II. Risk Factors

IV. Evaluation: Approach

  1. Acute Chest Pain Approach
  2. See Angina Diagnosis
  3. Focus Areas
    1. First exclude serious Chest Pain Causes
    2. Evaluate for signs of Myocardial Infarction complications (e.g. acute Congestive Heart Failure)
    3. Identify non-cardiac cause of Chest Pain

V. Precautions

  1. No single finding is absolutely pathognomonic nor completely reassuring in Chest Pain presentation
    1. Risk stratification, evaluation and management is based on an overall analysis of all clinical data
    2. Approach should be based on combination of factors
      1. Chest Pain Decision Rules
      2. Exam, ekg and Serum Cardiac Markers
  2. Myocardial Infarction without Chest Pain occurs in up to 50% of patients
    1. Men: 31% overall (13% under age 45)
    2. Women: 42% overall (20% under age 45)
    3. Mortality is 10-15% for painless MI (contrast with 1-2% for those with Chest Pain)
    4. Canto (2000) JAMA 283(24): 3223-9 [PubMed]
    5. Canto (2012) JAMA 307(8): 813-22 [PubMed]
  3. Cardiac Risk Factors only weakly predict Acute Coronary Syndrome (especially with advancing age)
    1. Age 40-65 years: 2.1 Positive Likelihood Ratio
    2. Age over 65 years: 1.1 Positive Likelihood Ratio
    3. Han (2007) Ann Emerg Med 49(2): 145-52 [PubMed]
  4. Sudden Dyspnea may be only presenting symptom of ACS
    1. Only symptom in up to 14% of patients with MI
  5. Myocardial Infarction often presents with gastrointestinal symptoms
    1. Indigestion or burning pain (23%)
    2. Nausea (60%)
    3. Upper Abdominal Pain (20%)
  6. Esophageal pain often presents with MI type findings
    1. Pain radiates to left arm (11%)
    2. Responds to Nitroglycerin (30-50%)
  7. 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 [PubMed]
  8. Sharp or stabbing Chest Pain may still be cardiac
    1. Up to 22% with sharp Chest Pain have ACS
    2. Several atypical symptoms lower ACS likelihood
    3. ACS may present with Pain fully reproduced with palpation (8-10%)
  9. Intrascapular pain without Chest Pain can represent catastrophic cardiovascular events
    1. Evaluate for Acute Coronary Syndrome and Aortic Dissection
    2. Evaluate for Pulmonary Embolism
    3. Diagnosis of spinal or musculoskeletal causes are after exclusion of intra-thoracic causes
  10. Women often present atypically with Myocardial Infarctions
    1. Even prior stress testing may have been falsely reasuring
      1. Non-occlusive CAD is twice as common in women
      2. Non-occlusive Plaque may embed within artery wall, erode and cause acute thrombus or vasospasm
    2. Presentations are more similar as men and women age (contrary to prior doctrine)
      1. By age 75 years old, both men and women present without Chest Pain in 50% of cases
    3. Greatest discrepancy between male and female ACS presentations are in the under age 45 cohort
      1. Women with MI under age 45 present without Chest Pain in 20% of cases (contrast with 13% in men)
    4. Canto (2012) JAMA 307(8): 813-22 [PubMed]
    5. Pepine (2015) J Am Coll Cardiol 66(17): 1918-33 +PMID:26493665 [PubMed]

VI. Symptoms

  1. See precautions above
  2. See Likelihood of Coronary Disease as Cause of Chest Pain
  3. Findings that most increase the likelihood of Acute Coronary Syndrome
    1. Pain radiation to the right chest or bilateral chest (or Shoulder)
    2. Exertional pain
    3. Pain with diaphoresis
    4. Pain associated with Vomiting (not only Nausea)
  4. Other findings that increase the likelihood of Acute Coronary Syndrome
    1. Pain duration >1 hour (and less than 48 hours)
    2. Central Chest Pain
  5. Findings that decrease the likelihood of Acute Coronary Syndrome
    1. Pleuritic Chest Pain
    2. Sharp Chest Pain
    3. Positional Chest Pain
    4. Pain at rest
    5. Pain fully reproducible on palpation
    6. Pain for more than 48 hours

VII. Signs

  1. See Likelihood of Coronary Disease as Cause of Chest Pain
  2. Findings that increase the likelihood of Acute Coronary Syndrome (acute Congestive Heart Failure findings)
    1. New S3 Gallup Rhythm or Third Heart Sound (Positive Likelihood Ratio 3.2)
    2. Hypotension (Positive Likelihood Ratio: 3.1)
    3. New Mitral Regurgitation murmur
    4. Pulmonary Rales
    5. New Jugular Venous Distention
  3. Finding that decrease the likelihood of Acute Coronary Syndrome
    1. Pain reproducible on palpation (Negative Likelihood Ratio: 0.2 to 0.4)

XII. 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 (Positive Likelihood Ratio 7.1)
    2. Pericarditis
    3. Spontaneous Pneumothorax
    4. Esophageal Spasm
  2. Pain radiates to back or intrascapular
    1. Aortic Dissection
    2. Pericarditis
    3. Acute Coronary Syndrome
    4. Spontaneous Pneumothorax
    5. Esophageal Spasm
    6. Thoracic Spine radicular pain (e.g. thoracic compression Fracture, T4 syndrome)
    7. Pulmonary Embolism
  3. Pain Radiates to Neck, throat, or jaw
    1. Spontaneous Pneumomediastinum
    2. Pericarditis
    3. Acute Coronary Syndrome
    4. Esophageal Spasm

XIII. Differential Diagnosis: Diagnoses of Exclusion

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Ontology: Chest Pain (C0008031)

Definition (ICF) Sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the chest.
Definition (ICF-CY) Sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the chest.
Definition (MSHCZE) Tlak, pálení nebo znecitlivění v hrudníku.
Definition (MEDLINEPLUS)

Having a pain in your chest can be scary. It does not always mean that you are having a heart attack. There can be many other causes, including

Some of these problems can be serious. Get immediate medical care if you have chest pain that does not go away, crushing pain or pressure in the chest, or chest pain along with nausea, sweating, dizziness or shortness of breath. Treatment depends on the cause of the pain.

Definition (NCI_NCI-GLOSS) Chest pain.
Definition (NCI) Pain in the chest.
Definition (MSH) Pressure, burning, or numbness in the chest.
Concepts Sign or Symptom (T184)
MSH D002637
ICD9 786.50, 786.5
ICD10 R07.4 , R07.9
SnomedCT 207078009, 207093008, 271330001, 139228007, 158404009, 161978005, 158393008, 139240007, 207079001, 29857009
LNC LP98885-4, MTHU035552
English Chest Pains, Unspecified chest pain, Pains, Chest, THORACIC PAIN, Chest pain, unspecified, [D]Chest pain (context-dependent category), [D]Chest pain NOS (context-dependent category), [D]Chest pain, unspecified (context-dependent category), [D]Chest pain, [D]Chest pain NOS, [D]Chest pain, unspecified, Thoracalgia, chest pain or discomfort (symptom), chest pain or discomfort, chest pain (diagnosis), chest pain, Pain chest, Pain in chest, Thoracic pain, Thorax pain, Chest pain NOS, Nonspecific chest pain, Chest Pain [Disease/Finding], Pain;chest, pain thoracic, thoracic pain, thorax pain, Pain, Chest, [D]Chest pain (situation), [D]Chest pain, unspecified (situation), Chest pain NOS (finding), [D]Chest pain NOS (situation), Thorax painful, chest pain or discomfort reported as pain, chest pain or discomfort reported as pain (symptom), reported chest pain, thoracodynia, PAIN IN CHEST, CHEST PAIN, thoracalgia, Chest pain, Chest pain (finding), Chest pain nos, chest; pain, pain; chest, pain; thorax, thorax; pain, Chest pain, NOS, Chest Pain
French DOULEUR THORACIQUE, Douleur thoracique non précisée, Douleur thoracique non spécifique, Douleur dans la poitrine, Thoracalgie, Douleur thoracique NS, Douleur thoracique, Douleur du thorax
Portuguese DOR NO PEITO, Dor no tórax, Dor torácica NE, Dor torácica inespecífica, Toracalgia, DOR TORACICA, Opressão no Peito, Precordialgia, Dor Torácica, Dor no Tórax, Pressão no Peito, Dor Precordial, Dor na Região Precordial, Dor torácica, Dor no Peito
Dutch thoraxpijn, pijn op de borst, niet-specifieke pijn op de borst, niet-gespecificeerde borstpijn, thoracalgie, Pijn op de borst nao, borst; pijn, pijn; borst, pijn; thorax, thorax; pijn, Pijn op borst, niet gespecificeerd, borstkaspijn, Borstpijn, Pijn op de borst
German Thoraxschmerz, unspezifischer Brustschmerz, Schmerz, Brust, Thorakalgie, BRUSTKORBSCHMERZ, Brustschmerzen, nicht naeher bezeichnet, THORAXSCHMERZ, Brustkorbschmerz, Brustschmerzen, Schmerzen im Brustkorb, Thoraxschmerzen
Italian Dolore toracico non specifico, Dolore al torace, Dolore toracico non specificato, Toracoalgia, Dolore toracico
Spanish Dolor de tórax, Dolor de pecho no específico, Dolor torácico no especificado, Dolor de pecho, [D]dolor torácico, SAI (categoría dependiente del contexto), [D]dolor torácico (categoría dependiente del contexto), [D]dolor torácico, no especificado (categoría dependiente del contexto), Toracalgia, TORACICO, DOLOR, TORAX, DOLOR, Dolor en el Pecho, dolor torácico, SAI, dolor torácico, SAI (hallazgo), [D]dolor torácico, no especificado (situación), [D]dolor torácico, [D]dolor torácico (situación), Chest pain NOS, [D]dolor torácico, SAI, [D]dolor torácico, SAI (situación), [D]dolor torácico, no especificado, Dolor Precordial, Dolor en el Torax, Dolor de Torax, Precordialgía, Opresión en el Pecho, Presión en el Pecho, Dolor de Pecho, Dolor Torácico, dolor de pecho (hallazgo), dolor de pecho, Dolor torácico
Japanese 胸郭痛, 非特異的胸痛, 胸痛, 詳細不明の胸痛, キョウツウ, キョウカクツウ, ショウサイフメイノキョウツウ, ヒトクイテキキョウツウ
Swedish Bröstsmärta
Finnish Rintakipu
Russian GRUDNAIA KLETKA, BOLI, ГРУДНАЯ КЛЕТКА, БОЛИ
Czech Bolest na hrudi, Nespecifikovaná bolest na hrudi, Bolest hrudníku, Torakalgie, Nespecifická bolest na hrudi, bolesti na hrudi, bolest na hrudi, hrudník - bolest
Korean 상세불명의 가슴통증
Croatian PRSNI KOŠ, BOL
Polish Ból w klatce piersiowej, Ból zamostkowy
Hungarian Mellkasi fájdalom, Thorax fájdalom, Fájdalom a mellkasban, Thoracalis fájdalom, Aspecifikus mellkasi fájdalom, Nem meghatározott mellkasi fájdalom, Thoracalgia
Norwegian Brystsmerter

Ontology: Precordial pain (C0232286)

Concepts Sign or Symptom (T184)
ICD9 786.51
ICD10 R07.2
SnomedCT 207080003, 71884009, 158394002, 139231008
English CHEST PAIN PRECORDIAL, [D]Precordial pain (context-dependent category), [D]Precordial pain, Precordial chest pain, Precordial pain, Chest pain precordial, Pain precordial, precordial chest pain, precordial pain, [D]Precordial pain (situation), Precordial pain (finding), pain; precordial, precordial; pain
Dutch precordiale pijn op de borst, precordiale pijn, pijn precordiaal, pijn; precordiaal, precordiaal; pijn, Precordiale pijn
French Douleur précordiale, Douleur thoracique précordiale, DOULEUR THORACIQUE PRECORDIALE
German praekordialer Schmerz, Brustschmerz, praekordial, Schmerz, praekordial, PRAEKORDIALSCHMERZ, Praekordiale Schmerzen
Italian Dolore precordiale, Dolore toracico precordiale
Portuguese Dor precordial, Dor torácica precordial, DOR TORAXICA PRECORDIAL
Spanish Dolor torácico precordial, Dolor precordial, [D]dolor precordial (categoría dependiente del contexto), PRECORDIAL, DOLOR, [D]dolor precordial, [D]dolor precordial (situación), dolor de pecho precordial, dolor precordial (hallazgo), dolor precordial
Japanese 前胸部痛, ゼンキョウブツウ
Czech Bolest prekordiální, Prekordiální bolest na hrudi, Prekordiální bolest
Korean 명치 통증
Hungarian Praecordalis fájdalom, Praecordialis fájdalom, Mellkasi praecordalis fájdalom