Chest pain history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2], Nuha Al-Howthi, MD[3], José Eduardo Riceto Loyola Junior, M.D.[4]

Overview

The symptoms of chest pain can help to discern whether there is an underlying cause that may be dangerous. Symptoms that should cause alarm are; chest pain radiating to the back (aortic dissection), left arm or jaw pain, nausea, vomiting, lightheadedness, and angina pain that is different from baseline (myocardial infarction). Pain that is reproduced with palpation, greatest in the abdominal region, radiating to lower extremities, brought on by inspiration, or brought on any movement or postural changes, is less characteristic of myocardial ischemia.

History and Symptoms

Clinical syndrome	Aspect
❑ ACS	❑ Diaphoresis ❑ Tachypnea ❑ Tachycardia ❑ Hypotension ❑ Crackles ❑ S3 ❑ Mitral Regurgitation murmur ❑ Normal examination in uncomplicated cases
❑ Pulmonary embolism	❑ Tachycardia ❑ Tachypnea ❑ Pleuritic chest pain
❑ Aortic dissection	❑ Connective tissue disorder (Marfan syndrome) ❑ Differential extremity pulses (30% of patients, type A> B) ❑Severe chest pain ❑ Abrupt onset chest pain ❑ Pulse differential ❑ Widend mediastinum on CXR ❑ Syncope >10% ❑ Aortic Regurgitation 40-75% (type A)
❑ Esophageal rupture	❑Emesis ❑Subcutaneous emphysema ❑Pneumothorax (20% of patients) ❑Unilateral decreased or absent breath sounds
❑ Non coronary causes of chest pain (Aortic Stenosis, Aortic Regurgitation, Hypertrophic cardiomyopathy)	❑ AS ❑ Systolic murmuur, tardus or parvus carotid pulse ❑ AR ❑ Diastolic murmus at right sternal border ❑Rapid carotid upstroke ❑HCM ❑Increased or displaced left ventricular impulse ❑Systolic murmur ❑ Prominent a wave in jugular venous pressure
❑ Pericarditis	❑ Fever ❑Pleuritic chest pain ❑Increased in supine position ❑ Friction rub
❑ Myocarditis	❑ Fever ❑ Chest pain ❑ Heart failure ❑ S3
❑ Esophagitis, peptic ulcer disease, gall bladder disease	❑ Epigasteric tenderness ❑Right upper quadrant tenderness ❑Murphy sign
❑ Pneumonia	❑ Fever ❑ Localized chest pain ❑ Pleuritic chest pain ❑ Friction rub ❑ Dullness on percussion ❑ Egophony
❑ Pneumothorax	❑Dyspnea or chest pain on inspiration ❑Unilateral absence of breath sounds
❑ Costochonritis, Tietze syndrome	❑ Tenderness on costochondral joints
❑ Herpes zoster	❑ Chest pain on dermatomal distribution ❑Triggered by tough ❑ Dermatomal rash distribution

The patient's history must be thoroughly investigated to exclude the life-threatening causes of chest pain, such as the cardiovascular ones: acute coronary syndrome, aortic dissection, pulmonary embolism but also the non-cardiac such as tension pneumothorax and esophageal rupture.

Chest pain suggestive of cardiac ischemia as the underlying cause:

• Describing the pain as heaviness, a pressure, discomfort or a bandilike tightness.
• Radiation of the pain to neck, jaw, arms, shoulders, back or upper abdomen.
• Sweating
• Nausea
• Palpitations
• Pain with exertion
• Dizziness
• Shortness of breath
• A sense of impending doom.
  • Be mindful that women and patients with diabetes mellitus may present with the other symptoms rather than chest pain.
  • The discomfort caused by cardiac ischemia is usually deep, sometimes vaguely described and hard to pinpoint, being characteristically diffuse.
  • Aspects such as duration, location, triggers, worsening and relieving factors, radiation are also very valuable on establishing if chest pain is suggestive of a cardiac or cardiovascular cause. Pain that is suggestive of acute coronary syndrome is usually retrosternal, triggered by emotional or physical distress or at rest, becomes progressively more intense in a few minutes and is worsened by exercise. It is relieved by resting or with the use of nitrates, it radiates to the left shoulder, arm or neck, but it may indeed radiate to basically any location between the jaw and the umbilicus. It often is accompanied by nausea, vomiting, sweating, paleness, dyspnea and lightheadedness.

Special considerations for specific groups

• In recent studies, women are more likely to present with associated symptoms than men, and those presenting with moderate-to-severe ischemia are more symptomatic than men. Chest pain is still the predominant symptom in women.
• Considerations for older patients: older patients presenting with chest pain require a more extensive workup for alternative diagnoses associated with chest pain, besides acute coronary syndromes. Increased age is a very important risk factor for comorbidities that predispose to other causes of chest pain.
• Studies have showed that black patients are less likely to be treated urgently for chest pain and to be monitored than other groups. This also happens with hispanics and South Asians, which leads to worse outcomes in both of these population subgroups. It is of utmost importance to take into consideration the patient's ethnicity, race and sociocultural differences while assessing them.

Chest pain not characteristic of myocardial ischemia:

• Muscular pain; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
• Pleura related pain (pleuritic pain); a sharp or knife-like pain brought on by respiratory movements as deep breathing or cough
• Primary or sole location of discomfort in the middle or lower abdominal region
• Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costochondral junction
• Pain reproduced with movement or palpation of the chest wall or arms
• Very brief episodes of pain that last a few seconds or less
• Pain that radiates into the lower extremities

The relief of chest pain by administration of sublingual nitroglycerin in an outpatient setting is not diagnostic of coronary artery disease. For instance, esophageal pain can be relieved by the administration of nitroglycerin. Likewise, the relief of chest pain by the administration of liquid or chewable antacids and anti-reflux drugs does not exclude coronary artery disease as the underlying etiology of the pain.