pain

Life-threatening causes

Organ system	Cause	Typical features
Cardiac	Acute coronary syndrome	Heavy, dull, squeezing pain. Substernal pain with radiation to left shoulder. Nausea/vomiting. Sweating. Pain improves with nitroglycerine. Pathological ECG. Elevated troponins.
	Aortic dissection	Sudden onset, severe, sharp, tearing chest or abdominal pain that radiates to the back. Hypotension. Syncope. Asymmetric blood pressure between the arms.
	Cardiac tamponade	Hypotension. Jugular venous distension. Distant heart sounds. Tachypnoea. Dyspnoea. Pulsus paradoxus.
	Chronic heart failure exacerbation	Cough. Pulmonary crackles. Jugular venous distension. Peripheral oedema.
	Takotsubo cardiomyopathy	Recent stressful event. Acute heart failure.
Pulmonary	Pulmonary embolism	Acute onset. Pleuritic chest pain. Dyspnoea. Hypoxaemia. Cough. Haemoptysis. History of DVT or DVT risk factors. Obstructive shock if severe. ECG signs of right heart strain.
	Tension pneumothorax	Severe, sharp chest pain. Dyspnoea. Hypoxaemia. History of trauma. Hyperresonance on percussion. Decreased breathing sounds on auscultation.
Gastrointestinal	Oesophageal perforation	Retrosternal/neck/epigastric pain radiates to the back. Recent procedure near the oesophagus or severe emesis. Signs of sepsis. Vomiting. Subcutaneous emphysema.

Non-life-threatening causes

Organ system	Cause	Typical features
Cardiac	Stable angina	Retrosternal chest pain in relation to exercise, relieved with rest. Improves with nitroglycerine. Normal ECG and troponins.
	Pericarditis	Sharp retrosternal pain, worsens on inspiration, improves when leaning forward. Pericardial friction rub on auscultation.
Pulmonary	Pneumonia	Fever. Cough Ill appearance. Elevated inflammatory markers.
	Asthma exacerbation	Known asthma or recurrent episodes of dry cough and wheezing. Worsening of known symptoms. Dyspnoea. Tachypnoea. Hypoxaemia. Silent chest on auscultation. Hyperresonance on percussion.
	COPD exacerbation	Known COPD or known cough + dyspnoea. Worsening of known symptoms. Purulent sputum. Tachypnoea. Wheezing. Hypoxaemia, hypercapnia.
Gastrointestinal	Gastroesophageal reflux disease	Burning sensation substernally, aggravated in supinated position and after food. Epigastric tenderness.
	Peptic ulcer disease	Pain either relieved or worsened by food. Known risk factors.
Musculoskeletal	Costochondritis	Tenderness of the costochondral joint. Pain in the chest wall. Worsen with movement of the thorax, but not related to exercise.
	Intercostal muscle strain	Tenderness and pain in the intercostal muscles. Don’t worsen with exercise.
Other	Anxiety attack	Chest tightness. Palpitations. Tachypnoea. Diaphoresis. Anxious appearance.
	Herpes zoster	Burning pain. Maculopapular/vesicular rash on the chest.