Chest pain: Difference between revisions
(Created page with "'''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...") |
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Latest revision as of 11:17, 23 November 2023
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:
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. |