Chest Pain

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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 (appearing at exertion and resolving at rest, known as "stable angina").


CAUSES


Cardiopulmonary

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


• Hemothorax


• Pneumothorax and Tension Pneumothorax

Other causes

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)


• Peptic Ulcer Disease


• Cholecystitis


• Pancreatitis (unusual presentation)


• Anxiety Attack


• Tietze's Syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease


• Bornholm Disease - a Viral disease that can mimic many other conditions

Common, non-life threatening causes include chest wall pain (ribs, muscle, cartilage); nerve irritation ("pinched nerve" in the lower neck or upper back); esophageal spasm, anxiety, and GERD; and strains and sprains, to name a few.


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-ray s or Blood Test s (e.g. Aortic Dissection ). Occasionally, visible medical signs will direct the diagnosis towards particular causes, such as Levine's Sign in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.

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-ray s 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 Test s:


• --- Full Blood Count


• --- Electrolyte s and Renal Function ( Creatinine )


• --- Liver Enzyme s


• --- Creatine Kinase (and ''CK-MB'' fraction in many hospitals)


• --- 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 ("unstable angina") is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time ( CK-MB or Troponin ). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.


REFERENCES

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

EXTERNAL LINKS

• Wilderness Medicine: Chest Pain - eMedicine.com


• 100+ Causes of Chest Pain - wrongdiagnosis.com