Chest pain may be a symptom of a number of serious conditions and is, in general, 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.
- In the US, an estimated 5 million patients per year present to the Emergency Department with chest pain.
- More than 50% of patients presenting to emergency facilities with unexplained chest pain will have coronary disease ruled out.
- 1.5 million patients are admitted annually for workup of acute coronary syndrome (ACS).
- Approximately 8 billion dollars are used annually to evaluate complaints of chest pain.
Differential diagnosis
Causes of chest pain range from non-serious to serious to life-threatening. DiagnosisPro lists more than 440 causes on its website.
In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%). Other less common causes include: pneumonia, lung cancer, and aortic aneurysms.
In children the most common causes for chest pain are musculoskeletal and unknown.
Cardiovascular
- Acute coronary syndrome
- Unstable Angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction.
- Myocardial infarction ("heart attack")
- Aortic dissection
- Pericarditis and cardiac tamponade
- Arrhythmia - atrial fibrillation 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
- Myocarditis
- Mitral valve prolapse syndrome
- Aortic aneurysm
Respiratory
- Bronchitis
- Pulmonary embolism
- Pneumonia
- Hemothorax
- Pneumothorax and Tension pneumothorax
- Pleurisy - an inflammation that can cause painful respiration
- Tuberculosis
- Tracheitis
- Lung malignancy
Gastrointestinal
- Gastroesophageal reflux disease (GERD) and other causes of heartburn
- Hiatus hernia
- Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus
- Functional dyspepsia
Chest wall
- Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
- Spinal nerve problem
- Fibromyalgia
- Chest wall problems
- Radiculopathy
- Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
- Breast conditions
- Herpes zoster commonly known as shingles
- Tuberculosis
- Osteoarthritis
- Bornholm disease
Psychological
- Panic attack
- Anxiety
- Clinical depression
- Somatization disorder
- Hypochondria
Others
- Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
- Da costa's syndrome
- Carbon monoxide poisoning
- Sarcoidosis
- Lead poisoning
- High abdominal pain may also mimic chest pain
- Prolapsed intervertebral disc
- Thoracic outlet syndrome
Diagnostic approach
History taking
Knowing a patient's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors.
Physical examination
In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of 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. Features of the pain suggestive of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to the neck, jaw or left arm; sweating; nausea; palpitations; pain felt upon exertion; dizziness; shortness of breath; and a "sense of impending doom."
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. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. A rapid diagnosis can be life-saving and often has to be made without the help of medical tests. However, in general, additional tests are required to establish the diagnosis.
Medical tests
On the basis of the above, a number of tests may be ordered:
- An electrocardiogram (ECG)
- CT scanning may be used in unexplained chest pain when other tests are inconclusive.
- V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is suspected)
- X-rays of the chest and abdomen. Routine X-rays, however, are not needed.
- Blood tests:
- Troponin I or T (to indicate myocardial damage)
- Complete blood count
- Electrolytes and renal function (creatinine)
- Liver enzymes
- Creatine kinase (and CK-MB fraction in many hospitals)
- D-dimer (when suspicion for pulmonary embolism is present but low)
- serum lipase or amylase to exclude acute pancreatitis
Management
Aspirin increases survival in patients with acute coronary syndrome and it is reasonable for EMS dispatchers to recommend it in people with no recent serious bleeding.
In people with chest pain supplemental oxygen 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. However, there is little evidence about its effectiveness.
Epidemiology
Chest pain is the presenting symptom in about 12% of emergency department visits in the United States and has a one-year mortality of about 5%. The rate of ED visits in the US for chest pain increased 13% from 2006-2011.
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