Chest pain

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Chest pain is pain in any region of the chest. Chest pain may be a symptom of a number of serious disorders and is, in general, considered a medical emergency. Chest pain can be differentiated into heart-related and non heart related chest pain. Cardiac chest pain is called angina pectoris. Even though it may be determined that the pain is noncardiac in origin (does not come from a heart problem), noncardiac chest pain can still be a medical emergency and present significant disease.

Chest pain is a common presenting problem:

• In the United States, an estimated 6-8 million people per year present to the emergency department with chest pain.
• An estimated 50-70% of patients presenting with chest pain in the emergency department will be placed in an observation unit or admitted to the hospital.
• 1.5 million people are admitted annually for workup of acute coronary syndrome (ACS).
• Approximately 8 billion dollars are used annually to evaluate complaints of chest pain.
• Children with chest pain account for 0.3% to 0.6% of pediatric emergency department visits.

Video Chest pain

Signs and symptoms

Chest pain may present in different ways depending upon the underlying diagnosis. Chest pain may also vary from person to person based upon age, sex, weight, and other differences. Chest pain may present as a stabbing, burning, aching, sharp, or pressure-like sensation in the chest. Other associated symptoms with chest pain can include nausea, vomiting, dizziness, shortness of breath, anxiety, and sweating.

Maps Chest pain

Differential diagnosis

Causes of chest pain range from non-serious to serious to life-threatening.

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 (76-89%), exercise-induced asthma (4-12%), gastrointestinal illness (8%), and psychogenic causes (4%). Chest pain in children can also have congenital causes.

Cardiovascular

• Acute coronary syndrome
  • Stable or unstable angina
  • Myocardial infarction ("heart attack") - People usually complained of a pressure or squeezing sensation over the chest. Other associated symptoms are: excessive sweating, nausea, vomiting, and weakness. The Levine's sign, where the patient placed his fist on the chest while describing his pain, is strongly suggestive of cardiac cause of chest pain. Chest pain is more commonly associated with anterior infarction because of left ventricular impairment; inferior infarction is more commonly associated with nausea, vomitng, and excessive sweating due to irritation of vagus nerve; lateral infarction is associated with left arm pain.
• Prinzmetal's angina - Chest pain is caused by coronary vasospasm. More common in women younger than 50 years. Patient usually complain of chest pain at rest. It may occur early in the morning which awaken patient from sleep.
• Cocaine abuse - This condition is suspected when a patient with few or no risk of arteriosclerosis presented with non-traumatic chest pain. Ingestion of cocaine can cause vasoconstriction of coronary arteries, thus producing chest pain similar to heart attack. Symptoms can appear within one hour of cocaine use.
• Aortic stenosis - This condition happens when the patient has underlying congenital bicuspid valve, aortic sclerosis, or history of rheumatic fever. Chest pain usually happens during physical activity. Syncope is a late symptom. Signs and symptoms of heart failure may also present. On auscultation, loud ejection systolic murmur can be best heard at the right second intercostal space and radiates to the carotid artery in the neck. Splitting of second heart sound is heard in severe stenosis.
• Hypertrophic cardiomyopathy - It is the hypertrophy of interventricular septum that causes outflow obstruction of left ventricle. Dyspnoea and chest pain commonly occurs during daily activities. Sometimes, syncope may happen. On physical examination, significant findings include: loud systolic murmur and palpable triple apical impulse due to palpable presystolic fourth heart sound.
• Aortic dissection is characterised by severe chest pain that radiates the back. It is usually associated with Marfan's syndrome and hypertension. On examination, murmur of aortic insufficiency can be heard with unequal radial pulses.
• Pericarditis - This condition can be the result of viral infection such as coxsackie virus and echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial infarction (Dressler syndrome). The chest pain is often pleuritic in nature (associated with respiration) which is aggravated when lying down and relieved on sitting forward, sometimes, accompanied by fever. On auscultation, pericardial friction rub can be heard.
• cardiac tamponade
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Myocarditis
• Mitral valve prolapse syndrome - Those affected are usually thin females presented with chest pain which is sharp in quality, localised at the apex, and relieved when lying down. Other symptoms include: shortness of breath, fatique, and palpitations. On auscultation, midsystolic click followed by late systolic murmur can be heard, louder when patient is in standing position.
• Aortic aneurysm

Respiratory

• Bronchitis
• Pulmonary embolism - Common signs and symptoms are shortness of breath, pleuritic chest pain, blood in sputum during cough (haemoptysis), and lower limb swelling. Risk factors includes: recent surgery, malignancy, and bedridden state. Source of embolus usually comes from venous thromboembolism.
• Pneumonia
• Hemothorax
• Pneumothorax - Those who are at a higher risk of developing pneumothorax are tall, thin, male smoker who had underlying lung diseases such as emphysema. Those affected can have a sharp chest pain which radiates to the shoulder of the same side. Physical examination revealed absent breath sounds and hyperresonance on the affected side of the chest.
• Pleurisy - an inflammation that can cause painful respiration
• Tuberculosis
• Tracheitis
• Lung malignancy

Gastrointestinal

• Achalasia, nutcracker esophagus, and other motility disorders of the esophagus
• Diffuse esophageal spasm - Unlike cardiac chest pain, oesophageal pain is not related to activity. The pain is usually associated with swallowing of hot or cold water.
• Esophageal rupture - Those affected usually complained of sudden, severe, and constant pain that starts from the neck to the upper abdomen. The pain is aggravated by swallowing. On examination, neck swelling and crepitations can be felt due to subcutaneous emphysema as free air is entering from oesophagus into the subcutaneous tissue.
• Esophagitis - There are many causes of oesophagitis. Oesophagitis caused by Candida albicans is usually found in chemotherapy or HIV patients. Medication such as nonsteroidal anti-inflammatory drug (NSAIDs) and alendronate can induce oesophagitis if not swallowed properly.
• Gastroesophageal reflux disease (GERD) - The pain is aggravated when lying down or after meals. Patients may describe this as a heartburn. Besides, they may also complain of tasting bitter contents from the stomach.
• Functional dyspepsia
• Hiatus hernia
• Jackhammer esophagus
• Acute cholecystitis - Characterised by positive Murphy's sign where the patient had a cessation of inhalation when the doctor placed his finger at the right subcoastal region of the abdomen.
• Acute pancreatitis - History of alcohol abuse, cholelithiasis (stones in the gallbladder), and hypertriglyceridemia are risk factors for pancreatitis. It is a constant, boring pain in the upper abdomen.
• Perforated peptic ulcer - Sudden onset of severe pain in the upper abdomen which later developed into peritonitis (inflammation of tissues that lines the abdominal organs).

Chest wall

• Costochondritis or Tietze's syndrome - an inflammation of costochondral junction. Any movements or palpation of the chest can reproduce the symptoms.
• 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 - It is usually described as a burning sensation over the chest in a unilateral dermatome distribution. However, diagnosis can be difficult because the pain usually appears before the characteristic rash is visible.
• 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
• Prolapsed intervertebral disc
• Thoracic outlet syndrome
• Adverse effect from certain medications

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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. Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of acute coronary syndrome.

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 ("heart attack") is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.

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)
• Chest radiograph or chest x rays are frequently performed
• CT scanning is used in the diagnosis of aortic dissection
• V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is suspected)
• 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

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Management

Aspirin increases survival in people 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.

For people with non-cardiac chest pain, cognitive behavioral therapy (CBT) might be helpful. A 2015 Cochrane review found that CBT might reduce the frequency of chest pain episodes the first three months after treatment.

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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 decreased 10% from 1999 to 2008 but a subsequent increase of 13% was seen from 2006-2011.

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References

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External links

Source of the article : Wikipedia