Chest pain overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Causes
There are many organ systems, that when affected, can lead to the symptoms of chest pain. The most common organs involved are the heart, lungs, and the digestive system. Psychiatric disorders, can also lead to the perception of chest pain. The most important facet of diagnosis is distinguishing the life-threatening causes of chest pain, to the more benign causes.
Differential Diagnosis
There are several life-threatening causes of chest pain which need to be evaluated for first, which include; myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. The other possible causes of chest pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.
Diagnosis
History and Symptoms
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 anginal 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 my movement or postural changes, is less characteristic of myocardial ischemia.
Physical Examination
Physical examination should focus on evaluating for the life-threatening causes of chest pain first. A complete physical exam should be done, which includes a thorough cardiac, lung, and abdominal exam.
Laboratory Findings
Serial troponins and CK-MB should be ordered. Additional laboratory tests include serum electrolytes, a complete blood count, renal function tests, and liver function tests.
Electrocardiogram
The key findings to look for on EKG is ST elevation which is characteristic of myocardial infarction. Diffuse ST elevation may point to the diagnosis of pericarditis. Serial EKG's should be obtain to evaluate for continued or progression of myocardial injury over time.
Chest X-ray
Chest X-ray can be useful in the initial evaluation of the patient to ascertain if there is cardiomegaly, pulmonary edema and aortic dissection. CT scanning may be better for visualizing the etiology of chest pain depending on the patient history and their symptoms.
CT
CT angiography may be helpful in ruling out a pulmonary embolism. These tests are sometimes combined with lower extremity venous ultrasound or D-dimer testing. To rule out aortic dissection, a chest CT scan with contrast, MRI or transesophageal echocardiography can be used.
MRI
To rule out aortic dissection, a chest CT scan with contrast, MRI or transesophageal echocardiography may be done.
Echocardiography
An echocardiogram is usually required for patients with suspected coronary artery disease. In an acute setting a transesophageal echocardiogram may be indicated to rule out aortic dissection.
Other Imaging Findings
Other imaging studies that may be used in the evaluation of chest pain include V/Q scintigraphy, CT angiogram, and endoscopy.
Other Diagnostic Studies
Other diagnostic studies used in the evaluation of chest pain include cardiac stress testing, peak flow studies, and pulmonary function testing.
Treatment
Medical Therapy
A correct diagnosis of the underlying cause of the chest pain should be obtained prior to deciding on an appropriate treatment strategy. The most dangerous causes should be evaluated first. If myocardial infarction or ischemia is suspected, the immediate pharmacotherapies often used include morphine, oxygen, nitrate, aspirin, and possibly also beta-blockers, ACE inhibitors, thrombolytic therapy and Glycoprotein IIb/IIIa inhibitors.
Surgery
Surgery may be indicated in the setting of an MI (angioplasty) or in an aortic dissection.