Causes of chest pain & typical features
Pain
Causes
Typical features
Cardiac pain
Myocardial ischaemia or infarction
Central, tight or heavy; may radiate to the jaw or left
arm
Vascular pain
Aortic dissection
Very sudden onset, radiates to the back
Pleuropericardial
pain
Pericarditis and/or myocarditis
Infective pleurisy
Pneumothorax
Pleuritic pain, worse when lying down
Pleuritic pain
Sudden onset, sharp, associated with dyspnoea
Pneumonia
Often pleuritic, associated with fever & dyspnoea
Autoimmune disease
Mesothelioma
Metastatic tumour
Pleuritic pain
Severe & constant
Severe & constant, localised
Persistent cough
Muscular strains
Intercostal myositis
Thoracic zoster
Coxsackie B virus infection
Thoracic nerve compression
Rib fracture
Rib tumour, primary or metastatic
Tiezte's syndrome
Worse with movement, chest wall tender
Worse with movement, chest wall tender
Sharp, localised, worse with movement
Severe, follows dermatome, precedes rash
Pleuritic pain
Follows nerve root distribution
History of trauma, localised tenderness
Constant, severe, localised
Chest wall pain
Costal cartilage tender
Gastrointestinal
pain
Gastro-oesophageal reflux
Not related to exertion, may be worse when the
patient lies down
Relieved by swallowing
Diffuse oesophageal spasm
Airway pain
Tracheitis
Central bronchial carcinoma
Inhaled foreign body
Pain in throat, breathing painful
Central pain
Panic attacks
Often preceded by anxiety, associated with
breathlessness & hyperventilation syndromes
Mediastinal pain
Mediastinitis
Sarcoid adenopathy, lymphoma
Differential diagnosis of chest pain
Favours angina
Favours pericarditis or
pleurisy
Favours oesophageal (acid)
reflux pain
Quality
Tight or heavy
Sharp or stabbing
Burning
Context
Onset predictable with
exertion
Not exertional
Not exertional
Relieving
factors
Relieved by rest
Present at rest
Present at rest
Relieved rapidly by nitrates
Unaffected by nitrates
Unaffected by nitrates unless
spasm
Not positional
Worse supine (pericarditis)
Onset may be when supine
Not affected by respiration
Worse with respiration
Pericardial or pleural rub
Unaffected by respiration
Cardiac chest pain differential diagnoses
Favours
Favours
myocardial
myocardial
infarction (acute ischaemia
coronary
syndrome)
Favours
angina
Favours aortic
dissection
Favours chest
wall pain
Onset
Onset at rest
Exertional
Exertional
Instantaneous
onset
Often worse at
rest
Time course
Subacute onset
(minutes)
Brief episodes
Severity/quality/
radiation
Severe central
chest pain
Diffuse
Relieving factors
No relief with
nitrates
Relief when
Rapid relief
ceasing exertion with nitrates
Associated
symptoms
Sweating,
anxiety, nausea
& vomiting
NO chest wall
tenderness
7 causes of dangerous chest pain
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Acute coronary syndrome
Aortic dissection
PE
Pneumonia
Tension pneumothorax
Tamponade
Oesophageal rupture
Structures that can cause chest pain
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Heart
Pericardium
Lungs
Pleura
Aorta
Oesophagus
Chest wall
Spine
Skin
Abdominal organs
Mechanisms of chest pain
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Cardiac muscle ischaemia
o Sympathetic afferent nerves (T1-T5)
Prolonged pain
Moderate pain Very severe,
tearing pain radiates to back
No associated
symptoms
No relief
Positional,
localised
Positional relief
o
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Vagal afferent nerves (medulla)
Pericardial inflammation
o Branch of phrenic nerve
Pleural inflammation
o Thoracic nerves
o NO lung pain fibres
Aortic dissection
Oesophageal irritation by acid
Muscle/bone/joint pain
Skin inflammation