CHEST PAIN
(Linda Costarella)
I. Transmission of thoracic pain
A. Perception of pain, general
-fear of heart disease
-pain is non-specific from viscera because afferent fibers unmyelinated; slower to progress and resolve,
dull
-cutaneous pain is more specific (myelinated fibers); sharper pain
B. Visceral pain
1. referred pain
-dorsal root ganglion; felt in the dermatome pattern; Heart T-1 -T-4; may feel pain in others areas
that also are innervated by these roots eg. left sided pain with heart
2. Descending afferent fibers, modulation of pain
-from the gray matter; short circuits the cortex so they do not think about it the pain
3. Autonomic dysfunction
-sympathetic: tachycardia, sweating
-parasympathetic: nausea, vomitting
-reflex constriction of skeletal muscle(splinting); can be complication of pain
II. Cardiovascular causes of thoracic pain
-usually found in the older population
A. Angina Pectoris
1. Mechanism of ischemia
-if using maximum O2 at rest, an increase in myocardial demand on coronary arteries during
activity can cause ischemia; it is important how large lumen is; if coronary arteries are reduced by
70%(dilated maximally at rest) there is no room to increase lumen size during exercise
2. Mechanims of pain
-increased metabolites from anaerobic metabolism may be causing the pain; it is not clearly
understood(theory)
3. Myocardial pain transmission
-usually radiates to T1 to T4; can radiate as high as C3 or as low as T8
4. Attributes of anginal pain
a. location
-retrosternal; can be upper, middle or lower sternum, more pain on the left or the right
b. radiation
-radiates to the left arm, occassionally the right arm, neck or jaw, and to the
precordium(anterior to heart)
c. quality
-tightness or pressure; indigestion; squeezing or aching that is dull; anginal "salute"(fist
over heart when decribing); occasionly jaw, neck, and arm pain but no chest pain; angina
attacks will be described the same on recurrent attacks with same person but each
description is different with each patient; pain is rarely described as burning
d. duration
-typically 2-10 min; can last as long as 15 minutes
-longer->consider other causes
e. onset
-increased exertion, emotional stress, high fat meal, tobacco smoking
f. aggravating /ameliorating
-<: exertion
->: rest; nitroglycerin(it can also relieve other pain: esophageal, anxiety ); valsalvre
manouvre
g. associated signs and symptoms
-shortness of breath(dyspnea), nausea, vomiting, tachycardia, dizziness, diaphoresis,
belching, palpitations, atrial gallop(S4)
B. Unstable angina
-unpredictable pain pattern; stable angina has consistent pattern; stable can progress to unstable which is
a poor prognosis(pre-infarction angina, coronary insuff)
C. Variant angina
-pain at rest; vasospasm of coronary arteries; not related to increased myocardial demand; can be
relieved by nitroglycerin
D. Myocaridal infarction
1. as compared to angina
-diff dx with angina: relative increase in pain, diaphoresis,anxiety, not relieved by nitroglycerin
2. Key features
-feeling of impending doom; nausea, vomitting, diaphoresis; denial; hyper or hypotensive; atrial
gallop; retrosternal pain; radiation pain similar to angina with propensity to the left; time may last
an hour or more
E. Aortic outflow obstruction
-aortic stenosis and aortic regurgitation; usually on exertion; similar symptoms to angina
F. Aortic dissection aneurysm
1. Description of pain
-abrupt onset of pain(hallmark sign), severe at onset; tearing, ripping, and stabbing pain in chest,
neck; can radiate to back (upper or lower) or abdomen; there may also be abdominal tenderness
2. Associated signs and symptoms
-palpable abdominal mass, tachycardia, murmurs, loss of consciousness briefly(syncope),
paralysis of arms briefly, hypotenson, assymetrical brachial pulses, weak or absent pedal of
femoral pulses, pale, cool, diaphoretic, skin might be mottled, prolonged capillary refill time in toes
-severe emergency situation
3. differential with myocardial infarction
-pain to intrascapular ->aortic aneurysm vs MI
-ECG will not show MI symptoms
-widened mediastinum in aortic aneurysm
G. Pericarditis
1. Attributes of the pain
-anterior chest, sharp, relieved by sitting up or leaning forward
-pain radiates to trapezius on right and/or left sides
-coughing, may aggravate pain
-aggravated by swallowing or deep breathing
-tachycardia and friction rub
-also associated with painful swallowing(odynophagia)
H. Mitral valve prolapse
1. Attributes of pain
-asymptomatic but occasionally chest pain associated and rarely angina pain
-may last for few moments or days
-decreased pain in incumbent position(not true of other conditions)
- may or may not be related to exertion
-uncertain what causes pain
-mid systolic click, possibly systolic click at apex
-assoc sx: dizziness, headache, weakness, severe fatigue that is episodic, dyspnea, tachycardia,
palpations, increased awareness
-young women in 20's and 30's
I. Cardiomyopathy and myocarditis
-mild chest pain and chest tightness
-may be asymptomatic
III. Gastrointestinal causes of chest pain
A. Esophageal pain
-ÊC7-C12; postprandial; brought on by drinking cold liquids; nocturnal; supine position; radiates to the
neck, jaw, arms, or back; squeezing or dull sensation(diff dx from angina); substernal and may last an
hour
1. Heartburn
- consequence of reflux of gastric contents and occassionally bile
-noxious stimulus
2. Anginal type pain
-reflux may cause muscle spasm; relieved by nitroglycerin
3. Odnophagia
-similar pain to 2. but always associated with swallowing; difficulty in swallowing(dysphagia)
B. Other GI disorders
1. acute pancreatis
-usually intense pain in epigastrium; often radiates toback, left scapular; relieved in sitting up; nausea and
vomitting; may find peritoneal involvement(abdominal rigidity and diminished bowel sounds)
2. Peptic ulcer
-sharp, burning pain in epigastric region; lasts longer than angina; nausea and vomitting is likely; may find
melana
3. Biliary tract disease
-cholecystitis; pain in epigastric or right upper quadrant; intense aching that radiates to back;
assoc sx: vomitting and nausea
-mass in RUQ: rigidity of abdominal wall
4. Splenic flexure syndrome
-gas; relieved by flatulence; can be very painful
IV. Pulmonary causes of chest pain
A. Pleuratic chest pain
1. Definition
-pain arises from parietal pleura (costal and diaphramatic) as there is no innervation in visceral pleura;
unilateral, sharp, well localized especially in lower and lateral aspects of the chest
2. comparison with musculoskeletal pain
-increases with breathing but not as severe with movements, often tenderness
-COPD-muscle strain (difficulty breathing) to compensate
B. Pleurisy
1. Viral
2. Lupus
3. Asbestos exposure
-pleural effusions as well
C. Pulmonary embolism
-dyspnea, tachypenia, pleural effusion
D. Spontaneous pneumothorax
-hass occurred with acupuncture at the wrong angle
1. type of px
-history of longstanding COPD
-young man with chest pain and associated dyspnea
-sharp, anterior pain that radiates to ipsilateral shoulder
-does not occur during exertion only
E. Parenchymal disease
-pleuratic pain
F. Pleural effusion
V. Musculoskeletal causes of chest pain
A. pancoast syndrome
B. Costochondritis
-young individual; local tendernes to palpation; commonly thought to be cardiac; usually worse with deep
respiration; trigger points
C. Thoracic outlet syndrome
-radiates to arm
-ddx with angina with decreased upper extremity pulses, numbness and tingling
VI. Miscellaneous causes of chest pain
A. Aortic arch syndrome
B. Neurocirculatory asthenia
C. Herpes Zoster