6 Chest Pain
Chest pain is one of the most common complaints of adult patients. Whether the patients admit it or not, they are usually concerned that this pain is caused by some type of cardiac disease. Therefore, the physician must be thoroughly familiar with the differential diagnosis of chest pain. Catastrophic events such as acute coronary syndrome, aortic dissection, pulmonary embolism, pericarditis, and esophageal rupture must be considered. Although the physician must realize that it is in the patient’s interest not to overlook any acute cardiac illness, it is just as essential that cardiac disease not be incorrectly diagnosed or inferred because such misdiagnosis may cause some patients to inappropriately fear they have a cardiac condition.
Common causes of chest pain are angina pectoris; myocardial infarction; musculoskeletal chest wall conditions (especially in children), including costochondritis, benign overuse myalgia, fibrositis, and referred pain; trauma; cervicodorsal arthritis; psychoneurosis; esophageal reflux; esophageal spasm; pleuritis; and mitral valve prolapse (Table 6-1). The most common cause of noncardiac chest pain is gastroesophageal reflux. Less common causes of chest pain include precordial catch syndrome in children, microvascular dysfunction in women, lung tumors, gas entrapment syndromes, pulmonary hypertension, pulmonary embolus, pericarditis, and panic disorder. Cocaine is implicated as the cause of nontraumatic chest pain in 14% to 25% of patients in urban centers. Patients with biliary disease, including cholelithiasis, cholecystitis, and common duct stones, may also present with pain in the chest. A patient complaining of burning chest pain in a dermatomal distribution should be examined for the lesions of herpes zoster (though pain may be experienced prior to appearance of the lesions).
|Resemble angina slightly|
|Not typical of angina|
From Seller RH: Cardiology. In Rakel RE, Conn HF, eds: Family Practice, 2nd ed. Philadelphia, WB Saunders, 1978.
Chest pain due to coronary artery disease (CAD) or other serious organic pathology is rare in young people. In children, chest pain most likely results from the musculoskeletal system (e.g., strain, trauma, overuse, precordial catch, costochondritis), an inflammatory process (e.g., pleurisy or Tietze’s syndrome/costochondritis), or a psychiatric problem (e.g., anxiety, conversion disorder, depression). When pain similar in quality to angina pectoris occurs in a child or adolescent, reflux esophagitis, mitral valve prolapse, or cocaine abuse should be suspected. Although they are uncommon, myocarditis and pericarditis may cause cardiac chest pain in children. Rarely, children with congenital anomalies of the coronary arteries may have ischemic pain. Although pulmonary embolism is uncommon in children, it should be suspected in any postoperative, immobilized, or bedridden patient.
Women are at increased risk for pulmonary embolism if they are taking oral contraceptives. They are more likely than men to have atypical symptoms rather than chest pain as manifestations of cardiac ischemia. These atypical symptoms include back pain, nausea, vomiting, dyspnea, and severe fatigue. Women with typical chest pain and no evidence of obstructive coronary artery disease are likely to have coronary microvascular dysfunction.
In adults, any cause of chest pain may occur. Some patients experience chest wall pain after aortocoronary bypass in which internal mammary artery grafts are used. In older patients, CAD, cervicodorsal arthritis, tumors, esophagitis, and pulmonary embolism are the most common causes.
In athletes chest pain may originate from the heart, lung, or esophagus, but musculoskeletal causes, such as costochondritis, intercostal muscle strain, and stress fractures, must be strongly considered. The musculoskeletal cause may originate in myofascial structures, articular surfaces, the ribs, or the sternum. The pain may be induced by direct trauma, overuse, or gastroesophageal reflux disease (GERD), and asthma may also be induced by exercise.
Although the physician must differentiate chest pain of cardiac origin from other types of pain, it is not sufficient to establish whether or not the pain is of cardiac origin. Patients with pain of cardiac origin should receive varying forms of therapy and have different prognoses, depending on whether their pain is caused by angina pectoris, Prinzmetal’s angina, hypertrophic cardiomyopathy (HCM), mitral valve prolapse, or pericarditis. An accurate diagnosis can usually be made from a precise history. In eliciting the history of chest pain, the examiner should note the following five specific characteristics of the discomfort: location of pain, quality of pain, duration of pain, factors that precipitate or exacerbate the pain, and ameliorating factors.
The distinctive clinical characteristics of angina pectoris are that the pain is paroxysmal (lasting 30 seconds to a few minutes), dull, pressing, squeezing, or aching; it is located substernally; and it may radiate to the precordium, upper extremities, neck, or jaw. The term anginal salute refers to the way patients hold a clenched fist over the sternum to describe the pain. Some patients experience no chest pain and only neck, arm, or jaw discomfort. The location of pain in patients with angina pectoris may vary greatly from person to person, but it differs little with recurrent episodes in the same patient. Thus, if the patient complains of chest pain in different locations during separate episodes, the pain is probably not caused by angina pectoris. Pain of biliary tract or esophageal origin is likely to be substernal, whereas the pain of pericarditis is likely to be precordial.
Patients with angina pectoris describe their pain as tightness, pressure, or heaviness and infrequently as a burning sensation. Burning is relatively uncommon and suggests the possibility of peptic esophagitis, the most frequent imitator of CAD. Rarely if ever is anginal pain described as knifelike, sharp, or sticking. Although some patients describe the pain as “sharp,” they usually mean that it is severe in intensity rather than knifelike in quality. The pain of pulmonary hypertension, which often occurs in patients with mitral stenosis or primary pulmonary disease, may be indistinguishable from the pain of angina pectoris. The pain of pulmonary hypertension is usually described as a dull, pressing, substernal pain. It is precipitated by exertion and relieved by rest or administration of nitroglycerin. Although this pain may radiate to either arm, it radiates more often to the right arm. Patients with pulmonary hypertension and CAD may experience chest pain as a result of pulmonary hypertension, CAD, or both.
The most frequent cause of noncardiac angina-like chest pain is esophageal dysfunction. This pain is usually due to gastroesophageal reflux, although esophageal dysmotility may be less frequently etiologic. Dull, achy, or burning chest pain may also be experienced by patients with pulmonary hypertension, cervicodorsal arthritis, gallbladder disease, diaphragmatic or paraesophageal hernias, and mitral valve prolapse. The associated exacerbating or ameliorating factors are most helpful in establishing the diagnosis.
Sharp, sticking pains, especially if they last only a few seconds, are more characteristic of anxiety, costochondritis, cervicodorsal arthritis, mitral valve prolapse, chest wall syndrome, pericarditis, and pleuritic processes. The location of the pain is usually not helpful in differentiating the cause of the chest pain in these conditions, with a few exceptions. Pain on the side of the chest, particularly if it is exacerbated by respiration, is more likely to be pleuritic. Pain localized to the costochondral junction or specific intercostal spaces is most likely caused by costochondritis or intercostal myositis. The pain of chest wall syndrome may occur during exercise or at rest; occasionally, it is nocturnal. The pain may be described as “sticking” but also as “dull” and “pressing.” The most critical finding in the diagnosis of chest wall syndrome is detection of chest wall tenderness on physical examination. It is more common in athletes. It is frequently located substernally, at the left parasternal region, near the shoulder, and in the fourth or fifth left intercostal space (Fig. 6-1). Pain that is positional, pleuritic, sharp, or reproduced by palpation portends a much lower probability of ischemic heart disease.
Figure 6-1 Regions of anterior chest where spontaneous pain is most often experienced and where tenderness may be elicited are shown in shades of blue. The light blue areas represent radiation of pain.
(Modified from Epstein SE, Gerber LH, Borer JS: Chest wall syndrome: a common cause of unexplained cardiac pain. JAMA 241:2793-2797, 1979.)