CHEST DISCOMFORTS (PAIN)

MUKESH SUNDARARAJAN
Learning Outcome

DEFINITION TYPE OF CHEST PAIN ETIOLOGY CHARACTERISTIC OF

CARDIAC CHEST PAIN

ISCHAEMIC CARDIAC DIFFERENTIAL

PAIN VS NON- DIAGNOSIS
CARDIAC CHEST PAIN
 Definition:
• A general term for any dull, aching pain in the thorax. It can be
cardiac or non-cardiac related.

Chest Pain
 ETIOLOGY

Cardiac Non-Cardiac
• Myocardial ischemia & trauma • Aortic stenosis
• Angina pectoris • Aortic dissection

• Acute Coronary Syndromes • Pericarditis

• Pulmonary embolism
• Pulmonary hypertension
• Pneumonia/pleuritis
• Spontaneous hypertension
• Esophageal reflux
• Esophageal spasm
• Peptic ulcer
• Gallbladder disease
• Musculoskeletal disease
• Herpes zoster
•Emotional & psychiatric conditions
 Types Of Chest Pain
Pressure
Burning
Tightness Sharp
Heaviness Esophageal reflux,
peptic ulcer, herpes
Burning Pericarditis
zoster
Angina, unstable
angina, acute MI
Pressure Pleuritic
Burning Tightness Pul. Embolism,
Burning Pneumonia,
Pleuritis,
Pressure Esophageal spasm Spontaneous
Gallbladder disease hypertension

Aching Variabl
Tearing/ripping
Musculoskeletal e
Emotional &
Aortic dissection disease psychiatric
conditions
 Evaluate a chest pain
1. Could the chest discomfort be due to an acute, potentially life-threatening
condition that warrants immediate hospitalization and aggressive
evaluation?
-Acute ischemic heart disease -Pulmonary embolism
-Aortic dissection -Spontaneous pneumothorax

2. If not, could the discomfort be due to a chronic condition likely to lead to

serious complication?
-Stable angina -Aortic stenosis -Pulmonary
hypertension

3. If not, could the discomfort be due to an acute condition that warrants

specific treatment?
-Pericarditis -Pneumonia/pleuritis -Herpes zoster

4. If not, could the discomfort be due to another treatable chronic condition?

-Oesophagel reflux, oesophageal spasm, peptic ulcer disease, other GI
condition, cervical disc disease, arthritis of the shoulder or spine,
costochondritis, other musculoskeletal disorders, anxiety state
Initial Evaluation of Suspected Cardiac
Pain
Importance of initial evaluation:-
• Crucial process
• Determine the:-
– Nature and extent of any underlying heart disease
– Risk of serious adverse event
– Management
Characteristics of ISCHAEMIC cardiac
Pain
• Characteristic of pain
• Site
• Radiation
• Provocation
• Onset
• Associated features
Character
• Dull, constricting, choking or heavy
• Squeezing, crushing, burning or aching
• Breathlessness
• Discomfort > pain
Site
• Centre of the chest
• Derivation of the nerve supply to the heart & mediastinum
(sensory sympathetic cardiac nerves; T1-T5, mostly dorsal root
ganglion Lt.)
Radiation
• Radiate to neck, jaw & upper or even lower arms
• Occasionally, at the sites of radiation or in the back
Provocation
• Angina pain: during exertion and promptly
relieved by rest (<5 minutes), pain may
exacerbated by emotion but occur more
readily by exertion; large meal, cold wind
• Crescendo/Unstable angina: similar pain can
be precipitated by minimal exertion or at
rest
• Decubitus angina: increase venous
return/preload by lying down can provoke
pain in vulnerable patients
Onset
• Myocardial infarction (MI): Pain
of MI takes several minutes or
longer to develop
• Angina: Pain builds up gradually in
proportion to the intensity of
exertion
• Aortic dissection, massive
pulmonary embolism or
pneumothorax : Pain is very
sudden or instantaneous
• Musculoskeletal or psychological:
Pain occur after exertion
Associated features
• Autonomic disturbance;
sweating, nausea, vomiting
• Breathlessness: pulmonary
congestion from transient
ischaemic Lt. ventricular
dysfunction
 ISCHAEMIC CARDIAC
CHEST PAIN NON-CARDIAC CHEST
CHARACTERISTIC
PAIN
LOCATION Central, diffuse Peripheral, localised
Jaw/neck/shoulder/arm
RADIATION (occasionally back) Other or no radiation

CHARACTER Tight, squeezing, choking Sharp, stabbing, catching

Spontaneous, provoked by
PRECIPITATION Exertion and/or emotion posture,respiration or
palpitation

Rest, quick response to Not relieved by rest, slow

RELIEVING FACTOR nitrates or no response to nitrates

Respiratory, gastrointestinal,
ASSOCIATED FEATURES Breathlessness locomotor or psychological
Differential
Diagnosis of
Chest Pain

• Anxiety/emotion
• Cardiac
• Aortic
• Oesophageal
• Lungs/pleura
• Musculoskeletal
• Neurological
 Anxiety
• Common cause for atypical chest pain
• Lack of relationship with exercise
• Receiving bad news
Cardiac
• Myocardial ishaemia (angina), MI, myocarditis,
pericarditis, mitral valve prolapse
• Myocarditis & pericarditis:
– Pain felt retrosternally, to the Lt. of the sternum, or in
the Lt./Rt. Shoulder
– Intensity varies with movement and phase of
respiration. ‘sharp’ and may ‘catch’ during inspiration,
coughing or lying flat.
– Occasionally, history of prodromal viral illness
 Aortic
• Aortic dissection, aortic aneurysm
• Aortic dissection:
– Pain is severe, sharp and tearing
– Penetrating through to the back
– Abrupt in onset
– Pain follows path of the dissection
Aortic dissection

Aortic aneurysm
 Oesophageal
• Oesophagitis, oesophageal spasm,
Mallory-Weiss syndrome
• Pressure, tightness, burning
• Retrosternal
• Mimic angina very closely
– Sometimes precipitated by exercise
– Sometimes relieved by nitrates
• Elicit history of chest pain to supine posture or
eating, drinking or oesophageal reflux
• Radiates to the back
 Lungs/Pleura
• Bronchospasm, pulmonary infarct,
pneumonia, tracheitis, pneumothorax,
pulmonary embolism, malignancy,
tuberculosis
• Bronchospasm:
– Reversible airways obstruction (e.g. asthma):
exertional chest tightness that is relieved by rest.
Difficult to distinguish from ischaemic chest
tightness
• Pneumonia, pleuritis and pulmonary
embolism:
– Pleuritic pain (sharp pain when
breathing)
 Musculoskeletal
• Osteoarthritis, rib fracture/injury, costochondritis
(Tietze’s syndrome), intercostal muscle injury,
epidemic myalgia (Bornholm disease-by
coxsackievirus)
• Aching
• Very variable in site and intensity
• Vary with posture and movement of upper body
• Can be accompanied by local tenderness over a
rib or costal cartilage
• Injuries related to everyday activities or viral
infection
 Neurological
• Prolapsed intervertebral disc
• Herpes zoster (Sharp or burning)
• Thoracic outlet syndrome
Stable Angina VS Acute Coronary Syndrome
 STABLE ANGINA ACUTE CORONARY
SYNDROMES
•Effort-related chest or (unstable angina, STEMI,
NSTEMI)
‘choking in the chest’
• Urgent evaluation
•Relationship to physical
•Prolonged, severe cardiac
exertion (and occasionally
chest pain
emotion) of the chest pain
•The duration of symptoms
should be noted because
patients with recent-onset
angina are at greater risk
 STABLE ANGINA ACUTE CORONARY SYNDROMES
(unstable angina, STEMI, NSTEMI)
•Physical examination: often •Physical examination: signs of
normal but may reveal evidence of important comorbidity, such as
risk factors (eg xanthoma indicate peripheral or cerebrovascular
hyperlipidaemia), disease, autonomic disturbance
Lt. ventricular dysfunction (pallor or sweating) and
(dyskinetic, apex beat, gallop complications (arrhythmia or heart
rhythm), other manifestations failure)
of arterial disease (eg bruits,
signs of peripheral vascular
disease) and unrelated
conditions that may
exacerbate angina (eg
anaemia, thyroid disease)
 STABLE ANGINA ACUTE CORONARY SYNDROMES
(unstable angina, STEMI, NSTEMI)
•Coronary artery disease, aortic •Signs of haemodynamic
valve disease and hypertrophic compromise (hypotension,
cardiomyopathy pulmonary oedema)
•Angina+murmur= • ECG changes: ST segment
echocardiography elevation or depression)
•A full blood count, fasting blood •Biochemical markers: elevated
glucose, lipids, TFT, 12-lead ECG, troponin I or T (short-term)
exercise testing • A 12-lead ECG
• CT Coronary angiography • New ECG changes or
an elevated plasma troponin
concentration confirm the
diagnosis of an acute coronary
syndrome. exercise test or CT
coronary angiogram to diagnose
underlying coronary artery
disease.
 Types Of Chest Pain
Pressure
Burning
Tightness Sharp
Heaviness Esophageal reflux,
peptic ulcer, herpes
Burning Pericarditis
zoster
Angina, unstable
angina, acute MI
Pressure Pleuritic
Burning Tightness Pul. Embolism,
Burning Pneumonia,
Pleuritis,
Pressure Spontaneous
Gallbladder disease Esophageal spasm
hypertension

Tearing/ripping Aching Variabl

Aortic dissection Musculoskeletal e
Emotional &
disease psychiatric
conditions
TYPICAL CLINICAL FEATURES OF MAJOR
CAUSES OF ACUTE CHEST DISCOMFORT
 Associated
Condition Duration Quality Location features
Angina 2 min <t< 10 min Pressure, Retrosternal, Precipitated by
tightness, often with exertion,
heaviness, radiation to or exposure to cold,
burning isolated psychologic stress
discomfort in S4 gallop or mitral
neck, jaw, regurgitation
sholders, or murmur during
arms- freq. left pain
Unstable 10-20 min Similar to Similar to angina Similar to angina
angina angina but but occurs with
>severe low levels of
exertion or even
at rest
Acute MI Variable; often Similar to Similar to angina Unrelieved with
>30 min angina but nitroglycerin
>severe May be
associated with
heart failure or
arrhythmia
 Condition Duration Quality Location Associated features
Aortic Recurrent Same as angina Same as angina Late-peaking systolic
stenosi episodes murmur radiating to
s carotid arteries
Pericarditis Hours-days; Sharp Retrosternal or May be relieved by sitting
may be toward cardiac apex; up and leaning forward
episodic may radiate to Lt. Pericardial friction rub
shoulder
Aortic Abrupt onset Tearing or Anterior chest offten Hypertension and/or
dissection of unrelenting ripping radiating to underlying connective
pain sensation back,between tissue disorder,e.g.,
; knifelike shoulder blades Marfan syndrome

Pulmonary Abrupt onset; Pleuritic Often lateral, on the Dyspnea, tachypnea,

embolism several min- side of the tachycardia and
few hours embolism hypotension
Pulmonary Variable Pressure Substernal Dyspnea,signs of increased
venous pressure including edema
hypertension & jv distension
 Associated
Condition Duration Quality Location features
Pneumonia/ Variable Pleuritic Unilateral,often Dyspnea, cough,
pleuritis localized fever, rales,
occasional rub
Spontaneous Sudden Pleuritic Lateral to side of Dyspnea,
hypertension onset; pneumothorax decreased breath
several sounds on side of
hours pneumothorax

Esophageal 10-60 min Burning Substernal, Worsened by

reflux epigastric postprandial
recumbency
Relieved by
antacids

Esophageal 2-30 min Pressure, Retrosternal Can closely mimic

spasm tightness, angina
burning
Peptic ulcer Prolonged Burning Epigastric, Relieved with
substernal food or antacids
 Associated
Condition Duration Quality Location features
Gallbladder Prolonged Burning, Epigastric, Rt. May follow meal
disease Upper quadrant,
pressure substernal
Musculoskeletal Variable Aching Variable Aggravated by
disease movement
May be
reproduced by
localized
pressure
one
examination
Herpes zoster Variable Sharp or Dermatomal Vesicular rash in
burning distribution area of discomfort
Emotional & Variable; Variable Variable; may be Situational factors
psychiatric may be retrosternal may precipitate
conditions fleeting symptoms
Anxiety or
depression often
detectable with
careful history
 Conclusion
Topics which are covered:-
• Define chest pain
• Types of chest pain
• Characteristic of cardiac chest pain
• Ischaemic cardiac pain vs non-cardiac
chest pain
• Differential diagnosis
 References
• Davidson’s Principles & Practice of Medicine
23rd Edition
• Harrison’s Internal Medicine 18th Edition
• Hutchinson’s Clinical Method 22nd Edition