Chest Pain

Chest Pain

1. Causes

   • Cardiovascular
     • MI
       • Location: Substernal and may radiate like angina Character: heaviness, pressure, burning, constriction Duration: >30 mins but variable Relieving factors: not relieved by rest/nitroglycerin Assoc, symptoms: SOB, sweating, weakness, nausea, vomiting
     • Angina pectoris
       • Location: Retrosternal, radiates to neck, jaw, epigastrium, shoulder, arms (left common) Quality: pressure, burning, squeezing, heaviness, indigestion Duration: <2-10 min Aggravating factors: exercise, cold, emotional stress (**atypical/Prinzmetal's angina may be unrelated to activity, often early morning) Relieving factors: rest, nitroglycerin  Associated symptoms/signs: S3 or murmur of papillary muscle dysfunction during pain
     • Pericarditis
       • Location: usually begins over sternum/toward cardiac apex and may radiate to neck/left shoulder; often more localised than pain of MI Character: Sharp, stabbing, knifelike Duration: lasts many hours-days; may wax and wane Aggravating: deep breathing, rotating chest, supine position Relieving: sitting up and leaning forward Assoc features: pericardial friction rub
     • Aortic dissection
       • Location: Anterior chest, may radiate to back Character: Excruciating, tearing, knifelike Onset/duration: Sudden, unrelenting Aggravating: usually occurs in setting of hypertension or predisposition (e.g. Marfan syndrome) Assoc features: Murmur of aortic insufficiency (early diastole), pulse or BP asymmetry; neurologic deficit
     • Unstable angina
       • Location: Same as angina Character: Same as angina but may be more severe Duration: Usually <20 mins Aggravating factors: same as angina, with decreasing tolerance for exertion/at rest Associated symptoms: similar to stable angina but may be pronounced; transient heart failure can occur
   • Pulmonary
     • PE
       • Location: substernal Character: pressure Duration: similar to angina Aggravating: exertion Assoc features: pain assoc with dyspnoea; signs of pulmonary hypertension (split S2, loud P2, parasternal heave, pulmonary regurg murmur, elevated JVP)
     • Pneumothorax
       • Location: Unilateral Character: Sharp, well localised Duration: sudden onset, lasts many hours Aggravating: breathing painful Assoc: dyspnoea, hyperresonance to percussion; decreased breath sounds and vocal resonance over involved lungs
     • Pneumonia/pleuritis
       • Location: localised over involved area Character: pleuritic, sharp, localised Duration: brief/prolonged Aggravating: painful breathing Assoc: dyspnoea, cough, fever, dull to percussion, bronchial breath sounds, rales, occasional pleural rub
   • GI
     • GORD
       • Site: Substernal, epigastric Character: burning, visceral discomfort Duration: 10-60 mins Aggrav: large meal, posprandial recumbency Relief: antacid Assoc: water brash
     • Oesophageal spasm
     • PUD
       • Site: epigastric, substernal Character: visceral burning, aching Duration: prolonged Relief: food, antacid
     • Biliary disease
       • Site: epigastric, RUQ Character: visceral Duration: prolonged Aggrav: may be unprovoked or follow meals Assoc: RUQ tenderness may be present
     • Pancreatitis
   • Neuromusculoskeletal
     • Cervical disk disease
     • Intercostal m. cramps
       • Site: variable Character: aching Duration: short or long Aggravation: movement, history of muscle exertion/injury Assoc: tender to pressure/movement
     • Herpes zoster
       • Site: Dermatomal distribution Character: burning, itching Duration: prolonged Aggravation: none Assoc: Vesicular rash appears in area of discomfort
     • costochondral/costosternal syndromes
   • Psych
     • panic disorder/anxiety
       • Site: often localised over precordium Character: variable, location often moves from place to place Duration: varies, often fleeting Aggrav: situational Assoc: sighing respirations, often chest wall tenderness

2. History

   • SOCRATES
   • Family history
     • Long QT
     • Hypertrophic cardiomyopathy
     • Premature atherosclerosis
   • Social history
     • Smoking, alcohol, drugs
     • Recent dental work

3. Physical Exam

   • Blood pressure both arms
     • Aortic dissection, coarcation, atherosclerotic disease
   • General appearance
     • Resp rate
     • thyroid disease
     • Haemachromatosis
   • Opthalmologic
     • diabetic/hypertensive retinopathy
     • Roth's spots (infectious endocarditis)
   • Opthalmologic