Chest pain is pain in any region of the chest. Chest pain may be a symptom of a number of serious disorders and is, in general, considered a medical emergency. Chest pain can be differentiated into heart-related and non heart related chest pain. Cardiac chest pain is called angina pectoris. Even though it may be determined that the pain is noncardiac in origin (does not come from a heart problem), noncardiac chest pain can still be a medical emergency and present significant disease.
|Synonym||Pectoralgia, stethalgia, thoracalgia, thoracodynia|
|Potential location of pain from a heart attack|
|Specialty||Emergency medicine, internal medicine|
Chest pain is a common presenting problem:
- In the United States, an estimated 6-8 million people per year present to the emergency department with chest pain.
- An estimated 50-70% of patients presenting with chest pain in the emergency department will be placed in an observation unit or admitted to the hospital.
- 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.
Signs and symptomsEdit
Chest pain may present in different ways depending upon the underlying diagnosis. Chest pain may also vary from person to person based upon age, sex, weight, and other differences. Chest pain may present as a stabbing, burning, aching, sharp, or pressure-like sensation in the chest. Other associated symptoms with chest pain can include nausea, vomiting, dizziness, shortness of breath, anxiety, and sweating.
Causes of chest pain range from non-serious to serious to life-threatening.
In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%). Other less common causes include: pneumonia, lung cancer, and aortic aneurysms.
In children, the most common causes for chest pain are musculoskeletal (76-89%), exercise-induced asthma (4-12%), gastrointestinal illness (8%), and psychogenic causes (4%). Chest pain in children can also have congenital causes.
- Acute coronary syndrome
- Stable or unstable angina
- Myocardial infarction ("heart attack") - People usually complained of a pressure or squeezing sensation over the chest. Other associated symptoms are: excessive sweating, nausea, vomiting, and weakness. The Levine's sign, where the patient placed his fist on the chest while describing his pain, is strongly suggestive of cardiac cause of chest pain. Chest pain is more commonly associated with anterior infarction because of left ventricular impairment; inferior infarction is more commonly associated with nausea, vomitng, and excessive sweating due to irritation of vagus nerve; lateral infarction is associated with left arm pain.
- Prinzmetal's angina - Chest pain is caused by coronary vasospasm. More common in women younger than 50 years. Patient usually complain of chest pain at rest. It may occur early in the morning which awaken patient from sleep.
- Cocaine abuse - This condition is suspected when a patient with few or no risk of arteriosclerosis presented with non-traumatic chest pain. Ingestion of cocaine can cause vasoconstriction of coronary arteries, thus producing chest pain similar to heart attack. Symptoms can appear within one hour of cocaine use.
- Aortic stenosis - This condition happens when the patient has underlying congenital bicuspid valve, aortic sclerosis, or history of rheumatic fever. Chest pain usually happens during physical activity. Syncope is a late symptom. Signs and symptoms of heart failure may also present. On auscultation, loud ejection systolic murmur can be best heard at the right second intercostal space and radiates to the carotid artery in the neck. Splitting of second heart sound is heard in severe stenosis.
- Hypertrophic cardiomyopathy - It is the hypertrophy of interventricular septum that causes outflow obstruction of left ventricle. Dyspnoea and chest pain commonly occurs during daily activities. Sometimes, syncope may happen. On physical examination, significant findings include: loud systolic murmur and palpable triple apical impulse due to palpable presystolic fourth heart sound.
- Aortic dissection is characterised by severe chest pain that radiates the back. It is usually associated with Marfan's syndrome and hypertension. On examination, murmur of aortic insufficiency can be heard with unequal radial pulses.
- Pericarditis - This condition can be the result of viral infection such as coxsackie virus and echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial infarction (Dressler syndrome). The chest pain is often pleuritic in nature (associated with respiration) which is aggravated when lying down and relieved on sitting forward, sometimes, accompanied by fever. On auscultation, pericardial friction rub can be heard.
- cardiac tamponade
- Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
- Mitral valve prolapse syndrome - Those affected are usually thin females presented with chest pain which is sharp in quality, localised at the apex, and relieved when lying down. Other symptoms include: shortness of breath, fatique, and palpitations. On auscultation, midsystolic click followed by late systolic murmur can be heard, louder when patient is in standing position.
- Aortic aneurysm
- Pulmonary embolism - Common signs and symptoms are shortness of breath, pleuritic chest pain, blood in sputum during cough (haemoptysis), and lower limb swelling. Risk factors includes: recent surgery, malignancy, and bedridden state. Source of embolus usually comes from venous thromboembolism.
- Pneumothorax - Those who are at a higher risk of developing pneumothorax are tall, thin, male smoker who had underlying lung diseases such as emphysema. Those affected can have a sharp chest pain which radiates to the shoulder of the same side. Physical examination revealed absent breath sounds and hyperresonance on the affected side of the chest.
- Pleurisy - an inflammation that can cause painful respiration
- Lung malignancy
- Achalasia, nutcracker esophagus, and other motility disorders of the esophagus
- Diffuse esophageal spasm - Unlike cardiac chest pain, oesophageal pain is not related to activity. The pain is usually associated with swallowing of hot or cold water.
- Esophageal rupture - Those affected usually complained of sudden, severe, and constant pain that starts from the neck to the upper abdomen. The pain is aggravated by swallowing. On examination, neck swelling and crepitations can be felt due to subcutaneous emphysema as free air is entering from oesophagus into the subcutaneous tissue.
- Esophagitis - There are many causes of oesophagitis. Oesophagitis caused by Candida albicans is usually found in chemotherapy or HIV patients. Medication such as nonsteroidal anti-inflammatory drug (NSAIDs) and alendronate can induce oesophagitis if not swallowed properly.
- Gastroesophageal reflux disease (GERD) - The pain is aggravated when lying down or after meals. Patients may describe this as a heartburn. Besides, they may also complain of tasting bitter contents from the stomach.
- Functional dyspepsia
- Hiatus hernia
- Jackhammer esophagus
- Acute cholecystitis - Characterised by positive Murphy's sign where the patient had a cessation of inhalation when the doctor placed his finger at the right subcoastal region of the abdomen.
- Acute pancreatitis - History of alcohol abuse, cholelithiasis (stones in the gallbladder), and hypertriglyceridemia are risk factors for pancreatitis. It is a constant, boring pain in the upper abdomen.
- Perforated peptic ulcer - Sudden onset of severe pain in the upper abdomen which later developed into peritonitis (inflammation of tissues that lines the abdominal organs).
- Costochondritis or Tietze's syndrome - an inflammation of costochondral junction. Any movements or palpation of the chest can reproduce the symptoms.
- Spinal nerve problem
- Chest wall problems
- 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 - It is usually described as a burning sensation over the chest in a unilateral dermatome distribution. However, diagnosis can be difficult because the pain usually appears before the characteristic rash is visible.
- Bornholm disease
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.
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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.
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.
On the basis of the above, a number of tests may be ordered:
- 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
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. Entonox is frequently used by EMS personnel in the prehospital environment. However, there is little evidence about its effectiveness.
For people with non-cardiac chest pain, cognitive behavioral therapy (CBT) might be helpful. A 2015 Cochrane review found that CBT might reduce the frequency of chest pain episodes the first three months after treatment.
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%. The rate of ED visits in the US for chest pain decreased 10% from 1999 to 2008 but a subsequent increase of 13% was seen from 2006-2011.
- Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline D (2016). Tintinalli's emergency medicine: a comprehensive study guide (Eighth ed.). New York: McGraw-Hill Education. ISBN 978-0-07-179476-3. OCLC 915775025.
- Schey R, Villarreal A, Fass R (April 2007). "Noncardiac chest pain: current treatment". Gastroenterology & Hepatology. 3 (4): 255–62. PMC . PMID 21960837.
- Wertli MM, Ruchti KB, Steurer J, Held U (November 2013). "Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis". BMC Medicine. 11: 239. doi:10.1186/1741-7015-11-239. PMC . PMID 24207111.
- Marx JA, Hockberger RS, Walls RM, Biros MH, Danzl DF, Gausche-Hill M, Jagoda A, Ling L, Newton E, Zink BJ, Rosen P (2014). Rosen's Emergency Medicine: Concepts and Clinical Practice (Eighth edition ed.). Philadelphia, PA: Elsevier/Saunders. ISBN 978-1-4557-0605-1. OCLC 853286850.
- Thull-Freedman J (March 2010). "Evaluation of chest pain in the pediatric patient". The Medical Clinics of North America. 94 (2): 327–47. doi:10.1016/j.mcna.2010.01.004. PMID 20380959.
- Woo KM, Schneider JI (November 2009). "High-risk chief complaints I: chest pain--the big three". Emergency Medicine Clinics of North America. 27 (4): 685–712, x. doi:10.1016/j.emc.2009.07.007. PMID 19932401.
- Kontos MC, Diercks DB, Kirk JD (March 2010). "Emergency department and office-based evaluation of patients with chest pain". Mayo Clinic Proceedings. 85 (3): 284–99. doi:10.4065/mcp.2009.0560. PMC . PMID 20194155.
- Baren JM, Rothrock SG, Brennan JA, Brown L (2008). Pediatric Emergency Medicine. Philadelphia: Saunders/Elsevier. p. 481. ISBN 978-1-4160-0087-7.
- Karnath B, Holden MD, Hussain N (April 2004). "Chest pain: Differentiating cardiac from non-cardiac causes" (PDF). Hospital Physician. 38: 24–27. Retrieved 8 December 2017.
- Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA (August 2016). "Acute Aortic Dissection and Intramural Hematoma: A Systematic Review". JAMA. 316 (7): 754–63. doi:10.1001/jama.2016.10026. PMID 27533160.
- Swap CJ, Nagurney JT (November 2005). "Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes". JAMA. 294 (20): 2623–9. doi:10.1001/jama.294.20.2623. PMID 16304077.
- Hess EP, Perry JJ, Ladouceur P, Wells GA, Stiell IG (March 2010). "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome". CJEM. 12 (2): 128–34. PMID 20219160.
- O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O'Neil BJ, Travers AH, Yannopoulos D (November 2010). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028. PMID 20956226.
- "Highlights of the 2010 AHA Guidelines for CPR and ECC" (PDF). American Heart Association.
- Castle N (February 2003). "Effective relief of acute coronary syndrome". Emergency Nurse. 10 (9): 15–9. doi:10.7748/en2003.02.10.9.15.c1090. PMID 12655961.
- "Entonox for the Treatment of Undiagnosed Chest Pain: Clinical Effectiveness and Guidelines" (PDF). Canadian Agency for Drugs and Technologies in Health. Retrieved 12 July 2011.
- Kisely SR, Campbell LA, Yelland MJ, Paydar A (June 2015). "Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy". The Cochrane Database of Systematic Reviews (6): CD004101. doi:10.1002/14651858.cd004101.pub5. PMID 26123045.
- Dubner SJ, Levitt SD (2009). SuperFreakonomics: Tales of Altruism, Terrorism, and Poorly Paid Prostitutes. New York: William Morrow. p. 77. ISBN 978-0-06-088957-9.
- "Products - Data Briefs - Number 43 - September 2010". www.cdc.gov. Retrieved 2018-01-19.
- Skiner HG, Blanchard J, Elixhauser A (September 2014). "Trends in Emergency Department Visits, 2006-2011". HCUP Statistical Brief #179. Rockville, MD: Agency for Healthcare Research and Quality.