Chest pain
Encyclopedia
Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency
. Even though it may be determined that the pain
is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.
lists more than 440 causes on its website.
, thoracic aortic dissection, esophageal rupture, tension pneumothorax and cardiac tamponade
. By elimination or confirmation the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.
If acute coronary syndrome
("unstable angina") is suspected, many people are admitted briefly for observation, sequential ECGs, and determination of cardiac enzymes over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.
As in all medicine, a careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be 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-ray
s or blood test
s (e.g. aortic dissection
). Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign
in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.
A focus on recent health changes, family history (premature atherosclerosis
, cholesterol
disorders), tobacco smoking
, diabetes and other risk factors is useful.
Features of the pain suggest of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; the pain coming upon exertion; dizziness; shortness of breath and a "sense of impending doom."
On the basis of the above, a number of tests may be ordered:
is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress. Entonox
is frequently used by EMS
personnel in the prehospital environment. There is however little evidence about its effectiveness.
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
. Even though it may be determined that the pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.
Differential diagnosis
Causes of chest pain range from non-serious to serious to life threatening. DiagnosisProDiagnosisPro
DiagnosisPro is a medical expert system. It provides exhaustive diagnostic possibilities for 11,000 diseases and 30,000 findings. It is supposed to give the most appropriate differential however this is not always the case. Between Oct 2008 and Oct 2009 the site averaged 61,000 visits per month....
lists more than 440 causes on its website.
Cardiovascular
- Acute coronary syndromeAcute coronary syndromeAcute coronary syndrome is usually one of three diseases involving the coronary arteries: ST elevation myocardial infarction , non ST elevation myocardial infarction , or unstable angina ....
- Unstable Angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction.
- Myocardial infarctionMyocardial infarctionMyocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
("heart attack")
- Aortic dissectionAortic dissectionAortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart. The dissection typically extends anterograde, but can extend retrograde from the site of the intimal tear. Aortic dissection is a medical...
- PericarditisPericarditisPericarditis is an inflammation of the pericardium . A characteristic chest pain is often present.The causes of pericarditis are varied, including viral infections of the pericardium, idiopathic causes, uremic pericarditis, bacterial infections of the precardium Pericarditis is an inflammation of...
and cardiac tamponadeCardiac tamponadeCardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium .... - Arrhythmia - atrial fibrillationAtrial fibrillationAtrial fibrillation is the most common cardiac arrhythmia . It is a common cause of irregular heart beat, identified clinically by taking a pulse. Chaotic electrical activity in the two upper chambers of the heart result in the muscle fibrillating , instead of achieving coordinated contraction...
and a number of other arrhythmias can cause chest pain. - Stable angina pectoris - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense
Pulmonary
- Pulmonary embolismPulmonary embolismPulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...
- PneumoniaPneumoniaPneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
- HemothoraxHemothoraxA hemothorax is a condition that results from blood accumulating in the pleural cavity.-Cause and presentation:Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs...
- PneumothoraxPneumothoraxPneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
and Tension pneumothorax - PleurisyPleurisyPleurisy is an inflammation of the pleura, the lining of the pleural cavity surrounding the lungs. Among other things, infections are the most common cause of pleurisy....
- an inflammation which can cause painful respiration
GI
- Gastroesophageal reflux diseaseGastroesophageal reflux diseaseGastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
(GERD) and other causes of heartburnHeartburnHeartburn, also known as pyrosis or acid indigestion is a burning sensation in the chest, just behind the breastbone or in the epigastrium... - Hiatus herniaHiatus herniaA hiatus hernia or hiatal hernia is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.- Classification :There are two major kinds of hiatus hernia:...
- AchalasiaAchalasiaAchalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...
, nutcracker esophagusNutcracker esophagusNutcracker esophagus is a disorder of the movement of the esophagus, and is one of many motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, to both solid and liquid foods, and can cause chest pain; it may also be...
and other neuromuscular disorders of the esophagusEsophagusThe esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach... - Functional dyspepsia
Chest wall
- CostochondritisCostochondritisCostochondritis is a benign inflammation of the costal cartilage, which is a length of cartilage which connects each rib, except the eleventh and twelfth, to the sternum. It causes pain in the chest that can be reproduced by pressing on the affected area between the ribs. This pain can be quite...
or Tietze's syndromeTietze's syndromeTietze syndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by the German surgeon Alexander Tietze .Though thought to be the same conditions, Tietze syndrome is not the same as costochondritis...
- a benign and harmless form of osteochondritis often mistaken for heart disease - Spinal nerveSpinal nerveThe term spinal nerve generally refers to a mixed spinal nerve, which carries motor, sensory, and autonomic signals between the spinal cord and the body...
problem - FibromyalgiaFibromyalgiaFibromyalgia is a medical disorder characterized by chronic widespread pain and allodynia, a heightened and painful response to pressure. It is an example of a diagnosis of exclusion...
- Chest wallThoracic cavityThe thoracic cavity is the chamber of the human body that is protected by the thoracic wall ....
problems - RadiculopathyRadiculopathyRadiculopathy is not a specific condition, but rather a description of a problem in which one or more nerves are affected and do not work properly . The emphasis is on the nerve root...
- Precordial catch syndromePrecordial catch syndromePrecordial Catch Syndrome , also known as Texidor's twinge, is a common cause of chest pain complaints in children and adolescents. It also occurs, though less frequently, in adults. PCS manifests itself as a very intense, sharp pain, typically at the left side of the chest, which is worse when...
- another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease - BreastBreastThe breast is the upper ventral region of the torso of a primate, in left and right sides, which in a female contains the mammary gland that secretes milk used to feed infants.Both men and women develop breasts from the same embryological tissues...
conditions - Herpes zosterHerpes zosterHerpes zoster , commonly known as shingles and also known as zona, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe...
commonly known as shingles - TuberculosisTuberculosisTuberculosis, MTB, or TB is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs but can also affect other parts of the body...
Psychological
- Panic attackPanic attackPanic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...
- AnxietyAnxietyAnxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
- Clinical depressionClinical depressionMajor depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
- Somatization disorderSomatization disorderSomatization disorder is a psychiatric diagnosis applied to patients who persistently complain of varied physical symptoms that have no identifiable physical origin...
- HypochondriaHypochondriaHypochondriasis or hypochondria refers to excessive preoccupation or worry about having a serious illness. This debilitating condition is the result of an inaccurate perception of the body’s condition despite the absence of an actual medication condition...
Others
- Hyperventilation syndromeHyperventilation syndromeHyperventilation syndrome is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly...
often presents with chest pain and a tingling sensation of the fingertips and around the mouth - Da costa's syndromeDa costa's syndromeDa Costa's syndrome, which was colloquially known as soldier's heart, is a syndrome with a set of symptoms that are similar to those of heart disease, though a physical examination does not reveal any physiological abnormalities...
- Bornholm diseaseBornholm diseaseBornholm disease or epidemic pleurodynia or epidemic myalgia is a disease caused by the Coxsackie B virus or other viruses.It is named after the Danish island Bornholm where early cases occurred.-Signs and symptoms:...
- a viralVirusA virus is a small infectious agent that can replicate only inside the living cells of organisms. Viruses infect all types of organisms, from animals and plants to bacteria and archaea...
disease that can mimic many other conditions - Carbon monoxide poisoningCarbon monoxide poisoningCarbon monoxide poisoning occurs after enough inhalation of carbon monoxide . Carbon monoxide is a toxic gas, but, being colorless, odorless, tasteless, and initially non-irritating, it is very difficult for people to detect...
- SarcoidosisSarcoidosisSarcoidosis , also called sarcoid, Besnier-Boeck disease or Besnier-Boeck-Schaumann disease, is a disease in which abnormal collections of chronic inflammatory cells form as nodules in multiple organs. The cause of sarcoidosis is unknown...
- Lead poisoningLead poisoningLead poisoning is a medical condition caused by increased levels of the heavy metal lead in the body. Lead interferes with a variety of body processes and is toxic to many organs and tissues including the heart, bones, intestines, kidneys, and reproductive and nervous systems...
- High abdominal painAbdominal painAbdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...
may also mimic chest pain
Diagnostic approach
In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolismPulmonary embolism
Pulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...
, thoracic aortic dissection, esophageal rupture, tension pneumothorax and cardiac tamponade
Cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium ....
. By elimination or confirmation the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.
If acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome is usually one of three diseases involving the coronary arteries: ST elevation myocardial infarction , non ST elevation myocardial infarction , or unstable angina ....
("unstable angina") is suspected, many people are admitted briefly for observation, sequential ECGs, and determination of cardiac enzymes over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.
As in all medicine, a careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be 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-ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
s or blood test
Blood test
A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick....
s (e.g. aortic dissection
Aortic dissection
Aortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart. The dissection typically extends anterograde, but can extend retrograde from the site of the intimal tear. Aortic dissection is a medical...
). Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign
Levine's sign
Levine's sign is a clenched fist held over the chest to describe ischemic chest pain. As the referred pain associated with ischemia radiates to the area of the left proximal forelimb, the right, unaffected arm is used to produce the gesture....
in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.
A focus on recent health changes, family history (premature atherosclerosis
Atherosclerosis
Atherosclerosis is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol...
, cholesterol
Cholesterol
Cholesterol is a complex isoprenoid. Specifically, it is a waxy steroid of fat that is produced in the liver or intestines. It is used to produce hormones and cell membranes and is transported in the blood plasma of all mammals. It is an essential structural component of mammalian cell membranes...
disorders), tobacco smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
, diabetes and other risk factors is useful.
Features of the pain suggest of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; the pain coming upon exertion; dizziness; shortness of breath and a "sense of impending doom."
On the basis of the above, a number of tests may be ordered:
- X-rayX-rayX-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
s of the chest and/or abdomen (CT scanningComputed tomographyX-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
may be better but is often not available). Routine X-rays and CT may however not be needed. - An electrocardiogramElectrocardiogramElectrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...
(ECG) - V/Q scintigraphyVentilation/perfusion scanA ventilation/perfusion lung scan, also called a V/Q lung scan, is a type of medical imaging using scintigraphy and medical isotopes to evaluate the circulation of air and blood within a patient's lungs, in order to determine the ventilation/perfusion ratio...
or CT pulmonary angiogramCT pulmonary angiogramCT pulmonary angiogram is a medical diagnostic test that employs computed tomography to obtain an image of the pulmonary arteries. Its main use is to diagnose pulmonary embolism...
(when a pulmonary embolismPulmonary embolismPulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...
is suspected) - Blood testBlood testA blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick....
s:- Complete blood countComplete blood countA complete blood count , also known as full blood count or full blood exam or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood...
- ElectrolyteElectrolyteIn chemistry, an electrolyte is any substance containing free ions that make the substance electrically conductive. The most typical electrolyte is an ionic solution, but molten electrolytes and solid electrolytes are also possible....
s and renal functionRenal functionRenal function, in nephrology, is an indication of the state of the kidney and its role in renal physiology. Glomerular filtration rate describes the flow rate of filtered fluid through the kidney...
(creatinineCreatinineCreatinine is a break-down product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body...
) - Liver enzymeLiver function testsLiver function tests , are groups of clinical biochemistry laboratory blood assays designed to give information about the state of a patient's liver. The parameters measured include PT/INR, aPTT, albumin, billirubin and others...
s - Creatine kinaseCreatine kinaseCreatine kinase , also known as creatine phosphokinase or phospho-creatine kinase , is an enzyme expressed by various tissues and cell types. CK catalyses the conversion of creatine and consumes adenosine triphosphate to create phosphocreatine and adenosine diphosphate...
(and CK-MB fraction in many hospitals) - TroponinTroponin400px|thumb|right|alt = Colored dice with checkered background|Ribbon representation of the human cardiac troponin core complex in the calcium-saturated form...
I or T (to indicate myocardial damage) - D-dimerD-dimerD-dimer is a fibrin degradation product , a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. It is so named because it contains two crosslinked D fragments of the fibrinogen protein....
(when suspicion for pulmonary embolismPulmonary embolismPulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...
is present but low) - serum amylaseAmylaseAmylase is an enzyme that catalyses the breakdown of starch into sugars. Amylase is present in human saliva, where it begins the chemical process of digestion. Food that contains much starch but little sugar, such as rice and potato, taste slightly sweet as they are chewed because amylase turns...
to exclude acute pancreatitis
- Complete blood count
Management
In people with chest pain supplemental oxygenOxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress. Entonox
Entonox
A mix of nitrous oxide 50% and oxygen 50% is a medical anaesthesia gas, commonly known as Entonox or Nitronox, or colloquially as gas and air, and is frequently used in pre-hospital care, childbirth and emergency medicine situations by medical professionals such as doctors, nurses, midwives and...
is frequently used by EMS
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
personnel in the prehospital environment. There is however little evidence about its effectiveness.