Chest Pain

Aka: Chest Pain, Chest Pain Causes, Precordial Pain, Chest Pain Plus

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II. Risk Factors

  1. See Cardiac Risk Factors
  2. See Framingham Score

III. Epidemiology

  1. Chest Pain is the presenting complaint in 1% of ambulatory visits
    1. Unstable Angina and Myocardial Infarction represent <4% of ambulatory Chest Pain presentations
    2. Most common cause for clinic Chest Pain presentations are Chest Wall Pain, GERD and constochondritis
    3. However, cardiac disease is the most common U.S. cause of death; have a high index of suspicion
  2. Acute Myocardial Infarction and Chest Pain are the two most commonly litigated ED Malpractice claims
    1. Brown (2010) Acad Emerg Med 17(5):553-60 +PMID:20536812 [PubMed]

IV. Precautions

  1. No single finding is absolutely pathognomonic nor completely reassuring in Chest Pain presentation
    1. Risk stratification, evaluation and management is based on an overall analysis of all clinical data
    2. Approach should be based on combination of factors
      1. Chest Pain Decision Rules
      2. Exam, ekg and Serum Cardiac Markers
    3. Consider atypical presentations of coronary syndromes in atypical patients
      1. Younger patients with Chest Pain
      2. Women with Chest Pain (see below)
      3. Non-diagnostic initial Electrocardiograms
      4. Atypical symptoms
      5. Rusnak (1989) Ann Emerg Med 18(10): 1029-34 +PMID:2802275 [PubMed]
  2. Myocardial Infarction without Chest Pain occurs in up to 50% of patients
    1. Men: 31% overall (13% under age 45)
    2. Women: 42% overall (20% under age 45)
    3. Mortality is 10-15% for painless MI (contrast with 1-2% for those with Chest Pain)
    4. Canto (2000) JAMA 283(24): 3223-9 [PubMed]
    5. Canto (2012) JAMA 307(8): 813-22 [PubMed]
  3. Cardiac Risk Factors only weakly predict Acute Coronary Syndrome (especially with advancing age)
    1. Age 40-65 years: 2.1 Positive Likelihood Ratio
    2. Age over 65 years: 1.1 Positive Likelihood Ratio
    3. Han (2007) Ann Emerg Med 49(2): 145-52 [PubMed]
  4. Sudden Dyspnea may be only presenting symptom of ACS
    1. Only symptom in up to 14% of patients with MI
  5. Myocardial Infarction often presents with gastrointestinal symptoms
    1. Indigestion or burning pain (23%)
    2. Nausea (60%)
    3. Upper Abdominal Pain (20%)
  6. Esophageal pain often presents with MI type findings
    1. Pain radiates to left arm (11%)
    2. Responds to Nitroglycerin (30-50%)
  7. Relief (or lack of relief) with Nitroglycerin does not predict cause
    1. Non-cardiac pain is often relieved with Nitroglycerin (e.g. Esophageal Spasm)
    2. Cardiac Chest Pain not relieved with Nitroglycerin may be an indication for emergency catheterization (PCI)
    3. Shry (2002) Am J Cardiol 90:1264-6 [PubMed]
  8. Sharp or stabbing Chest Pain may still be cardiac
    1. Up to 22% with sharp Chest Pain have ACS
    2. Several atypical symptoms lower ACS likelihood
    3. ACS may present with Pain fully reproduced with palpation (8-10%)
  9. Intrascapular pain without Chest Pain can represent catastrophic cardiovascular events
    1. Evaluate for Acute Coronary Syndrome and Aortic Dissection
    2. Evaluate for Pulmonary Embolism
    3. Diagnosis of spinal or musculoskeletal causes are after exclusion of intra-thoracic causes
  10. Women often present atypically (e.g. Dyspnea, weakness Nausea, Palpitations, Syncope) with Myocardial Infarctions
    1. Even prior stress testing may have been falsely reasuring
      1. Non-occlusive CAD is twice as common in women
      2. Non-occlusive Plaque may embed within artery wall, erode and cause acute thrombus or vasospasm
    2. Presentations are more similar as men and women age (contrary to prior doctrine)
      1. By age 75 years old, both men and women present without Chest Pain in 50% of cases
    3. Greatest discrepancy between male and female ACS presentations are in the under age 45 cohort
      1. Women with MI under age 45 present without Chest Pain in 20% of cases (contrast with 13% in men)
      2. Spontaneous Coronary Artery Dissection (SCAD) represents 40% of MI in women age under 50 years
    4. References
      1. Canto (2012) JAMA 307(8): 813-22 [PubMed]
      2. Pepine (2015) J Am Coll Cardiol 66(17): 1918-33 +PMID:26493665 [PubMed]
  11. Recent negative stress test does not exclude Acute Coronary Syndrome
    1. Despite JACC 2022 guideline, negative stress test in last year does not exclude Acute Coronary Syndrome
    2. However, normal angiogram or clean Coronary CT Angiography (CCTA) in last 2 years is very reassuring
  12. Under-Served Populations
    1. Black, LatinX, South Asian, Medicaid and Uninsured patients have a higher morbidity and mortality with Chest Pain
    2. Under-served populations receive less aggressive evaluation and management in Chest Pain presentations

V. History: Present Illness

  1. Chest Pain
    1. Use the term "Chest Discomfort" in place of "Chest Pain" when asking the patient about symptoms
      1. Many patients will deny Chest Pain, but admit to chest pressure, chest tightness or discomfort
    2. Chest Pain characteristics (sharp, dull, pressure, tightness, tearing)
    3. Onset
    4. Duration
    5. Location (e.g. substernal, left or right, upper or lower)
    6. Radiation (right arm, left arm, neck, jaw or back)
    7. Severity (at onset, at worst, and now)
      1. Perceived pain intensity does not always correlate with disease severity
    8. Palliative (e.g. rest, Nitroglycerin)
    9. Provocative (e.g. walking or other physical exertion, deep breathing, eating, torso movement, direct pressure)
  2. Shortness of Breath
    1. Shortness of Breath on exertion
    2. Shortness of Breath at rest
    3. Orthopnea
  3. Nausea or Vomiting
  4. Near Syncope or Light Headedness
  5. Other Associated Symptoms
    1. Abdominal Pain
    2. Back pain
    3. Black stools (Melana) or Vomiting blood

VI. History: Past History

  1. Coronary Artery Disease (prior PTCA or CABG?)
  2. Peripheral Arterial Disease
  3. Prior abnormal stress test
  4. Diabetes Mellitus
  5. Other risk factors
    1. See Coronary Artery Disease Risk Factors
    2. Hypertension
    3. Hyperlipidemia
    4. Tobacco Abuse
    5. Premature heart disease Family History (age <55 in father or brother, age <65 in mother or sister)

VII. Symptoms

  1. See precautions above
  2. See Likelihood of Coronary Disease as Cause of Chest Pain
  3. Findings that most increase the likelihood of Acute Coronary Syndrome
    1. Pain radiation to the right chest or bilateral chest or Shoulder (LR+ 4.7) or both Shoulders (LR+ 4.1 to 7.1)
    2. Exertional pain (LR 2.4)
    3. Pain with diaphoresis (LR 2.0)
    4. Pain associated with Nausea AND Vomiting (LR+ 1.9)
    5. Pain that is similar to prior MI or worse than previous Angina pain (LR+ 1.8)
  4. Other findings that increase the likelihood of Acute Coronary Syndrome
    1. Pain duration >1 hour (and less than 48 hours)
    2. Central Chest Pain
  5. Findings that decrease the likelihood of Acute Coronary Syndrome
    1. Fully reproducible Chest Pain on palpation (LR+ 0.3)
    2. Positional Chest Pain (LR 0.3)
    3. Pleuritic Chest Pain (LR+ 0.2)
    4. Sharp Chest Pain (LR+ 0.3)
    5. Pain at rest
    6. Pain for more than 48 hours
    7. No radiation to arm, Shoulder, neck or jaw

VIII. Signs

  1. See Likelihood of Coronary Disease as Cause of Chest Pain
  2. Findings that increase the likelihood of Acute Coronary Syndrome (acute Congestive Heart Failure findings)
    1. New S3 Gallup Rhythm or Third Heart Sound (Positive Likelihood Ratio 3.2)
    2. Hypotension (Positive Likelihood Ratio: 3.1)
    3. New Mitral Regurgitation murmur
    4. Pulmonary Rales
    5. New Jugular Venous Distention
  3. Finding that decrease the likelihood of Acute Coronary Syndrome
    1. Pain reproducible on palpation (Negative Likelihood Ratio: 0.2 to 0.4)

IX. Differential Diagnosis: By Cohort

  1. Adults
    1. Critical, more common causes
      1. Acute Coronary Syndrome
      2. Aortic Dissection
      3. Pulmonary Embolism
    2. Critical, less common causes
      1. Cardiac Tamponade
      2. Esophageal Rupture with Spontaneous Pneumomediastinum (Boerhaave Syndrome)
      3. Tension Pneumothorax
    3. Other common causes
      1. Chest Wall Pain
      2. Congestive Heart Failure
      3. Pericarditis
      4. Gastroesophageal Reflux
      5. Panic Attack
      6. Pneumonia
  2. Children
    1. Cardiac Causes (1-2% of cases; however consider risks, e.g. Marfan Syndrome)
      1. Pericarditis
      2. Myocarditis
      3. Kawasaki Disease (younger children)
    2. Respiratory
      1. Asthma
      2. Acute Bronchitis
      3. Pneumonia
      4. Pneumothorax
    3. Gastrointestinal referred pain
    4. Chest Wall Pain
    5. Anxiety
  3. References
    1. Saleeb (2011) Pediatrics 128(5): 1062-8 +PMID: 21987702 [PubMed]

X. Differential Diagnosis: Onset

  1. Sudden Onset
    1. Angina
    2. Myocardial Infarction
    3. Aortic Dissection
    4. Pulmonary Embolus
    5. Esophageal Rupture (Boerhaave Syndrome)
    6. Spontaneous Pneumomediastinum
    7. Spontaneous Pneumothorax
  2. Gradual or Variable Onset
    1. Pericarditis
    2. Musculoskeletal Chest Pain
    3. Costochondritis
    4. Epidemic Pleurodynia
    5. Mitral Valve Prolapse

XI. Differential Diagnosis: Characteristic

  1. Pressure Sensation
    1. Angina
    2. Myocardial Infarction
    3. Esophageal Spasm
  2. Tearing Sensation
    1. Aortic Dissection
  3. Sharp or Stabbing Sensation
    1. Pericarditis
    2. Pulmonary Embolus
    3. Musculoskeletal Chest Pain
    4. Epidemic Pleurodynia
    5. Mitral Valve Prolapse
    6. Spontaneous Pneumothorax
    7. Esophageal Spasm

XII. Differential Diagnosis: Provocative Factors

  1. Exertion or stress
    1. Angina
    2. Myocardial Infarction
  2. Hypertension
    1. Aortic Dissection
  3. Pleuritic (Deep breath or cough)
    1. See Pleuritic Chest Pain
    2. See Pleuritic Chest Pain due to Medications
    3. Pulmonary Embolus
    4. Pericarditis
    5. Spontaneous Pneumomediastinum
    6. Musculoskeletal Chest Pain
    7. Cough fracture
  4. Swallowing or Vomiting
    1. Esophageal Rupture
    2. Spontaneous Pneumomediastinum
  5. Supine Position
    1. Pericarditis
    2. Spontaneous Pneumomediastinum
  6. Movement
    1. Musculoskeletal Chest Pain
    2. Cough fracture

XIII. Differential Diagnosis: Radiation of pain

  1. Pain radiates to arm or Shoulder
    1. Angina or Myocardial Infarction
      1. Pain radiating to both arms strongly suggests MI (Positive Likelihood Ratio 7.1)
    2. Pericarditis
    3. Spontaneous Pneumothorax
    4. Esophageal Spasm
  2. Pain radiates to back or intrascapular
    1. Aortic Dissection
    2. Pericarditis
    3. Acute Coronary Syndrome
    4. Spontaneous Pneumothorax
    5. Esophageal Spasm
    6. Thoracic Spine radicular pain (e.g. thoracic compression Fracture, T4 syndrome)
    7. Pulmonary Embolism
  3. Pain Radiates to Neck, throat, or jaw
    1. Spontaneous Pneumomediastinum
    2. Pericarditis
    3. Acute Coronary Syndrome
    4. Esophageal Spasm

XIV. Differential Diagnosis: Chest Pain Plus Syndromes

  1. Subset of patients present with Chest Pain Plus another key symptom
    1. Headache
    2. Neurologic Deficit (stroke findings)
    3. Abdominal Pain
    4. Back Pain
    5. Syncope (see Syncope Plus)
    6. Pain out of proportion
    7. Seizure
  2. Associated Syndromes
    1. Subarachnoid Hemorrhage (may be associated with ST Elevation)
    2. Aortic Dissection
    3. Shock state with systemic hypoperfusion
    4. Embolic Occlusion of multiple vessels (e.g. coronary and Cerebral Vessels)

XV. Differential Diagnosis: Diagnoses of Exclusion

  1. Anxiety Disorder (e.g. Panic Attack)
  2. Gastroesophageal Reflux or Esophageal Spasm
  3. Musculoskeletal Chest Pain (Chest Wall Pain)

XVI. Diagnosis: Prediction Rules

  1. See Likelihood of Coronary Disease as Cause of Chest Pain
  2. HEART Score
  3. Emergency Department Assessment of Chest Pain Score (EDACS)
  4. Troponin-Only Manchester Acute Coronary Syndrome Decision Aid (T-Macs)
  5. Marburg Heart Score
  6. INTERCHEST Chest Pain Rule
  7. CAD Pretest Probability in Chest Pain Presentation
  8. TIMI Risk Score
  9. Bosner Chest Pain Decision Rule
  10. Diamond and Forrester Chest Pain Prediction Rule
  11. Goldman Criteria for ICU Chest Pain Admission
  12. Cardiac Risk in Diabetes Score

XVII. Diagnostics: Electrocardiogram

  1. See EKG in Cardiac Ischemia
  2. Consider subtle findings on EKG that could indicate ischemia
  3. Repeat Electrocardiograms with ongoing symptoms

XVIII. Evaluation: Approach

  1. Acute Chest Pain Approach
  2. See Angina Diagnosis
  3. Focus Areas
    1. First exclude serious Chest Pain Causes
    2. Evaluate for signs of Myocardial Infarction complications (e.g. acute Congestive Heart Failure)
    3. Identify non-cardiac cause of Chest Pain

XIX. Management

  1. See Acute Chest Pain Approach

XX. References

  1. Mattu in Herbert (2012) EM: Rap 12(9): 4
  2. Mattu in Swadron (2022) EM:Rap 22(5): 13-5
  3. Velasco, Lee, Chandra (2019) Crit Dec Emerg Med 33(1): 3-10
  4. Achar (2005) Am Fam Physician 72:119-26 [PubMed]
  5. Body (2010) Resuscitation 81(3): 281-6 [PubMed]
  6. Goodacre (2002) Acad Emerg Med 9:203-8 [PubMed]
  7. McConaghy (2013) Am Fam Physician 87(3):177-82 [PubMed]
  8. McConaghy (2020) Am Fam Physician 102(12):721-7 [PubMed]
  9. Panju (1998) JAMA 280(14): 1256-63 [PubMed]
  10. Swap (2005) JAMA 294(20): 2623-9 [PubMed]

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