Chest pain is
pain or discomfort in the
chest, typically the front of the chest.[1] It may be described as sharp, dull, pressure, heaviness or squeezing.[3] Associated symptoms may include pain in the shoulder, arm,
upper abdomen, or jaw, along with
nausea, sweating, or
shortness of breath.[1][3] It can be divided into
heart-related and non-heart-related pain.[1][2] Pain due to insufficient blood flow to the heart is also called
angina pectoris.[5] Those with
diabetes or the elderly may have less clear symptoms.[3]
Management of chest pain is based on the underlying cause.[1] Initial treatment often includes the medications
aspirin and
nitroglycerin.[1][4] The response to treatment does not usually indicate whether the pain is heart-related.[1] When the cause is unclear, the person may be referred for further evaluation.[3]
Chest pain represents about 5% of
presenting problems to the
emergency room.[3] In the United States, about 8 million people go to the emergency department with chest pain a year.[1] Of these, about 60% are admitted to either the hospital or an observation unit.[1] The cost of emergency visits for chest pain in the United States is more than US$8 billion per year.[6] Chest pain accounts for about 0.5% of visits by children to the emergency department.[7]
Signs and symptoms
Chest pain may present in different ways depending upon the underlying diagnosis. Chest pain may also vary from person to person based upon age, sex, weight, and other differences.[1] Chest pain may present as a stabbing, burning, aching, sharp, or pressure-like sensation in the chest.[8][1] Chest pain may also radiate, or move, to several other areas of the body. This may include the neck, left or right arms,
cervical spine, back, and
upper abdomen.[9] Other associated symptoms with chest pain can include
nausea,
vomiting,
dizziness,
shortness of breath,
anxiety, and
sweating.[8][1] The type, severity, duration, and associated symptoms of chest pain can help guide diagnosis and further treatment.
Differential diagnosis
Causes of chest pain range from non-serious to serious to life-threatening.[10]
Myocardial infarction ("heart attack"): People usually complained of a pressure or squeezing sensation over the chest.[1] Other associated symptoms are: excessive sweating, nausea, vomiting, and weakness.[1] Chest pain is more commonly associated with anterior infarction because of
left ventricular impairment; inferior infarction is more commonly associated with nausea, vomiting, and excessive sweating due to irritation of
vagus nerve; lateral infarction is associated with left arm pain.
Prinzmetal's angina: Chest pain is caused by
coronary vasospasm. More common in women younger than 50 years. Person usually complain of chest pain at rest. It may occur early in the morning which awaken person from sleep.
Cocaine use: This condition is suspected when a person with few or no risk of
arteriosclerosis presented with non-traumatic chest pain. Ingestion of cocaine can cause
vasoconstriction of coronary arteries, thus producing chest pain similar to heart attack. Symptoms can appear within one hour of cocaine use.
Hypertrophic cardiomyopathy: It is the hypertrophy of interventricular septum that causes outflow obstruction of left ventricle. Dyspnea and chest pain commonly occurs during daily activities. Sometimes, syncope (fainting) may happen. On physical examination, significant findings include: loud systolic murmur and palpable triple apical impulse due to palpable presystolic
fourth heart sound.
Aortic dissection is characterized by severe chest pain that radiates the back. It is usually associated with
Marfan's syndrome and
hypertension. On examination, murmur of aortic insufficiency can be heard with unequal radial pulses.[14]
Pericarditis: This condition can be the result of viral infection such as
coxsackie virus and
echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial infarction (
Dressler syndrome). The chest pain is often
pleuritic in nature (associated with respiration) which is aggravated when lying down and relieved on sitting forward, sometimes, accompanied by fever. On auscultation,
pericardial friction rub can be heard.
Mitral valve prolapse syndrome: Those affected are usually slim females presented with chest pain which is sharp in quality, localized at the apex, and relieved when lying down. Other symptoms include: shortness of breath, fatigue, and palpitations. On auscultation, midsystolic click followed by late systolic murmur can be heard, louder when person is in standing position.
Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. Chest pain usually happens during a strenuous activity or heavy exercise.
Pneumothorax: Those who are at a higher risk of developing pneumothorax are tall, slim male smokers who have had underlying lung diseases such as
emphysema. Those affected can have a sharp chest pain which radiates to the shoulder of the same side. Physical examination revealed absent breath sounds and hyperresonance on the affected side of the chest.
Gastroesophageal reflux disease: The pain is aggravated when lying down or after meals. Persons may describe this as a
heartburn. Besides, they may also complain of tasting bitter contents from the stomach.[11]
Diffuse esophageal spasm: Unlike cardiac chest pain, esophageal pain is not related to activity. The pain is usually associated with swallowing of hot or cold water.[11]
Esophageal rupture: Those affected usually complain of sudden, severe, and constant pain that starts from the neck to the upper abdomen. The pain is aggravated by swallowing. On examination, neck swelling and crepitations can be felt due to
subcutaneous emphysema as free air is entering from esophagus into the
subcutaneous tissue.
Acute cholecystitis: Characterized by positive
Murphy's sign where the person has a cessation of
inhalation when the doctor places his finger at the right subcostal region of the abdomen.
Perforated peptic ulcer: Sudden onset of severe pain in the upper abdomen which later develops into
peritonitis (inflammation of tissues that lines the abdominal organs).
Herpes zoster (shingles): It is usually described as a burning sensation over the chest in a unilateral
dermatome distribution. However, diagnosis can be difficult because the pain usually appears before the characteristic rash is visible.
Panic attack: Chest pain is a common symptom of panic attacks, with as high as 78% of persons describing chest pain with their worst panic attacks.[12] Overall chest pain is a symptom of up to 48% of sudden-onset panic attacks, and 10% of gradual-onset panic attacks.[12]
Knowing a person'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 (premature
atherosclerosis,
cholesterol disorders,
heart attack at early age), and other risk factors. Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by
diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to
acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of
acute coronary syndrome.[17] Other clues in the history can help lower the suspicion for myocardial infarction. These include chest pain described as "sharp" or "stabbing", chest pain that is positional or
pleuritic in nature, and chest pain that can be reproduced with palpation.[18][19] However, both atypical and typical symptoms of acute coronary syndrome can occur, and in general a history cannot be enough to rule out the diagnosis of acute coronary syndrome.[19] In some cases, chest pain may not even be a symptom of an acute cardiac event. An estimated 33% of persons with myocardial infarction in the United States do not present with chest pain, and carry a significantly higher mortality as a result of delayed treatment.[20]
Physical examination
Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialized units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as
Levine's sign in
cardiac ischemia.[21] However, in the case of
acute coronary syndrome, a
third heart sound,
diaphoresis, and
hypotension are the most strongly associated physical exam findings.[22] However these signs are limited in their prognostic and diagnostic value.[8] Other physical exam findings suggestive of cardiac chest pain may include
hypertension,
tachycardia,
bradycardia, and new
heart murmurs.[8] Chest pain that is reproducible during the physical exam with contact of the chest wall is more indicative of non-cardiac chest pain, but still cannot completely rule out acute coronary syndrome.[23] For this reason, in general, additional tests are required to establish the diagnosis.
The Global Registry of Acute Coronary Events score and the
Thrombosis in Myocardial Infarction performed at time of admission may help stratify persons into low, intermediate and high risk groups for acute coronary syndrome.[1] However these scores do not provide management guidelines for risk-stratified persons.
The HEART score, stratifies persons into low-risk and high-risk groups, and recommends either discharge or admission based upon the score.[1]
0-3: 2.5% risk of adverse cardiac event. Patient's can be discharged with follow-up.
4-6: 20.3% risk of adverse cardiac event. Patients should be admitted to the hospital for trending of troponin and provocative testing.
≥7: 72.7% risk of adverse cardiac event, suggesting early invasive measures with these patients and close coordination with inpatient cardiology.
If
acute coronary syndrome ("heart attack") is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of
cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause.
Medical tests
On the basis of the above, a number of tests may be ordered:[26]
Management of chest pain varies with the underlying cause of the pain and the stage of care.
Prehospital care
Chest pain is a common symptom encountered by
emergency medical services.
Aspirin increases survival in people with acute coronary syndrome and it is reasonable for
EMS dispatchers to recommend it in people with no recent serious bleeding.[28]Supplemental oxygen was used in the past for most people with chest pain but is not needed unless the
oxygen saturations are less than 94% or there are signs of
respiratory distress.[29][28]Entonox is frequently used by
EMS personnel in the prehospital environment.[30] However, there is little evidence about its effectiveness.[28][31]
For people with non-cardiac chest pain,
cognitive behavioral therapy might be helpful on an outpatient basis. A 2015 Cochrane review found that cognitive behavioral therapy might reduce the frequency of chest pain episodes the first three months after treatment.[32] For persons with chest pain due to
gastroesophageal reflux disease, a
proton-pump inhibitor has been shown to be the most effective treatment.[33] However, treatment with proton pump inhibitors has been shown to be no better than
placebo in persons with noncardiac chest pain not caused by gastroesophageal reflux disease.[33] For
musculoskeletal causes of chest pain,
manipulation therapy or
chiropractic therapy,
acupuncture, or a recommendation for increased exercise are often used as treatment.[33] Studies have shown conflicting results on the efficacy of these treatments.[33] A combination therapy of
nonsteroidal anti-inflammatory drugs and manipulation therapy with at-home exercises has been shown to be most effective in treatment of musculoskeletal chest pain.[9]
Epidemiology
Chest pain is a common
presenting problem. Overall chest pain is responsible for an estimated 6% of all emergency department visits in the United States and is the most common reason for hospital admission.[19] Chest pain is also very common in
primary care clinics, representing 1-3% of all visits.[34] The rate of emergency department visits in the US for chest pain decreased 10% from 1999 to 2008.[35] but a subsequent increase of 13% was seen from 2006 to 2011.[36] Less than 20% of all cases of chest pain admissions are found to be due to coronary artery disease.[37] The rate of chest pain as a symptom of
acute coronary syndrome varies among populations based upon age, sex, and previous
medical conditions.[20] In general, women are more likely than men to present without chest pain (49% vs. 38%) in cases of myocardial infarction.[20]
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