Chest pain

In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency, unless the patient is a known angina pectoris sufferer and the symptoms are familiar.

Causes

Important cardiovascular and pulmonary causes of chest pain:

• Angina pectoris
  • "Unstable" AP - this is an emergency and can resemble a heart attack
  • "Stable" AP - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense
• Myocardial infarction ("heart attack")
• Aortic dissection
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Pulmonary embolism
• Pneumonia

Other causes of chest pain include:

• Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
• Gastroesophageal reflux disease (GERD)
• Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
• Bornholm disease - a viral disease that can mimic all of the above
• Several others.

Common, non-life threatening causes include chest wall pain (ribs, muscle, cartilege); nerve irritation ("pinched nerve" in the lower next or upper back); esophagus spasm, stomach aches, and GERD; and strains and sprains, to name a few.

Analysis

As in all medicine, a careful medical history and physical examination is essential is separating dangerous and trivial causes of disease, and the management of chest pain is often done on specialised units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection).

An emergency medicine doctor will also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking.

On the basis of the above, a number of tests may be ordered:

• X-rays of the chest and/or abdomen (CT scanning may be better but is often not available)
• An electrocardiogram (ECG)
• V/Q scintigraphy (when a pulmonary embolism is suspected)
• Blood tests:
  • Full blood count
  • Electrolytes and renal function (creatinine)
  • Liver enzymes
  • Troponin I or T (to indicate myocardial damage)
  • D-dimer (when suspicion for pulmonary embolism is present but low)

Interpretation

In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analyses are not sensitive enough (Chun & McGee 2004). The physician's typical approach is to rule-out the most dangerous causes of chest pain first (eg: heart attack, blood clot in the lung, aneurism). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient. If acute coronary syndrome ("unstable angina") is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (CK-MB or troponin). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.

Reference

• Chun AA, McGee SR. Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004;117:334-43. PMID 15336583.
• R. Burton, MD. Emergency Medicine. Lectures on Chest Pain. 2004.