Chest pain may be a symptom of a number of serious conditions and is, in
general, considered a medical emergency. Even though it may be determined
that the pain is non-cardiac in origin, this is often a diagnosis of
exclusion made after ruling out more serious causes of the pain.
Differential diagnosis
Causes of chest pain range from non-serious to serious to life-threatening.
DiagnosisPro lists more than 440 causes on its website.
Cardiovascular
Acute coronary syndrome
Unstable Angina Pectoris - requiring emergency medical treatment but not
primary intervention as in a myocardial infarction.
Myocardial infarction
Aortic dissection
Pericarditis and cardiac tamponade
Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause
chest pain.
Stable angina pectoris - this can be treated medically, and, although it
warrants investigation, it is not an emergency in its strictest sense
Myocarditis
Mitral valve prolapse syndrome
Aortic aneurysm
Respiratory
Bronchitis
Pulmonary embolism
Pneumonia
Hemothorax
Pneumothorax and Tension pneumothorax
Pleurisy - an inflammation that can cause painful respiration
Tuberculosis
Tracheitis
Lung malignancy
Gastrointestinal
Gastroesophageal reflux disease and other causes of heartburn
Hiatus hernia
Achalasia, nutcracker esophagus and other neuromuscular disorders of the
esophagus
Functional dyspepsia
Chest wall
Costochondritis or Tietze's syndrome - a benign and harmless form of
osteochondritis often mistaken for heart disease
Spinal nerve problem
Fibromyalgia
Chest wall problems
Radiculopathy
Precordial catch syndrome - another benign and harmless form of a sharp,
localised chest pain often mistaken for heart disease
Breast conditions
Herpes zoster commonly known as shingles
Tuberculosis
Osteoarthritis
Bornholm disease
Psychological
Panic attack
Anxiety
Clinical depression
Somatization disorder
Hypochondria
Others
Hyperventilation syndrome often presents with chest pain and a tingling
sensation of the fingertips and around the mouth
Da costa's syndrome
Carbon monoxide poisoning
Sarcoidosis
Lead poisoning
High abdominal pain may also mimic chest pain
Prolapsed intervertebral disc
Thoracic outlet syndrome
Diagnostic approach
History taking:
Knowing a patient's risk factors can be extremely useful in ruling in or
ruling out serious causes of chest pain. For example, heart attack and
thoracic aortic dissection are very rare in healthy individuals under 30
years of age, but significantly more common in individuals with significant
risk factors, such as older age, smoking, hypertension, diabetes, history of
coronary artery disease or stroke, positive family history, and other risk
factors.
Physical examination:
In the emergency department the typical approach to chest pain involves
ruling out the most dangerous causes: heart attack, pulmonary embolism,
thoracic aortic dissection, esophageal rupture, tension pneumothorax, and
cardiac tamponade. By elimination or confirmation of the most serious
causes, a diagnosis of the origin of the pain may be made. Often, no
definite cause will be found and reassurance is then provided.
An electrocardiogram
CT scanning may be used in unexplained chest pain when other tests are
inconclusive.
V/Q scintigraphy or CT pulmonary angiogram
X-rays of the chest and abdomen . Routine X-rays, however, are not needed.
Blood tests:
Troponin I or T
Complete blood count
Electrolytes and renal function
Liver enzymes
Creatine kinase
D-dimer
serum lipase or amylase to exclude acute pancreatitis
Management
Administration of an aspirin tablet to be chewed and swallowed at admission
was found to correlate with a 30% increase in 30-day survival. "Because
aspirin should be administered as soon as possible after symptom onset to
patients with suspected ACS, it is reasonable for EMS dispatchers to
instruct patients with no history of aspirin allergy and without signs of
active or recent gastrointestinal bleeding to chew an aspirin while
awaiting the arrival of EMS providers ...".
In people with chest pain supplemental oxygen is not needed unless the
oxygen saturations are less than 94% or there are signs of respiratory
distress. Entonox is frequently used by EMS personnel in the prehospital
environment. However, there is little evidence about its effectiveness.
Epidemiology
Chest pain is the presenting symptom in about 12% of emergency department
visits in the United States and has a one-year mortality of about 5%.