Chest Pain

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Chest pain is common presentation of cardiac disease, but can also be a manifestation of anxiety or disease of the lungs, the musculoskeletal or gastrointestinal system.

Common causes of chest pain:

Central

Cardiac
• Myocardial ischaemia(angina)
• Myocardial infraction
• Myocarditis
• Pericarditis
• Mitral valve prolapse
Aortic
• Aortic dissection
• Aortic aneurysm
Oesophageal
• Oesophagitis
• Oesophageal spasm
• Mallory-Weiss syndrome
Lungs/Pleura
• Pulmonary embolism
• Malignancy
• Tracheitis

Peripheral

Lungs/pleura
• Bronchospasm
• Pulmonary infraction
• Pneumonia
• Tuberculosis
• Malignancy
• Pneumothorax
• Connective tissue disorders
Musculoskeletal
• Osteoarthritis
• Rib fracture/injury
• Intercostal muscle injury
• Costochondritis
Neurological
• Herpes zoster
• Prolapsed intervertebral disc

Differential diagnosis:
Causes of chest pain range from non-serious to serious to life threatening.

Cardiovascular:
• Acute coronary syndrome
o Unstable Angina Pectoris – requiring emergency medical treatment but not primary intervention as in a myocardial infarction.
o Myocardial infarction (“heart attack”)
• Aortic dissection
• Pericarditis and cardiac tamponade
• Arrhythmia – atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Stable angina pectoris – this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense
• Myocarditis
• Mitral valve prolapse syndrome
• Aortic aneurysm
Respiratory:
• Bronchitis
• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Pleurisy – an inflammation which can cause painful respiration
• Tuberculosis
• Tracheitis
• Lung malignancy
Gastrointestinal:
• Gastroesophageal reflux disease (GERD) and other causes of heartburn
• Hiatus hernia
• Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus
• Functional dyspepsia
Chest wall:
• Costochondritis or Tietze’s syndrome – a benign and harmless form of osteochondritis often mistaken for heart disease
• Spinal nerve problem
• Fibromyalgia
• Chest wall problems
• Radiculopathy
• Precordial catch syndrome – another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
• Breast conditions
• Herpes zoster commonly known as shingles
• Tuberculosis
• Osteoarthritis
• Bornholm disease

Psychological:
• Panic attack
• Anxiety
• Clinical depression
• Somatization disorder
• Hypochondria
Others:
• Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
• Da costa’s syndrome
• Carbon monoxide poisoning
• Sarcoidosis
• Lead poisoning
• High abdominal pain may also mimic chest pain
• Prolapsed intervertebral disc
• Thoracic outlet syndrome
• Cardiovascular conditions:
• Cardiovascular conditions.

Management: In people with chest pain supplemental oxygen is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress. Entonox is frequently used by EMS personnel in the prehospital environment. There is however little evidence about its effectiveness.

Reference:

  1. Davidson’s Principle and Practice of Medicine, 21st edition.
  2. Wikipedia the free encyclopedia.

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