Chest pain

- Chest pain is a common presentation of cardiac disease, but can also be a manifestation of anxiety or of disease of the lungs, the musculoskeletal system or the gastrointestinal system . Some patients deny 'pain' in favour of 'discomfort' but the significance remains the same. 



- COMMON CAUSES OF CHEST PAIN


- Cardiac


- Mycocardial ischaemia(angina)


- Myocardial infarction


- Myocarditis


- Pericarditis


- Mitral valve prolapse


- Aortic


- Aortic dissection


- Aortic aneurysm



* Oesophageal


Oesophagitis 

Oesophageal spasm 

Mallory-Weiss syndrome 

* Lungs/pleura 

Bronchospasm

Pulmonary infarct 

Pneumonia

Tracheitis 

Pneumothorax 

Pulmonary embolism 

Malignancy 

Tuberculosis 

Connective tissue disorders (rare

* Musculoskeletal 

Osteoarthritis 

Rib fracture/injury 

Intercostal muscle injury 

Costochondritis (Tietze's syndrome) 

Epidemic myalgia (Bornholm disease) 

     * Neurological 

Prolapsed intervertebral disc 

Herpes zoster 

Thoracic outlet syndrome.

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A number of key characteristics help to distinguish cardiac pain from that of other causes . Diagnosis may be difficult and it is often helpful to classify pain as possible, probable or definite ischaemic cardiac pain, based on the balance of evidence

- Site of origin of pain. Cardiac pain is typically located in the centre of the chest because of the derivation of the nerve supply to the heart and mediastinum.

- Radiation. Ischaemic cardiac pain, especially when severe, may radiate to the neck, jaw, and upper or even lower arms. Occasionally, cardiac pain may be experienced only at the sites of radiation or in the back. Pain situated over the left anterior chest and radiating laterally may have many causes, including pleural or lung disorders, musculoskeletal problems and anxiety.

- Character of the pain. Cardiac pain is typically dull, constricting, choking or 'heavy', and is usually described as squeezing, crushing, burning or aching but not sharp, stabbing, pricking or knife-like. The sensation can be described as breathlessness. Patients often emphasise that it is a discomfort rather than a pain. They typically use characteristic hand gestures (e.g. open hand or clenched fist) when describing ischaemic pain

In contrast, pleural or pericardial pain is usually described as a 'sharp' or 'catching' sensation that is exacerbated by breathing, coughing or movement. Pain associated with a specific movement (bending, stretching, turning) is likely to be musculoskeletal in origin.

- Pattern of onset. The pain of myocardial infarction typically takes several minutes or even longer to develop; similarly, angina builds up gradually in proportion to the intensity of exertion. Pain that occurs after rather than during exertion is usually musculoskeletal or psychological in origin. The pain of aortic dissection, massive pulmonary embolism or pneumothorax is usually very sudden or instantaneous in onset.

- Associated features. The pain of myocardial infarction, massive pulmonary embolism or aortic dissection is often accompanied by autonomic disturbance including sweating, nausea and vomiting. Breathlessness, due to pulmonary congestion arising from transient ischaemic left ventricular dysfunction, is often a prominent and occasionally the dominant feature of myocardial infarction or angina (angina equivalent). Breathlessness may also accompany any of the respiratory causes of chest pain and may be associated with cough, wheeze or other respiratory symptoms. Classical gastrointestinal symptoms (oesophageal reflux, oesophagitis, peptic ulceration or biliary disease) may provide the clue to the source of non-cardiac chest pain but effort-related 'indigestion' is usually due to heart disease.

- Emotional distress is a very common cause of atypical chest . This diagnosis should be considered if there are features of anxiety or neurosis, and the pain lacks a predictable relationship with exercise. However, it is important to remember that the prospect of heart disease is a frightening experience, particularly when it has been responsible for the death of a close friend or relative; psychological and organic features therefore often coexist. Anxiety may amplify the effects of organic disease and can create a very confusing picture. Patients who believe they are suffering from heart disease are sometimes afraid to take exercise and this may make it difficult to establish their true effort tolerance; assessment may also be complicated by the impact of physical deconditioning.

- Myocarditis and pericarditis These conditions may cause pain that is characteristically felt retrosternally, to the left of the sternum, or in the left or right shoulder, and typically varies in intensity with movement and the phase of respiration. The pain is usually described as 'sharp' and may 'catch' the patient during inspiration or coughing; there is occasionally a history of a prodromal viral illness.

- Mitral valve prolapse Sharp left-sided chest pain that is suggestive of a musculoskeletal problem may be a feature of mitral valve . Aortic dissection This pain is severe, sharp and tearing, often felt in or penetrating through to the back, and is typically very abrupt in onset . Oesophageal pain Oesophageal pain can mimic that of angina very closely, is sometimes precipitated by exercise and may be relieved by nitrates; however, it is usually possible to elicit a history relating chest pain to supine posture or eating, drinking or oesophageal reflux. It often radiates to the back.

- Bronchospasm Patients with reversible airways obstruction, such as asthma, may describe exertional chest tightness that is relieved by rest. This may be difficult to distinguish from ischaemic chest tightness. Bronchospasm may be associated with wheeze, atopy and cough.

- Musculoskeletal chest pain This is a common problem that is very variable in site and intensity but does not usually fall into any of the patterns described above. The pain may vary with posture or movement of the upper body and is sometimes accompanied by local tenderness over a rib or costal cartilage. There are numerous causes of chest wall pain, including arthritis, costochondritis, intercostal muscle injury and Coxsackie viral infection (epidemic myalgia or Bornholm disease). Many minor soft tissue injuries are related to everyday activities such as driving, manual work and sport.