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{{Chest pain}}
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'''''Abbreviations:''''' '''ABG ('''[[arterial blood gas]]'''); ACE ('''[[Angiotensin-converting enzyme|angiotensin converting enzyme]]'''); BMI ('''[[body mass index]]'''); CBC ('''[[Complete blood counts|complete blood count]]'''); CSF ('''[[cerebrospinal fluid]]'''); CXR ('''[[chest X-ray]]'''); ECG ('''[[electrocardiogram]]'''); FEF ('''[[Spirometry|forced expiratory flow rate]]'''); FEV1 ('''[[forced expiratory volume]]'''); FVC ('''[[forced vital capacity]]'''); JVD ('''[[jugular vein distention]]''');''' '''MCV ('''[[mean corpuscular volume]]'''); Plt ('''[[platelet]]'''); RV ('''[[residual volume]]'''); SIADH ('''[[syndrome of inappropriate antidiuretic hormone]]'''); TSH ('''[[thyroid stimulating hormone]]'''); Vt ('''[[tidal volume]]''');''' '''WBC ('''[[White blood cells|white blood cell]]'''); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning'''     
'''''Abbreviations:''''' '''ABG ('''[[arterial blood gas]]'''); ACE ('''[[Angiotensin-converting enzyme|angiotensin converting enzyme]]'''); BMI ('''[[body mass index]]'''); CBC ('''[[Complete blood counts|complete blood count]]'''); CSF ('''[[cerebrospinal fluid]]'''); CXR ('''[[chest X-ray]]'''); ECG ('''[[electrocardiogram]]'''); FEF ('''[[Spirometry|forced expiratory flow rate]]'''); FEV1 ('''[[forced expiratory volume]]'''); FVC ('''[[forced vital capacity]]'''); JVD ('''[[jugular vein distention]]''');''' '''MCV ('''[[mean corpuscular volume]]'''); Plt ('''[[platelet]]'''); RV ('''[[residual volume]]'''); SIADH ('''[[syndrome of inappropriate antidiuretic hormone]]'''); TSH ('''[[thyroid stimulating hormone]]'''); Vt ('''[[tidal volume]]''');''' '''WBC ('''[[White blood cells|white blood cell]]'''); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning'''     

Latest revision as of 15:42, 29 July 2018

Chest pain Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning

Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Cardiac Pericarditis[1][2][3] Acute or subacute May last for hours to days + + + -
Pericardial Tamponade[4][5] Acute or subacute May last for hours to days +/- + + - EKG findings:
Myocarditis[6][7][8] Acute or subacute Variable +/- + + -
Heart Failure[9][10][11] Subacute or chronic Variable
  • Dull
  • Left sided chest pain
 + - + + Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Pulmonary Pulmonary Embolism[12][13] Acute May last minutes to hours + +/- + -  Hormone replacement therapy

Cancer Oral contraceptive pills Stroke  Pregnancy Postpartum  Prior history of VTE Thrombophilia 

Pneumonia[14][15][16] Acute or chronic Variable
  • Dull
  • Localized to side of lesion
 + + + +/-
  • Long hospital stay
  • Ill contact exposure
  • Aspiration
Tracheitis/ Bronchitis[17][18][19][20] Acute Variable + + + -
  • Peaked P-wave
Pleuritis Acute or subacute or chronic May last minutes to hours + + + -
  • EKG done to rule out other causes in differential diagnoses
Pulmonary Hypertension[21][22][23] Acute or subacute or chronic Variable + - + -
Pleural Effusion[24][25][26] Acute or subacute or chronic Variable + +/- + +/-
  • Typically not indicated
Asthma & COPD[27][28][29][30] Acute or subacute or chronic Variable
  • Tightness
 + +/- + +/-
Pulmonary Malignancy[31][32][33][34] Chronic Variable
  • Dull aching
 + +/- + +
  • EKG may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage
Sarcoidosis[35][36][37][38] Chronic Days to week
  • Chest fullness
 + - + +
  • Diminished respiratory sounds
Acute chest syndrome (Sickle cell anemia)[39][40][41] Acute May last minutes to hours
  • Chest tightness
 + +/- + -
  • EKG typically not indicated
 ---
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Gastrointestinal GERD, Peptic Ulcer[42][43][44] Acute +/- - - +/-
  • Not any auscultatory findings associated with this disease
  • Enamel erosion or other dental manifestations
Diffuse Esophageal Spasm[45][46][47][48] Acute
  • Minutes to hours
  • 5 to 60 minutes
 + - +/- +/- --- ---
  • Barium swallow: Multiple areas of spasm throughout the length of the esophagus
  • Impedance testing: Higher amplitudes and better transit of swallowed boluses
  • No ECG findings associated with DES, but ECG is done to exclude variant angina due to higher concurrent association of variant angina with DES 
  • Esophageal manometry : ≥20 percent premature contractions (distal latency <4.5 seconds)
Esophagitis[49][50][51] Acute Variable + + - +/-
  • No auscultatory finding
Eosinophilic Esophagitis[52][53][54][55][56][57] Chronic Variable + - - -
  • No auscultatory finding in the this disease
  • Typically no finding on EKG
Mediastinitis[58][59][60][61] Acute, Chronic Variable
  • Retrosternal irritation
 +/- + + -
  • Nonspecific
  • Infection
  • Esophageal perforation
  • Post operative complication
  • Positive organisms in sternal culture
  • Leukocytosis
  • Positive blood cultures
  • Diffuse ST elevation
  • CT: Localize the infection and extent of spread
  • MRI: Assesses vascular involvement and complications
 CT scan
Sliding Hiatal Hernia[62][63][64] Acute Variable + - + -
  • Trauma
  • Iatrogenic
  • Congenital malformation
  • Bowel sounds may be heard in the chest
  • Non specific
  • T wave inversion in anterior lead.
  • Barium swallow: At least three rugal folds traversing the diaphragm 
  • Upper endoscopy: A greater than 2-cm separation between the squamocolumnar junction and the diaphragmatic impression
  • High resolution manometry: The separation of the crural diaphragm from the lower esophageal sphincter (LES) by a pressure trough
  • Upper endoscopy
  • High resolution manometry (for smaller hernias)
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab workup EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Rheumatic Relapsing polychondritis[65] Chronic Years Intermittent pain in: + + + +
  • Autoimmune diseases
  • Negative rheumatoid factor
  • Anti-type II collagen antibodies
  • Antineutrophil cytoplasmic antibodies
  • ECG is done to rule out the cardiovascular complications of this disease
  • Non specific
  • Related to specific organ involvent
  • No gold standard test for this disease
Psychiatric Panic attack/ Disorder[66][67][68] Acute or subacute or chronic Variable Variable + - + -
  • Psychiatric disorders
  • Anxious
  • Tachypneic
  • Thyroid function tests
  • Complete blood count
  • Chemistry panel
  • Sinus Tachycardia
  • No any specific radiographic test is done
 ---
  • Others
 Substance abuse

(Cocaine)[69][70][71]

Acute (hours) Minutes to hours Pressure like pain in the center of chest + + + +
  • Psychiatric disorders
    • QT prolongation
    • Sinus Tachycardia
    • Arrhythmias
    • Cardiac conduction abnormalities
 ---
  • Gold standard test depends on the type of substance is abuse

References

  1. ↑ Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R (March 2004). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". J. Am. Coll. Cardiol. 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364.
  2. ↑ Troughton RW, Asher CR, Klein AL (February 2004). "Pericarditis". Lancet. 363 (9410): 717–27. doi:10.1016/S0140-6736(04)15648-1. PMID 15001332.
  3. ↑ Spodick DH (March 2003). "Acute pericarditis: current concepts and practice". JAMA. 289 (9): 1150–3. PMID 12622586.
  4. ↑ Ewart W (March 1896). "Practical Aids in the Diagnosis of Pericardial Effusion, in Connection with the Question as to Surgical Treatment". Br Med J. 1 (1838): 717–21. PMC 2406464. PMID 20756103.
  5. ↑ Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W, Achenbach S, Agewall S, Al-Attar N, Angel Ferrer J, Arad M, Asteggiano R, Bueno H, Caforio AL, Carerj S, Ceconi C, Evangelista A, Flachskampf F, Giannakoulas G, Gielen S, Habib G, Kolh P, Lambrinou E, Lancellotti P, Lazaros G, Linhart A, Meurin P, Nieman K, Piepoli MF, Price S, Roos-Hesselink J, Roubille F, Ruschitzka F, Sagristà Sauleda J, Sousa-Uva M, Uwe Voigt J, Luis Zamorano J (November 2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS)". Eur. Heart J. 36 (42): 2921–64. doi:10.1093/eurheartj/ehv318. PMID 26320112.
  6. ↑ Dec GW, Palacios IF, Fallon JT, Aretz HT, Mills J, Lee DC, Johnson RA (April 1985). "Active myocarditis in the spectrum of acute dilated cardiomyopathies. Clinical features, histologic correlates, and clinical outcome". N. Engl. J. Med. 312 (14): 885–90. doi:10.1056/NEJM198504043121404. PMID 3974674.
  7. ↑ Caforio AL, Calabrese F, Angelini A, Tona F, Vinci A, Bottaro S, Ramondo A, Carturan E, Iliceto S, Thiene G, Daliento L (June 2007). "A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis". Eur. Heart J. 28 (11): 1326–33. doi:10.1093/eurheartj/ehm076. PMID 17493945.
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  9. ↑ Anker SD, Sharma R (September 2002). "The syndrome of cardiac cachexia". Int. J. Cardiol. 85 (1): 51–66. PMID 12163209.
  10. ↑ Horwich TB, Kalantar-Zadeh K, MacLellan RW, Fonarow GC (May 2008). "Albumin levels predict survival in patients with systolic heart failure". Am. Heart J. 155 (5): 883–9. doi:10.1016/j.ahj.2007.11.043. PMID 18440336.
  11. ↑ Breathett K, Allen LA, Udelson J, Davis G, Bristow M (October 2016). "Changes in Left Ventricular Ejection Fraction Predict Survival and Hospitalization in Heart Failure With Reduced Ejection Fraction". Circ Heart Fail. 9 (10). doi:10.1161/CIRCHEARTFAILURE.115.002962. PMC 5082710. PMID 27656000.
  12. ↑ Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK (October 2007). "Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II". Am. J. Med. 120 (10): 871–9. doi:10.1016/j.amjmed.2007.03.024. PMC 2071924. PMID 17904458.
  13. ↑ "Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED)". JAMA. 263 (20): 2753–9. 1990. PMID 2332918.
  14. ↑ File TM (December 2003). "Community-acquired pneumonia". Lancet. 362 (9400): 1991–2001. doi:10.1016/S0140-6736(03)15021-0. PMID 14683661.
  15. ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin. Infect. Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
  16. ↑ Musher DM, Thorner AR (October 2014). "Community-acquired pneumonia". N. Engl. J. Med. 371 (17): 1619–28. doi:10.1056/NEJMra1312885. PMID 25337751.
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  32. ↑ Hyde L, Hyde CI (March 1974). "Clinical manifestations of lung cancer". Chest. 65 (3): 299–306. PMID 4813837.
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  34. ↑ Hiraki A, Ueoka H, Takata I, Gemba K, Bessho A, Segawa Y, Kiura K, Eguchi K, Yoneda T, Tanimoto M, Harada M (March 2004). "Hypercalcemia-leukocytosis syndrome associated with lung cancer". Lung Cancer. 43 (3): 301–7. doi:10.1016/j.lungcan.2003.09.006. PMID 15165088.
  35. ↑ Ungprasert P, Carmona EM, Utz JP, Ryu JH, Crowson CS, Matteson EL (February 2016). "Epidemiology of Sarcoidosis 1946-2013: A Population-Based Study". Mayo Clin. Proc. 91 (2): 183–8. doi:10.1016/j.mayocp.2015.10.024. PMC 4744129. PMID 26727158.
  36. ↑ Baughman RP, Teirstein AS, Judson MA, Rossman MD, Yeager H, Bresnitz EA, DePalo L, Hunninghake G, Iannuzzi MC, Johns CJ, McLennan G, Moller DR, Newman LS, Rabin DL, Rose C, Rybicki B, Weinberger SE, Terrin ML, Knatterud GL, Cherniak R (November 2001). "Clinical characteristics of patients in a case control study of sarcoidosis". Am. J. Respir. Crit. Care Med. 164 (10 Pt 1): 1885–9. doi:10.1164/ajrccm.164.10.2104046. PMID 11734441.
  37. ↑ Rizzato G, Tinelli C (2005). "Unusual presentation of sarcoidosis". Respiration. 72 (1): 3–6. doi:10.1159/000083392. PMID 15753626.
  38. ↑ Rizzato G, Palmieri G, Agrati AM, Zanussi C (June 2004). "The organ-specific extrapulmonary presentation of sarcoidosis: a frequent occurrence but a challenge to an early diagnosis. A 3-year-long prospective observational study". Sarcoidosis Vasc Diffuse Lung Dis. 21 (2): 119–26. PMID 15281433.
  39. ↑ Vichinsky EP, Styles LA, Colangelo LH, Wright EC, Castro O, Nickerson B (March 1997). "Acute chest syndrome in sickle cell disease: clinical presentation and course. Cooperative Study of Sickle Cell Disease". Blood. 89 (5): 1787–92. PMID 9057664.
  40. ↑ Castro O, Brambilla DJ, Thorington B, Reindorf CA, Scott RB, Gillette P, Vera JC, Levy PS (July 1994). "The acute chest syndrome in sickle cell disease: incidence and risk factors. The Cooperative Study of Sickle Cell Disease". Blood. 84 (2): 643–9. PMID 7517723.
  41. ↑ Vichinsky EP, Neumayr LD, Earles AN, Williams R, Lennette ET, Dean D, Nickerson B, Orringer E, McKie V, Bellevue R, Daeschner C, Manci EA (June 2000). "Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group". N. Engl. J. Med. 342 (25): 1855–65. doi:10.1056/NEJM200006223422502. PMID 10861320.
  42. ↑ Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R (August 2006). "The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus". Am. J. Gastroenterol. 101 (8): 1900–20, quiz 1943. doi:10.1111/j.1572-0241.2006.00630.x. PMID 16928254.
  43. ↑ Vakil NB, Traxler B, Levine D (August 2004). "Dysphagia in patients with erosive esophagitis: prevalence, severity, and response to proton pump inhibitor treatment". Clin. Gastroenterol. Hepatol. 2 (8): 665–8. PMID 15290658.
  44. ↑ Giannini EG, Zentilin P, Dulbecco P, Vigneri S, Scarlata P, Savarino V (February 2008). "Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment". Am. J. Gastroenterol. 103 (2): 267–75. doi:10.1111/j.1572-0241.2007.01659.x. PMID 18289194.
  45. ↑ Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO (April 1987). "Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients". Ann. Intern. Med. 106 (4): 593–7. PMID 3826958.
  46. ↑ Kahrilas PJ (May 2010). "Esophageal motor disorders in terms of high-resolution esophageal pressure topography: what has changed?". Am. J. Gastroenterol. 105 (5): 981–7. doi:10.1038/ajg.2010.43. PMC 2888528. PMID 20179690.
  47. ↑ Pandolfino JE, Ghosh SK, Rice J, Clarke JO, Kwiatek MA, Kahrilas PJ (January 2008). "Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls". Am. J. Gastroenterol. 103 (1): 27–37. doi:10.1111/j.1572-0241.2007.01532.x. PMID 17900331.
  48. ↑ Kahrilas PJ, Ghosh SK, Pandolfino JE (2008). "Esophageal motility disorders in terms of pressure topography: the Chicago Classification". J. Clin. Gastroenterol. 42 (5): 627–35. doi:10.1097/MCG.0b013e31815ea291. PMC 2895002. PMID 18364587.
  49. ↑ Bott S, Prakash C, McCallum RW (August 1987). "Medication-induced esophageal injury: survey of the literature". Am. J. Gastroenterol. 82 (8): 758–63. PMID 3605035.
  50. ↑ Parfitt JR, Jayakumar S, Driman DK (September 2008). "Mycophenolate mofetil-related gastrointestinal mucosal injury: variable injury patterns, including graft-versus-host disease-like changes". Am. J. Surg. Pathol. 32 (9): 1367–72. PMID 18763324.
  51. ↑ Jaspersen D (March 2000). "Drug-induced oesophageal disorders: pathogenesis, incidence, prevention and management". Drug Saf. 22 (3): 237–49. PMID 10738847.
  52. ↑ Kapel RC, Miller JK, Torres C, Aksoy S, Lash R, Katzka DA (May 2008). "Eosinophilic esophagitis: a prevalent disease in the United States that affects all age groups". Gastroenterology. 134 (5): 1316–21. doi:10.1053/j.gastro.2008.02.016. PMID 18471509.
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