Chest pain

In medicine, chest pain is "pressure, burning, or numbness in the chest." Chest pain can be caused by an extremely wide range of conditions, including some, such as myocardial infarction, which, if untreated, could lead to death within minutes or hours. Other causes may be less urgent, while others can indicate self-limiting disease. There are idiopathic chest pain syndromes that have no apparent cause.

Diagnosis

Workup of emergent chest pain

See also: Acute coronary syndrome

Patients with all of the following findings have sufficiently low risk that even an electrocardiogram is not needed:

• "sharp or stabbing pain"
• "no history of angina or myocardial infarction"
• "pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall"

In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.".

A normal electrocardiogram has been reported not to exclude acute coronary syndrome, even when the electrocardiogram is taken during pain. Although this study defined unstable angina as either a coronary stenosis or positive stress test and so likely includes patients without true acute coronary syndrome as defined by the American Heart Association, the study was still not able to show that a normal electrocardiogram helped exclude a NSTEMI.

Computed tomographic cardiac angiography may reduce the rate of hospital admissions according to a randomized controlled trial:

• Patients: Thrombolysis in Myocardial Infarction (TIMI) risk score 0 - 2, with normal electrocardiogram, but the emergency room physician thought that "admission or objective testing to rule out an acute coronary syndrome." 4% of patients had a coronary stenosis ≥ 70%
• Intervention: Computed tomographic cardiac angiography
• Comparison: usual care
• Outcome: resource use and diagnosis of coronary artery disease ( ≥ 50%)
• Result:
  • Increased diagnosis of coronary artery disease (9% vs 3.5%)
  • Increased rate of discharge from the emergency room (50% vs. 23%)

First categorization

• If there is a history of chest trauma, go to chest trauma. Note that chest trauma can still have major physiologic effects on the heart and lungs
• If the patient is hypotensive orin shock begin emergency hypotension protocol, unless the patient is also in acute distress from pain or dyspnea; if so, begin immediate acute cardiac syndrome care
  • Consider:
    • Aortic dissection
    • Leaking aortic aneurysm
    • Myocardial infarction with vagotonia
  • If the patient also exhibits central venous hypervolemia (e.g., jugular venous distention), consider:
    • Tension pneumothorax
    • Cardiac tamponade
    • Cardiogenic shock
    • Pulmonary embolism
  • If central venous hypervolemia is not present, consider:
    • Heart failure
    • Pericardial effusion

Non-emergent chest pain

• chostochondritis
• anxiety
• gout and pseudogout
• Abdominal injury or disease with referred pain
• Herpes zoster
• Acromioclavicular injury
• Anxiety
• Lung cancer
• Sternoclavicular joint injury

Treatment

Strong analgesics such as morphine are usually indicated in sudden, severe chest pain, with care to avoid depressing respiration. If the etiology is cardiac, morphine may improve survival as well as relieve pain.

Since chest pain is a symptom rather than a disease, diagnosis and treatment need to focus on the underlying disease(s).

Idiopathic chest pain

Among patients who have chest pain without any identifiable cause, antidepressants, either tricyclic antidepressants or second-generation antidepressants may reduce pain.