Chest Pain

Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. When you encounter a patient with chest pain, eliminating life-threatening causes, such as acute coronary syndrome (ACS) and pulmonary embolism, should be a priority. A thorough history and examination should be performed to narrow the differential diagnosis and guide diagnostic workup and management.

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Overview

Anatomy

The anatomy of the chest and thorax includes: heart, lungs, breasts, and chest wall.

History

Description of chest pain:

  • Onset of pain
  • Provocation/palliation
  • Quality of pain
  • Radiation
  • Site of pain
  • Timing

Typical chest pain descriptions and their clinical significance:

  • Pressure and squeezing pain: acute coronary syndrome (ACS)
  • Sharp pain, worse with inspiration: pulmonary embolism or pneumothorax
  • Ripping or tearing pain: aortic dissection
  • Constant boring pain: esophageal rupture or pericarditis
  • Sudden onset: aortic dissection, pulmonary embolism, or pneumothorax
  • Radiation to arm or jaw: ACS
  • Radiation to back: aortic dissection
  • Associated diaphoresis or nausea: ACS
  • Associated dyspnea: ACS, pulmonary embolism, or pneumothorax

Risk factors:

  • Hypertension
  • Diabetes mellitus
  • Peripheral artery disease (PAD)
  • Malignancy
  • Bicuspid aortic valve (BAV)
  • Connective tissue disorders
  • Recent pregnancy
  • Recent trauma

Physical examination

Vital sign abnormalities and their possible diseases:

  • Fever: esophageal rupture or pulmonary embolism
  • Sinus tachycardia: pulmonary embolism, tamponade, dissection, tension pneumothorax
  • Arrhythmia tachycardia: ACS or pulmonary embolism
  • Bradycardia: ACS involving the conduction system
  • Tachypnea: pulmonary embolism or pneumothorax
  • Hypotension: pulmonary embolism, dissection, tension pneumothorax

Examples of important findings in the physical exam:

  • Absent breath sounds: pneumothorax
  • Muffled heart sounds: tamponade
  • Heart murmur: aortic dissection
  • Pulse deficits: aortic dissection
  • Jugular venous distension (JVD): tamponade, pneumothorax
  • Unilateral edema: pulmonary embolism
  • Stroke symptoms/focal deficits: aortic dissection

Diagnostic workup

  • ECG
  • Laboratories:
    • CBC
    • CMP
    • Erythrocyte sedimentation rate (ESR)/CRP
  • Chest X-ray:  
    • Widening of mediastinum: aortic dissection, mediastinitis 
    • Globular heart: pericardial effusion
    • Absent lung markings: pneumothorax
  • Other tests are done based on the clinical suspicion:
    • Serial troponin: ACS
    • D-dimer: low-risk pulmonary embolism
    • Chest CTA: moderate-to-high-risk pulmonary embolism or aortic dissection
    • Echocardiogram: pericarditis, tamponade, heart failure

Differential Diagnosis

Cardiovascular causes

  • STEMI
    • Chest pressure/squeezing +/- radiation to left shoulder
    • Nausea, vomiting, diaphoresis, anxiety, dizziness, lightheadedness, syncope
    • ECG: ST-segment elevation/depression, T-wave inversions, Q waves   
    • ↑ Troponin
    • Management: emergent percutaneous coronary intervention (PCI), thrombolytics, heparin, aspirin, beta-blockers, oxygen, and nitroglycerin.
  • NSTEMI/unstable angina
    • ECG: nonspecific changes, including T-wave inversions, ST-segment depressions
    • ↑ Or normal troponin
    • Management: emergent PCI, thrombolytics, heparin, aspirin, beta-blockers, oxygen, and nitroglycerin.
  • Aortic dissection
    • Sudden onset of severe, sharp, tearing chest pain that radiates to the back 
    • ↓ Or asymmetric blood pressure, weak pulses, syncope, neurological symptoms
    • New diastolic murmur
    • Symptoms of myocardial ischemia on ECG
    • Management: blood pressure control (type B) or emergent surgery (Type A)
  • Cardiac tamponade
    • ↑ RR, ↑ HR
    • Pulsus paradoxus
    • Cardiogenic shock
    • Beck’s triad: hypotension, ↑ JVD, muffled heart sounds
    • Management: pericardiocentesis or pericardial window surgery, fluid resuscitation
  • Pericarditis
    • Sharp, pleuritic, retrosternal chest pain
    • Exacerbated by lying down, improved by leaning forward
    • Not relieved with nitrates
    • High-pitched pericardial friction rub
    • Pericardial friction rub
    • Management: NSAIDs

Gastrointestinal causes

  • Esophageal perforation
    • Chest pain, neck pain, epigastric pain (radiation to the back)
    • Dyspnea, ↑ RR, ↑ HR
    • Signs of sepsis
    • Mackler triad (chest pain, vomiting, subcutaneous emphysema)
    • Mediastinal crepitus
    • History of recent endoscopy or severe emesis (Boerhaave syndrome)
    • Management: cardiothoracic surgery
  • GERD, erosive esophagitis, and peptic ulcer disease (PUD)
    • Epigastric pain, chest pain, burning, reflux symptoms
    • Aggravated by certain foods
    • Duodenal ulcer (DU): pain relieved with food, weight gain 
    • Gastric ulcer: pain exacerbated by food, weight loss 
    • Vomiting blood, coffee-ground emesis
    • History of NSAID overuse
    • Management: proton pump inhibitors (PPIs), H2 blockers
  • Acute pancreatitis
    • Nausea, vomiting
    • Severe epigastric pain that radiates to the back
    • Epigastric tenderness, guarding, rigidity
    • Hypoactive bowel sounds 
    • History of gallstones, diabetes, or alcohol use
    • Management: nil per os, nausea and pain medications, IV hydration
  • Mallory-Weiss syndrome
    • Epigastric pain
    • Repeated episodes of severe vomiting
    • Hematemesis, GI bleeding, dizziness
    • Management: supportive, endoscopy, possible surgery

Pulmonary causes

  • Pulmonary embolism
    • Pleuritic chest pain, syncope, shortness of breath, hypoxemia
    • Cough, hemoptysis
    • Unilateral leg swelling or history of deep vein thrombosis (DVT)
    • Hypotension, shock
    • Management: thrombolytics, thrombectomy
  • Tension pneumothorax
    • Severe, sharp chest pain
    • Dyspnea, hypoxemia
    • History of trauma
    • Hyperresonance, ↓ breath sounds, tracheal deviation
    • Tachycardia, hypotension
    • Management: immediate needle decompression followed by chest tube
  • Spontaneous pneumothorax
    • Sudden, sharp, unilateral chest pain
    • Often skinny, young men
    • Acute dyspnea, hypoxemia
    • Hyperresonance, ↓ breath sounds on affected side
    • History of lung disease, smoking
    • Management: chest tube
  • Pneumonia
    • Fever, chills, sepsis
    • Cough, dyspnea
    • Hypoxemia
    • Crackles, egophony
    • Management: dependent on infectious cause
  • Asthma exacerbation
    • Shortness of breath, cough
    • ↑ HR, ↑ RR, hypoxemia
    • Wheezing, ↓ or absent breath sounds
    • ↑ Work of breathing
    • Management: short-acting beta-agonist inhalers/nebulizers, steroids, oxygen
  • Chronic obstructive pulmonary disease (COPD) exacerbation
    • Shortness of breath, cough
    • Purulent sputum
    • ↑ RR, hypoxemia
    • Diffuse wheezing, ↓ breath sounds
    • ↑ Work of breathing
    • Management: short-acting beta-agonist inhalers/nebulizers, steroids, oxygen
  • Pleural effusion
    • Unilateral, pleuritic chest pain
    • Shortness of breath
    • Dry, nonproductive cough
    • Dullness to percussion, ↓ breath sounds, ↓ tactile fremitus
    • Pleural friction rub
    • Management: supportive, thoracentesis

Other causes

  • Costochondritis
    • Sharp, well-localized pain
    • Reproducible on palpation of costal cartilage
    • History of recent exercise, exertion, or chest wall trauma
    • Management: NSAIDs, supportive
  • Acute herpes zoster
    • Maculopapular rash that develops into a vesicular rash in a dermatomal distribution
    • Burning pain
    • Management: antivirals
  • Panic disorder
    • Chest tightness, palpitations, ↑ HR
    • ↑ RR, diaphoresis, dizziness, paresthesias
    • Anxiety, recent stressful exposure
    • Management: anxiolytics, breathing exercises or destress activities, psychiatry consult
  • Functional chest pain
    • Retrosternal chest pain or discomfort
    • Diagnosis of exclusion
    • Management: reassure the patient, psychiatrist consult

Management

Directed toward the most likely diagnosis:

  • ACS: oxygen, nitroglycerin, aspirin, morphine
  • Pulmonary embolism: heparin, possible tissue plasminogen activator ((TPa) clot buster), thrombectomy 
  • Aortic dissection: morphine, IV beta-blocker, surgery
  • Pericarditis: NSAIDs
  • Tension pneumothorax: thoracostomy
  • Pericardial tamponade: pericardiocentesis

Disease and consultants:

  • ACS: interventional cardiology 
  • Pulmonary embolism: interventional cardiology or radiology
  • Aortic dissection: vascular or cardiothoracic surgeon
  • Tension pneumothorax: cardiothoracic surgeon
  • Tamponade: cardiothoracic surgeon
  • Esophageal rupture: GI or cardiothoracic surgeon

Clinical Relevance

  • Acute coronary syndrome: acute anginal pain because of partial or total occlusion of 1 or more coronary arteries. A clinical spectrum including 3 clinical entities can be identified: unstable angina, NSTEMI, and STEMI. The entities can be differentiated based on the ECG changes and cardiac markers.
  • Aortic dissection: a fissure of the aortic wall that causes blood to split the wall. Aortic dissection is marked by severe pain, characteristically known as a tearing pain. Aortic dissection is a serious medical emergency and needs urgent diagnosis and management. Risk factors include hypertension, genetic diseases, and trauma.
  • Pulmonary embolism: mechanical obstruction of the pulmonary artery or its branches by embolic material (such as thrombus, air, or fat). Acute features include pleurisy, dyspnea, hemoptysis, tachycardia, tachypnea, hypotension, or signs of DVT. Diagnosis is confirmed with CT chest. 
  • Pericardial tamponade: a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Features include Beck’s triad (hypotension, distended jugular venous pressure (JVP), muffled heart sound), dyspnea, tachycardia, and clear lung fields
  • Pneumothorax: abnormal collection of air in the pleural space due to laceration of the lungs. Types of pneumothorax include simple (spontaneous) pneumothorax and tension pneumothorax. Physical exam findings include tachypnea, decreased breath sounds, and hyperresonance on percussion. Treatment includes needle decompression and chest tube placement.
  • Mediastinitis: inflammation of the tissues in the midchest, or mediastinum. Mediastinitis is usually a complication of cardiac surgery. Features include constant boring pain, fever, tachycardia, wound drainage, and purulent discharge. A chest X-ray might demonstrate widening of the mediastinum. Management involves surgical debridement and antibiotic therapy.

References

  1. Hollander, J. (2020). Evaluation of the adult with chest pain in the emergency department. UpToDate. Retrieved August 15, 2021, from https://www.uptodate.com/contents/evaluation-of-the-adult-with-chest-pain-in-the-emergency-department
  2. Cuffari, C. (2016). Mallory-Weiss syndrome treatment & management. Emedicine. Retrieved August 15, 2021, from https://emedicine.medscape.com/article/931141-treatment?ecd=ppc_google_rlsa-traf_mscp_emed_md-ldlm-cohort_us#d6 
  3. Cheng, S. (2020). Evaluating and managing low-risk chest pain in the ED. Emedicine. Retrieved August 15, 2021, from https://www.medscape.com/viewarticle/760262_1?ecd=ppc_google_rlsa-traf_mscp_news-perspectives_md-ldlm-cohort_us 
  4. Alaeddini, J. (2018). Angina pectoris. Emedicine. Retrieved August 15, 2021, from https://emedicine.medscape.com/article/150215-overview 
  5. Pray, S. (2019). The patient with chest pain. Medscape. Retrieved August 15, 2021, from https://www.medscape.com/viewarticle/557161
  6. Garry, J. (2018). Pediatric costochondritis. Medscape. Retrieved August 15, 2021, from https://emedicine.medscape.com/article/1006486-overview

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