Chest pain overview
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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]
Overview
Chest pain is discomfort or pain that you feel anywhere along the front of your body between your neck and upper abdomen. It may be crushing or burning, and may present in certain cases as pain that shoots up the neck, into the jaw and may travel to the back or upper limbs. Chest pain has various etiologies with the most serious cases involving the cardiovascular or respiratory system. Common causes of chest pain may require emergent medical attention, and serious pathologies should be ruled out before more benign etiologies can be considered.
Historical Perspective
The first recorded description of chest pain was given by Benivieni, a Florentine physician in the early 1500s. The first concise account of angina pectoris was given by the then Earl of Clarendon when he described his father's illness. Angina pectoris was described by a medical practitioner when Dr. William Heberden read his paper to the College of Physicians in London on 21 July 1768.
Classification
Chest pain may be classified according to its characteristics into 3 subtypes/groups: Typical Angina (definite), Atypical angina (probable), Non-cardiac chest pain
Pathophysiology
The cardiovascular system, respiratory system, part of the gastrointestinal system, and the great vessels give off afferent visceral input via common thoracic autonomic ganglia. Painful stimuli in any of the aforementioned systems are usually sensed as originating from the chest. However, due to the fact that afferent nerve fibers overlap in the dorsal ganglia, pain in the thorax may be experienced at any point between the umbilicus and the ear, as well as in the upper limbs.
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.
Differentiating Chest pain from Other Diseases
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.
Epidemiology and Demographics
There is a significant difference in the epidemiology of chest pain in the outpatient and emergency settings. The incidenceof chest pain is approximately 1,500 per 100,000 individuals worldwide. According to a study conducted in Belgium, the prevalence of chest pain is approximately 2000-5000 per 100,000 individuals worldwide. The incidence of patients presenting with chest pain increases with age and men are more likely to present with chest pain than women.
Risk Factors
Common risk factors in the development of chest pain may be associated with the cardiac, respiratory, or gastrointestinal systems. Other risk factors include smoking, obesity, drug abuse, and psychiatric disorders.
Screening
There is insufficient evidence to recommend routine screening for chest pain
Natural History, Complications, and Prognosis
Chest Pain in Pregnancy
Causes of chest pain in pregnancy are similar to those in the general population. Acute life-threatening causes include myocardial infarction, aortic dissection, tension pneumothorax, as well as thromboembolic diseases that are more common in pregnancy, such as pulmonary embolism and amniotic fluid embolism. Occasionally, chest pain in pregnant women is caused by physiological changes in pregnancy, namely chest expansion and breast tenderness.
Diagnosis
Diagnostic Study of Choice
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.
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.
Echocardiography and Ultrasound
CT scan
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.
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.
Interventions
Surgery
Surgery may be indicated in the setting of an MI (angioplasty) or in an aortic dissection.