Chest Pain
Overview
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.
Aetiology
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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