Chest pain - Definition and Overview

In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency, unless the patient is a known angina pectoris sufferer and the symptoms are familiar.

Causes

Important cardiovascular and pulmonary causes of chest pain:

• Angina pectoris
  • "Unstable" AP - this is an emergency and can resemble a heart attack
  • "Stable" AP - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense
• Myocardial infarction ("heart attack")
• Aortic dissection
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Pulmonary embolism
• Pneumonia

Other causes of chest pain include:

• Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
• Gastroesophageal reflux disease (GERD)
• Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
• Bornholm disease - a viral disease that can mimic all of the above
• Several others

Analysis

As in all medicine, a careful medical history and physical examination is essential is separating dangerous and trivial causes of disease, and the management of chest pain is often done on specialised units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection).

An emergency medicine doctor will also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking.

On the basis of the above, a number of tests may be ordered:

• X-rays of the chest and/or abdomen (CT scanning may be better but is often not available)
• An electrocardiogram (ECG)
• V/Q scintigraphy (when a pulmonary embolism is suspected)
• Blood tests:
  • Full blood count
  • Electrolytes and renal function (creatinine)
  • Liver enzymes
  • Troponin I or T (to indicate myocardial damage)
  • D-dimer (when suspicion for pulmonary embolism is present but low)

Interpretation

In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analyses are not sensitive enough (Chun & McGee 2004). Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient. If acute coronary syndrome ("unstable angina") is suspected, many patients are admitted briefly for observation and determination of cardiac enzyme levels (CK-MB or troponin).

Reference

• Chun AA, McGee SR. Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004;117:334-43. PMID 15336583.