Chest pain is a frequent complaint that encompasses a wide range of potential diagnoses, some of which are life-threatening. When faced with chest pain, it’s critical to first rule out serious conditions before considering less severe causes. Terms often used to describe visceral pain include dull, deep, pressure, and squeezing sensations. Visceral pain can also manifest in locations distant from the origin due to the interconnectedness of nerves as they travel through somatic nerve fibers to the spinal cord. For instance, the pain associated with an ischemic heart condition might be felt in the left or right shoulder, jaw, or left arm. This article aims to provide a detailed overview of chest pain differential diagnosis, emphasizing the crucial steps in identifying the underlying cause and appropriate management.
Understanding the Origins of Chest Pain
To effectively diagnose chest pain, understanding its various origins is essential. Pain can broadly be categorized as visceral or somatic, each with distinct characteristics.
Visceral pain is often described as vague and diffuse, making it challenging for patients to pinpoint the exact location. When asked to indicate the pain area, individuals tend to use a broad hand motion rather than a single finger. Common descriptors include dull, deep, pressure, and squeezing. A key feature of visceral pain is its ability to radiate to other areas of the body. This referred pain occurs because visceral and somatic nerve fibers converge as they ascend to the spinal cord. A classic example is ischemic heart pain, which can be felt in the shoulder, jaw, or arm. Accompanying symptoms like nausea and vomiting can also suggest visceral pain. Furthermore, irritation of the diaphragm can sometimes manifest as shoulder pain.[1]
In contrast, somatic pain is more localized and specific. Patients can typically point to the precise spot where the pain originates. Somatic pain is less likely to radiate to other body parts and is often described as sharp, stabbing, or poking.
Prevalence of Chest Pain and Serious Underlying Conditions
Chest pain is a common reason for emergency department visits, accounting for about 5% of all cases. When evaluating chest pain, healthcare providers must prioritize ruling out life-threatening conditions. A study by Fruerfaard et al. provides insights into the prevalence of serious causes of chest pain in emergency settings:[2]
- Acute Coronary Syndrome (ACS): 31%
- Pulmonary Embolism (PE): 2%
- Pneumothorax (PTX): Occurrence unreported in this study
- Pericardial Tamponade: Occurrence unreported (Pericarditis, a related condition, at 4%)
- Aortic Dissection: 1%
- Esophageal Perforation: Occurrence unreported
Other frequent causes of chest pain, with their approximate prevalence in emergency department patients, include:
- Gastroesophageal Reflux Disease (GERD): 30%
- Musculoskeletal Issues: 28%
- Pneumonia/Pleuritis: 2%
- Herpes Zoster (Shingles): 0.5%
- Pericarditis: Occurrence unreported
History and Physical Examination: Key Steps in Chest Pain Assessment
A thorough evaluation of chest pain begins with a detailed patient history and physical examination.
History Taking
Obtaining a comprehensive history is paramount. Start by understanding the patient’s chief complaint in detail:
- Onset: Determine when the pain started and what the patient was doing at that time. Was it triggered by exertion or did it occur at rest?
- Location: Ask the patient to pinpoint the pain. Is it localized to a specific point, or is it diffuse?
- Duration: How long does the pain last? Is it constant or intermittent?
- Character: Encourage the patient to describe the pain in their own words (e.g., sharp, dull, pressure, burning).
- Aggravating/Alleviating Factors: Identify factors that worsen or relieve the pain. Is it related to exertion, eating, breathing, or body position? Inquire about new physical activities, sports, or heavy lifting. Ask about any medications tried and their effects.
- Radiation: Does the pain radiate to other areas? This can be a crucial indicator of visceral pain.
- Timing: How frequently does the pain occur? How long are the pain-free intervals?
Inquire about associated symptoms:
- Shortness of breath
- Nausea and vomiting
- Fever
- Sweating (Diaphoresis)
- Cough
- Heartburn (Dyspepsia)
- Swelling (Edema)
- Calf pain or swelling
- Recent illness
Assess for risk factors for serious conditions:
- ACS Risks: Previous heart attack (myocardial infarction or MI), family history of heart disease, smoking, high blood pressure (hypertension or HTN), high cholesterol (hyperlipidemia or HLD), and diabetes.
- PE Risks: Prior deep vein thrombosis (DVT) or PE, hormone therapy (including oral contraceptives), recent surgery, cancer, or prolonged immobility.
- Recent gastrointestinal (GI) procedures like endoscopy.
- Drug abuse (particularly cocaine and methamphetamines).
Carefully review the patient’s medical history for pre-existing cardiac conditions, bleeding disorders (coagulopathies), and kidney disease. Gather family history, especially related to cardiac issues, and social history, including drug and tobacco use.
Once life-threatening causes are considered, explore other possibilities. Pneumonia should be suspected in patients with a productive cough and/or recent upper respiratory infection (URI). GERD is a common cause of chest pain, so inquire about reflux symptoms. New exercise routines or recent injuries might suggest a musculoskeletal origin.[2]
Physical Examination
The physical exam should include:
- Vital Signs: Complete set, including blood pressure (BP) in both arms to check for differences which might suggest aortic dissection.
- General Appearance: Note any signs of distress or sweating (diaphoresis).
- Skin Exam: Look for rashes or lesions, such as those from shingles (herpes zoster).
- Neck Exam: Check for jugular venous distension (JVD), particularly with inspiration (Kussmaul sign), which can indicate heart failure or pericardial tamponade.
- Chest: Palpate to identify any areas of reproducible pain or crepitus (crackling sensation), which might suggest musculoskeletal issues or subcutaneous air.
- Heart Exam: Auscultate heart sounds for murmurs, rubs, or gallops.
- Lung Exam: Auscultate breath sounds for wheezing, crackles, or decreased breath sounds.
- Abdominal Exam: Palpate for tenderness or masses.
- Extremities: Examine for unilateral swelling, calf tenderness, edema, and assess pulses for symmetry and equality.
Diagnostic Evaluation for Chest Pain
Many healthcare facilities have established protocols for chest pain evaluation. At a minimum, the following investigations are typically indicated:
- Electrocardiogram (ECG): Ideally performed within 10 minutes of arrival. Serial ECGs may be necessary to detect evolving cardiac ischemia.
- Chest X-ray: To evaluate for pneumonia, pneumothorax, pleural effusion, or widened mediastinum (suggesting aortic dissection).
- Blood Tests: Complete blood count (CBC), basic metabolic panel (BMP), troponin levels (serial troponins, often drawn 4 hours apart, to assess for myocardial injury), and lipase (if pancreatitis is suspected).
- Computed Tomography Pulmonary Angiography (CTPA): If pulmonary embolism (PE) is suspected. A ventilation-perfusion (VQ) scan can be considered if CTPA is contraindicated (e.g., due to contrast allergy or kidney issues).
- Bedside Ultrasound (US): Useful if pericardial tamponade is suspected, allowing for rapid assessment of pericardial effusion.
Treatment and Management Strategies
The treatment approach for chest pain is dictated by the underlying diagnosis.
Acute Coronary Syndrome (ACS) Management
While comprehensive ACS management is extensive, initial steps are crucial. Patients with suspected ACS should be immediately placed on a cardiac monitor, intravenous (IV) access established, and chewable aspirin (162 mg to 325 mg) administered. Clopidogrel or ticagrelor may also be given unless bypass surgery is anticipated. Pain management is essential, and oxygen (O2) therapy should be considered. Nitroglycerin can be beneficial, aiming for a 10% reduction in mean arterial pressure (MAP) in normotensive patients and a 30% reduction in hypertensive patients. However, it should be avoided in hypotensive patients and those with inferior ST-segment elevation on ECG.
Patients with ST-elevation myocardial infarction (STEMI) on ECG require immediate reperfusion therapy, either pharmacologic (thrombolytics) or transfer to a cardiac catheterization laboratory for percutaneous coronary intervention (PCI). PCI is the preferred method and should be initiated within 90 minutes at the presenting facility or within 120 minutes if transfer is necessary. If PCI is not feasible within these timeframes, thrombolytics should be administered within 30 minutes.
Patients with non-ST-elevation myocardial infarction (NSTEMI) and unstable angina should be admitted to the hospital for cardiology consultation and further evaluation. Stable angina may be managed with outpatient workup. Elderly patients and those with comorbidities should often be admitted for observation and further cardiac assessment.[3][4]
Pulmonary Embolism (PE) Management
CT pulmonary angiography (CTPA) is the definitive diagnostic test for PE. A VQ scan is an alternative, but it is less accurate in patients with pre-existing lung disease. Hemodynamically unstable patients with PE require thrombolytics. Stable patients should be started on anticoagulants.[5][6]
Pneumothorax (PTX) Management
Pneumothorax necessitates decompression, typically with a chest tube insertion.[7][8]
Pericardial Tamponade Management
Bedside ultrasound is invaluable for diagnosing pericardial tamponade. A fluid bolus may be used as a temporary measure. Definitive treatment involves needle pericardiocentesis (pericardial tap) or creating a pericardial window to relieve pressure within the pericardial sac.[9]
Aortic Dissection Management
Aortic dissection often requires immediate surgical intervention. Early consultation with cardiothoracic surgery is critical. CT angiography is the preferred diagnostic imaging modality. Management includes rapid blood pressure reduction to a systolic range of 100 mmHg to 130 mmHg, often initiated with beta-blocker therapy to prevent reflex tachycardia. Two large-bore IV lines should be placed promptly.[10][11][12]
Esophageal Perforation Management
A left pleural effusion on chest x-ray can suggest esophageal rupture. A contrast esophagram is the best confirmatory test. Esophageal perforation is a medical emergency requiring immediate surgical consultation.[11]
Gastroesophageal Reflux Disease (GERD) Management
A “GI cocktail” consisting of viscous lidocaine mixed with Maalox can be administered for symptomatic relief. While therapeutic, it is not diagnostic, and it’s crucial to rule out ACS before attributing chest pain solely to GERD, as ACS can sometimes present with similar symptoms. Long-term GERD management typically involves proton pump inhibitors (PPIs) or H2 receptor blockers.[13]
Differential Diagnosis of Chest Pressure
The differential diagnosis for chest pain is broad and includes:
- Acute Coronary Syndrome (ACS)
- Aortic Dissection
- Pulmonary Embolism (PE)
- Gastroesophageal Reflux Disease (GERD)
- Musculoskeletal Pain
- Esophageal Rupture
- Pericarditis
- Pneumonia
- Herpes Zoster (Shingles)
- Pneumothorax
- Cervical Radiculopathy
- Esophageal Spasm
Key Considerations and Clinical Pearls
Aortic dissection can manifest as stroke symptoms, so it’s important to consider it in the differential diagnosis of stroke. Younger individuals and those without traditional risk factors can still experience myocardial infarction. Patients with diabetes and elderly individuals may have nerve damage (neuropathy) that can alter their pain perception, leading to atypical presentations of conditions like ACS. Always maintain a high index of suspicion, especially when evaluating chest pain.
Enhancing Healthcare Team Outcomes in Chest Pain Management
Chest pain is a common symptom encountered across various healthcare settings and by diverse healthcare professionals, including nurse practitioners, primary care providers, internists, emergency department physicians, and surgeons. A thorough medical history is often the most valuable tool in determining the diagnosis. The critical objective is to promptly identify and manage life-threatening conditions such as acute MI and aortic dissection. When the cause of chest pain remains unclear, referral to a specialist for further evaluation is recommended. Patient outcomes in chest pain management are highly dependent on the underlying etiology, emphasizing the importance of accurate and timely diagnosis and treatment.
References
1.Jänig W. [Neurobiology of visceral pain]. Schmerz. 2014 Jun;28(3):233-51. [PubMed: 24903037]
2.Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K. The diagnoses of patients admitted with acute chest pain but without myocardial infarction. Eur Heart J. 1996 Jul;17(7):1028-34. [PubMed: 8809520]
3.de Bliek EC. ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation. Turk J Emerg Med. 2018 Mar;18(1):1-10. [PMC free article: PMC6009807] [PubMed: 29942875]
4.Solhpour A, Chang KW, Arain SA, Balan P, Zhao Y, Loghin C, McCarthy JJ, Vernon Anderson H, Smalling RW. Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction. Catheter Cardiovasc Interv. 2016 Nov;88(5):709-715. [PubMed: 27028120]
5.Fruergaard P, Launbjerg J, Hesse B. Frequency of pulmonary embolism in patients admitted with chest pain and suspicion of acute myocardial infarction but in whom this diagnosis is ruled out. Cardiology. 1996 Jul-Aug;87(4):331-4. [PubMed: 8793169]
6.Meyer G. Effective diagnosis and treatment of pulmonary embolism: Improving patient outcomes. Arch Cardiovasc Dis. 2014 Jun-Jul;107(6-7):406-14. [PubMed: 25023859]
7.Habibi B, Achachi L, Hayoun S, Raoufi M, Herrak L, Ftouh ME. [Management of spontaneous pneumothorax: about 138 cases]. Pan Afr Med J. 2017;26:152. [PMC free article: PMC5429453] [PubMed: 28533875]
8.Hsu KA, Levsky JM, Haramati LB, Gohari A. Performance of a simple robust empiric timing protocol for CT pulmonary angiography. Clin Imaging. 2018 Mar-Apr;48:17-21. [PubMed: 29024836]
9.Shokoohi H, Boniface KS, Zaragoza M, Pourmand A, Earls JP. Point-of-care ultrasound leads to diagnostic shifts in patients with undifferentiated hypotension. Am J Emerg Med. 2017 Dec;35(12):1984.e3-1984.e7. [PubMed: 28851498]
10.Zhao DL, Liu XD, Zhao CL, Zhou HT, Wang GK, Liang HW, Zhang JL. Multislice spiral CT angiography for evaluation of acute aortic syndrome. Echocardiography. 2017 Oct;34(10):1495-1499. [PubMed: 28833419]
11.Shiber JR, Fontane E, Ra JH, Kerwin AJ. Hydropneumothorax Due to Esophageal Rupture. J Emerg Med. 2017 Jun;52(6):856-858. [PubMed: 28336238]
12.Khoynezhad A, Plestis KA. Managing emergency hypertension in aortic dissection and aortic aneurysm surgery. J Card Surg. 2006 Mar-Apr;21 Suppl 1:S3-7. [PubMed: 16492293]
13.Alzubaidi M, Gabbard S. GERD: Diagnosing and treating the burn. Cleve Clin J Med. 2015 Oct;82(10):685-92. [PubMed: 26469826]
