Chest Pain

1. See Also
   1. Angina
   2. Angina Diagnosis
   3. Chest Wall Pain
2. Evaluation
   1. See Angina Diagnosis if suspect Acute Coronary Syndrome
   2. High Risk Findings
      1. Chest Pain
      2. History of known Coronary Artery Disease
      3. Radiation of pain to left arm or neck
      4. Pain longer than 1 hour
      5. Diaphoresis
   3. Low risk Findings
      1. Sharp Chest Pain
      2. Chest Pain longer than 48 hours
      3. Chest Pain fully reproduced with palpation
   4. Focus Areas
      1. Identify non-cardiac cause of Chest Pain
      2. Complications of Myocardial Infarction
3. Precautions
   1. Sudden Dyspnea may be only presenting symptom
      1. Only symptom in up to 14% of patients with MI
   2. Myocardial Infarction often presents with GI Symptoms
      1. Indigestion or burning pain (23%)
      2. Stabbing or sharp pain (5-20%)
      3. Pain fully reproduced with palpation (8-10%)
      4. Nausea (60%)
   3. Esophageal pain often presents with MI type findings
      1. Pain radiates to left arm (11%)
      2. Responds to Nitroglycerin (30-50%)
   4. Relief with Nitroglycerin does not predict cause
      1. Non-cardiac pain is often relieved with Nitroglycerin
      2. Shry (2002) Am J Cardiol 90:1264-6
   5. Sharp or stabbing Chest Pain may still be cardiac
      1. Up to 22% with sharp Chest Pain have ACS
      2. Several atypical symptoms lowers ACS likelihood
4. Differential Diagnosis: Onset
   1. Sudden Onset
      1. Angina
      2. Myocardial Infarction
      3. Aortic Dissection
      4. Pulmonary Embolus
      5. Esophageal Rupture
      6. Spontaneous Pneumomediastinum
      7. Spontaneous Pneumothorax
   2. Gradual or Variable Onset
      1. Pericarditis
      2. Musculoskeletal Chest Pain
      3. Costochondritis
      4. Epidemic Pleurodynia
      5. Mitral Valve Prolapse
5. Differential Diagnosis: Characteristic
   1. Pressure Sensation
      1. Angina
      2. Myocardial Infarction
      3. Esophageal Spasm
   2. Tearing Sensation
      1. Aortic Dissection
   3. Sharp or Stabbing Sensation
      1. Pericarditis
      2. Pulmonary Embolus
      3. Musculoskeletal Chest Pain
      4. Epidemic Pleurodynia
      5. Mitral Valve Prolapse
      6. Spontaneous Pneumothorax
      7. Esophageal Spasm
6. Differential Diagnosis: Provocative Factors
   1. Exertion or stress
      1. Angina
      2. Myocardial Infarction
   2. Hypertension
      1. Aortic Dissection
   3. Pleuritic (Deep breath or cough)
      1. See Pleuritic Chest Pain
      2. See Pleuritic Chest Pain due to Medications
      3. Pulmonary Embolus
      4. Pericarditis
      5. Spontaneous Pneumomediastinum
      6. Musculoskeletal Chest Pain
      7. Cough fracture
   4. Swallowing or Vomiting
      1. Esophageal Rupture
      2. Spontaneous Pneumomediastinum
   5. Supine Position
      1. Pericarditis
      2. Spontaneous Pneumomediastinum
   6. Movement
      1. Musculoskeletal Chest Pain
      2. Cough fracture
7. Differential Diagnosis: Radiation of pain
   1. Pain radiates to arm or Shoulder
      1. Angina or Myocardial Infarction
         1. Pain radiating to both arms strongly suggests MI
      2. Pericarditis
      3. Spontaneous Pneumothorax
      4. Esophageal Spasm
   2. Pain radiates to back
      1. Aortic Dissection
      2. Pericarditis
      3. Spontaneous Pneumothorax
      4. Esophageal Spasm
   3. Pain Radiates to Neck, throat, or jaw
      1. Spontaneous Pneumomediastinum
      2. Pericarditis
      3. Angina
      4. Myocardial Infarction
      5. Esophageal Spasm
8. References
   1. Achar (2005) Am Fam Physician 72:119-26
   2. Goodacre (2002) Acad Emerg Med 9:203-8