Chest Pain

Definition

(Show Disclaimer) Note: I copy the "definition" of something straight from the book. I find it's best to have an all-encompassing definition in order to better orient myself when I am studying.

Show Definition Chest pain is a localized sensation of distress or discomfort that may/may not be associated with actual tissue damage. (click to hide definition)

Incidence and Prevalence

It is very common.

Pathogenesis

Causes by system: (1) Cardiac, (2) MSK, (3) Neurologic, (4) GI, (5) Pleural, (6) Psychiatric.

Important however to r/o life threatening causes of chest pain:

ACS: MI (NSTEMI, STEMI); (~ UA is potentially fatal but not acute in nature)
Aortic Dissection
Tension Pneumothorax
Pulmonary Embolism
Esophageal Perforation (as in Booerhave's syndrome)

(I just hid the other causes initially because it takes up so much space)

Cardiac:
- Ischemia/atherosclerosis/valvular problems secondary to angina/MI.
- Pericarditis.
- Endocarditis.
- Dissecting aortic aneurysm.
- Mitral valve prolapse.
MSK:
- Muscle strain and inflammation caused by costochondritis.
- Chest wall syndrome.
- Cervicodorsal arthritis.
- Intercostal myositis.
Neuro:
- Herpes zoster.
- Nerve root compression.
GI causes:
- Structural defects.
- GERD.
- Hiatal hernia.
- Oesophageal spasm.
- Pancreatitis.
- Cholecystitis.
- Peptic ulcer disease (PUD).
Respiratory causes:
- Pneumonia.
- Pulmonary embolus.
- Pulmonary hypertension.
- Spontaneous pneumothorax.
- Lung/mediastinal tumours.
Psychiatric:
- Stress secondary to depression, anxiety, or panic disorders.

Predisposing factors

Depending on etiology, may change.

Common Findings

Primary complaint: Pain somewhere in the chest.
“Levine’s sign”: Placing the fist on the center of the chest to demonstrate pain.
Fatigue.
Cough.

Indigestion.
Dyspnea.
Syncope.
Palpitations.
Profound fatigue.

Other Signs and Symptoms

Non-pleuritic, non-tender (to palpation), non-positional chest pain typical in angina/MI. MI pain is acute in nature, often < 30 min.
MSK pain may be tender to palpation, relieved/aggravated by position change, secondary to trauma.
If herpes (neurologic), associated w/ skin lesions.

GI pain may be post-prandial, relieved/aggravated by position, associated w/ "water brash" in mouth, may have referred pain to other sites.
Resp. system may be associated with cough, URI sx, SOB.
Psychogenic pain may be associated with a specific event.

History

HPI:
Need to know: (1) Duration (2) Character of the pain (LIQR - Location, Intensity, Quality [if ripping, may indicate dissection], Radiation [if radiates to two arms, predictor of MI. If radiates in between scapulae, may signal thoracic aortic dissection]) (3) Precipitating factors (exertion, breathing, eating, cold, stress, sex) (4) Relieving factors (resting, eating, antacids, nitroglycerin, positional change).
ROS:
ALL/MEDS/HIITS: (What are HIITS? - Click to expand)
PMH: Risk factors - Tobacco use, HLD, obesity, diabetes, (+) FamHx, sedentary lifestyle. Also previous diagnostic tests, Tx, Rx (e.g. nitroglycerin, OTC, herbals), trauma, recent illness (e.g.post-viral), physical labor.
PMH/FAMHx/OBGYN:
SOCHx:
Drug and caffeine use.

Physical Exam

Coming soon.

Diagnostic Tests

A normal ECG and physical exam does not rule out ACS, more investigation is required.

(You may not necessarily order everything here, but:)

ECG.
Chest radiography, whenever diagnosis of chest pain is not clear.
Echo.
Stress test.
Cardiac cath.
Barium tests.
Endoscopy to rule out GI aetiology.
Oesophageal pH.

Laboratory tests:
1. Troponin I or T/Myoglobin/CK-MB
2. Creatine kinase (CK)/LDH
3. C-reactive protein (CRP)/Ferritin
4. Brain natriuretic peptide (BNP) for clinical findings/risk of heart failure (HF).
5. D-dimer for suspected venous thrombotic event (deep vein thrombosis [DVT] or pulmonary embolism [PE]).

DDx

(Very long list, but useful for DDx)

Broadly separated into cardiac and non-cardiac.
Cardiac:
- ACS:
  - Acute MI: Chest pain lasting more than 15 minutes.
  - Unstable/Stable angina
  - Prinzmetal’s or variant angina.
- Valvular heart disease: MVP, Aortic Stenosis.
- Hypertrophic cardiomyopathy.
- Pericarditis.
- Endocarditis.
- Aortic dissection.
Non-Cardiac:
- Pulmonary:
  - Pneumonia.
  - Pleurisy.
  - PE.
  - Pulmonary HTN.
  - Pneumothorax.
  - Tracheobronchitis.
  - Lung cancer.
- GI:
  - GERD.
  - Oesophageal spasm.
  - PUD.
  - Pancreatitis.
  - Chulecystitis.
  - Flatulence.
- Rheumatulogy:
  - Fibromyalgia.
  - Costochondritis.
  - Arthritis.
- Chest Wall:
  - Rib fracture.
  - Muscle strain.
  - Cervical or thoracic spine disease.
  - Metastatic bone disease.
  - Breast conditions.
- Neurulogic:
  - Herpes zoster.
  - Postherpetic pain syndrome.
  - Nerve root compression.
- Psychogenic
  - Panic disorder.
  - Generalized anxiety.
  - Depression.
  - Somatoform disorders.

Plan

Aside from diagnostic tests, plan mainly revolves around pharmacology.

If cardiac in origin, nitroglycerin.
If GI, H₂ Blocker + PPI
If MSK, NSAIDs
If Psychogenic, SSRIs, TCAs, Benzos

Follow-up

Nothing important.

Consultation/Referral

Refer if cardiac chest pain, pregnant.

Individual Considerations

In geriatric patients, typical sx of cardiac chest pain are not present.

Most commonly they present with lethargy, fatigue, decreased LOC, crackles, CHF, persistent cough, hypotension.