Chest Pain

There is little correlation between the severity of chest pain and the seriousness

of its cause.

POTENTIALLY SERIOUS CAUSES

The differential diagnosis of chest pain is shown in Fig. 32-1. It is useful to

characterize the chest pain as (1) new,acute, and ongoing; (2) recurrent, episodic;

and (3) persistent,sometimes for days (Table 32-1).

MYOCARDIAL ISCHEMIA Angina Pectoris Substernal pressure,

squeezing,constriction, with radiation typically to left arm; usually on exertion,

especially after meals or with emotional arousal. Characteristically relieved by

rest and nitroglycerin.

Acute Myocardial Infarction (Chap. 123) Similar to angina but usually

more severe,of longer duration (_30 min),and not immediately relieved by

rest or nitroglycerin. S3 and S4 common.

PULMONARY EMBOLISM (Chap. 135) May be substernal or lateral,

pleuritic in nature,and associated with hemoptysis, tachycardia, and

hypoxemia.

AORTIC DISSECTION (Chap. 127) Very severe,in center of chest, a

“ripping” quality,radiates to back, not affected by changes in position. May be

associated with weak or absent peripheral pulses.

MEDIASTINAL EMPHYSEMA Sharp,intense,localized to substernal

region; often associated with audible crepitus.

ACUTE PERICARDITIS (Chap. 121) Usually steady,crushing, substernal;

often has pleuritic component aggravated by cough,deep inspiration,

supine position,and relieved by sitting upright; one-, two-, or three-component

pericardial friction rub often audible.

PLEURISY Due to inflammation; less commonly tumor and pneumothorax.

Usually unilateral,knifelike,superficial, aggravated by cough and respiration.

LESS SERIOUS CAUSES

COSTOCHONDRAL PAIN 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.

CHEST WALL PAIN Due to strain of muscles or ligaments from excessive

exercise or rib fracture from trauma; accompanied by local tenderness.

ESOPHAGEAL PAIN Deep thoracic discomfort; may be accompanied

by dysphagia and regurgitation. pain; associated with fatigue,emotional strain.

OTHER CAUSES

(1) Cervical disk; (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).

A meticulous history of the behavior of pain,what precipitates it and what

relieves it,aids diagnosis of recurrent chest pain. Figure 32-2 presents clues to

diagnosis and workup of acute,life-threatening chest pain.