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Chest Pain



  • Chest pain is a very common presenting complaint, and the most pressing concern is to rule out life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection and tension pneumothorax. A thorough history is vital for differentiating between these causes and other less emergent conditions that may cause chest pain.


    • Causes of Chest Pain

    • Cardiac

    • Stable angina
    • Acute coronary syndrome - unstable angina, NSTEMI, STEMI
    • Other cardiac ischaemia - vasospasm (prinzmetal angina), severe aortic stenosis, hypertensive ischaemia, rate-related ischaemia, dilated cardiomyopathy, Tako-tsubo cardiomyopathy
    • Non-ischaemic - pericarditis, myocarditis, myocardial contusion
    • Non-Cardiac

    • Vascular - aortic dissection, pulmonary embolism
    • Respiratory - pneumonia with pleurisy, pneumothorax, lung cancer
    • Gastrointestinal - peptic ulcer, gastritis, oesophagitis, oesophageal spasm, oesophageal rupture
    • Musculoskeletal - costochondritis, osteomyelitis, rib fracture, cervical spinal disease
    • Psychogenic - panic disorder, malingering

History of Presenting Complaint

    • Site  

      Where the pain is - central, the left or right side, the ribs, or generalised.
    • Retrosternal chest painReflux, angina
    • Pain in chest wall / ribs Suggestive of a musculoskeletal cause - unlikely to be anginal
    • Onset

      Whether the pain began suddenly or gradually, and what the patient was doing at the time.
    • Onset at restSuggestive of acute coronary syndrome over stable angina if typical ischaemic pain
    • Onset during exertionSuggestive of stable angina if typical ischaemic pain
    • Onset post traumaMay represent pneumothorax or rib fractures
    • Character

       The type of pain - sharp, dull, tight, crushing, burning or tearing.
    • Central, crushing chest painTypical of acute coronary syndrome
    • Tearing pain that radiates to the backCharacteristic of aortic dissection
    • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE, chest wall pain (unlikely anginal)
    • Radiation  

      Whether the pain radiates anywhere else, such as the shoulder, arm, jaw or back.
    • Pain radiating to the shoulders / arms or jawTypical of acute coronary syndrome
    • Pain radiating to the backSuggestive of aortic dissection
    • Associated Symptoms

      Whether the pain is associated with any other symptoms.
    • Nausea, vomiting and diaphoresisSuggestive of angina / acute coronary syndrome
    • FeversSuggestive of pneumonia, pericarditis or costochondritis
    • Shortness of breathSuggestive of respiratory cause such as pneumonia, pneumothorax or PE
    • CoughSuggestive of pneumonia or reflux
    • Sour taste / acid refluxSuggestive of reflux pain
    • Timing

      How long the pain has been going on for.
    • Central crushing chest pain lasting >20 minutesSuggestive of acute coronary syndrome rather than stable angina
    • Exacerbating Factors

      Whether anything makes the pain worse, such as breathing in or sitting forward.
    • Exertional chest painSuggestive of cardiac pain
    • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE or chest wall pain (unlikely anginal)
    • Brought on with foodSuggestive of reflux
    • Worsened by sitting forward or lying downSuggestive of reflux
    • Alleviating Factors

      Whether anything they've tried has improved or resolved the pain.
    • Relief with GTNStrongly suggestive of cardiac ischaemia, though GTN may also relieve oesophageal pain
    • Relief with reflux medsMore likely to represent reflux pain
    • Relief with passing gasSuggestive of ‘pseudo-angina’ - gas in stomach or splenic flexure
    • Improved with sitting forwardSuggestive of pericarditis
    • Severity

    • How severe the pain is out of 10, with 10 being the worse possible pain.
    • How the pain is impacting the patient’s life, such as work, hobbies or even mobility.

Extra Credit

    • High Likelihood of Acute Coronary Syndrome

    • Pressure-like sensation (e.g. tight or crushing)
    • Radiating to one or both arms
    • Associated with exertion, nausea, vomiting or diaphoresis
    • Low Likelihood of Acute Coronary Syndrome

    • Stabbing pain
    • Pleuritic pain
    • Positional pain
    • Inframammary pain
    • Reproducible with palpation
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