- Potentially Serious Causes
- Myocardial Ischemia: Angina Pectoris
- Acute Myocardial Infarction or Unstable Angina
- Pulmonary Embolism
- Thoracic Aortic Aneurysm
- Aortic Dissection
- Mediastinal Emphysema
- Acute Pericarditis
- Pleurisy
- Less Serious Causes
- Costochondral Pain
- Chest Wall Pain
- Esophageal Pain
- Emotional Disorders
- Other Causes
There is little correlation between the severity of chest pain and the seriousness of its cause. The range of disorders that cause chest discomfort is shown in Table 33-1 Diagnoses of Pts Admitted to Hospital with Acute Chest Pain Ruled Not Myocardial Infarction.
The differential diagnosis of chest pain is shown in Figs. 33-1. Differential Diagnosis of Recurrent Chest Pain and 33-2. Differential Diagnosis of Serious Conditions that Cause Acute Chest Pain. It is useful to characterize the chest pain as (1) new, acute, and ongoing; (2) recurrent, episodic; and (3) persistent, e.g., for hours or days at a time.
Myocardial Ischemia: Angina Pectoris 
Substernal pressure, squeezing, constriction, with radiation often to left arm; usually on exertion, especially after meals or with emotional arousal. Characteristically relieved by rest and nitroglycerin.
Acute Myocardial Infarction or Unstable Angina
Similar to angina but more severe, of longer duration (≥30 min), and not immediately relieved by rest or nitroglycerin (Chaps. 121 ST-Segment Elevation Myocardial Infarction and 122 Unstable Angina and Non-ST-Elevation Myocardial Infarction). S3 and/or S4 may be present.
May be substernal or lateral, pleuritic in nature, and associated with hemoptysis, tachycardia, and hypoxemia (Chap. 135 Pulmonary Thromboembolism and Deep-Vein Thrombosis).
May impinge on neighboring structures and cause deep, persistent chest pain, dysphagia, hoarseness, or cough (Chap. 127 Diseases of the Aorta).
Very severe, in center of chest, a sharp “ripping” quality, radiates to back, not affected by changes in position (Chap. 127 Diseases of the Aorta). May be associated with weak or absent peripheral pulses.
Sharp, intense, localized to substernal region; often associated with audible crepitus.
Usually steady, crushing, substernal; often has pleuritic component aggravated by cough, deep inspiration, supine position, and relieved by sitting upright; pericardial friction rub often audible (Chap. 118 Pericardial Disease).
In anterior chest, usually sharply localized, may be brief and darting or a persistent dull ache. Can be reproduced by pressure on costochondral and/or chondrosternal junctions. In Tietze's syndrome (costochondritis), joints are swollen, red, and tender.
Due to strain of muscles or ligaments from excessive exercise or rib fracture from trauma; accompanied by local tenderness.
(1) Cervical disk disease; (2) osteoarthritis of cervical or thoracic spine; (3) abdominal disorders: peptic ulcer, hiatus hernia, pancreatitis, biliary colic; (4) tracheobronchitis, pneumonia; (5) diseases of the breast (inflammation, tumor); (6) intercostal neuritis (herpes zoster).
| APPROACH TO THE PATIENT | ||
Chest PainA meticulous history of the behavior of pain, what precipitates it and what relieves it, aids diagnosis of recurrent chest pain. Figure 33-2. Differential Diagnosis of Serious Conditions that Cause Acute Chest Pain presents clues to diagnosis and workup of acute, life-threatening chest pain. Critical pathway algorithms help differentiate pts with acute high-risk cardiopulmonary conditions from those with more benign causes. In particular, the history, ECG, and measurement of cardiac troponin (especially high sensitivity assay) are key to the initial evaluation to distinguish pts with acute ST-elevation MI, who warrant immediate reperfusion approaches (Chap. 121 ST-Segment Elevation Myocardial Infarction). CT angiography may be appropriate for pts with low-intermediate probability of an acute coronary syndrome, to exclude important CAD and to assess for aortic dissection, pulmonary embolism, and pericardial effusion. |