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CHEST PAIN Chest pain is a clinical syndrome that may be caused by almost any condition affecting the thorax,

abdomen or internal organs. It is critically important to distinguish the two major presentations of chest pain, emergent and nonemergent, as their clinical epidemiology is very different. Emergent chest pain is usually defined as the type of pain that cannot be ignored and that prompts most individuals to seek immediate medical attention usually in the emergency room. Most of the medical literature on the subject of chest pain describes the type of pain, for which the probability of acute cardiac ischemia or unstable coronary artery disease (C !" is #uite high. Nonemergent chest pain is less compelling and patients usually choose to seek medical care during routine office hours. It is a common complaint in the primary care setting, representing $%&' of office visits. lthough few studies have described these patients, it is clear that the probability of acute cardiac ischemia or unstable C ! in this setting is significantly lower than is seen in the

emergent setting( the most fre#uently recorded diagnoses are musculoskeletal chest pain and gastrointestinal tract conditions. significant proportion of cases remain undiagnosed or labeled atypical or noncardiac chest pain. )his chapter presents a suggested approach to the diagnosis of nonemergent chest pain as seen in routine office practice, followed by common clinical presentations of the most fre#uently seen conditions, and laboratory and ancillary studies helpful in establishing a diagnosis. *pecific management recommendations are left for the chapters describing each condition in more detail. 1. General approach to the evaluation of chest pain a. +erform severity and acuity assessment. If the patient has emergently sought care at the office for acute onset of severe pain or pain associated with diaphoresis or difficulty breathing, evaluate as for emergent chest pain. !iagnostic evaluation should focus on the exclusion of severe cardiac disease.

b. Use pro a ilities to focus attention on the most li!el" #iagnostic possi ilities. ,egin with the prevalence data supplied in section II as a crude estimate of the prior probability of possible diagnoses, then adjust these probabilities up or down, based on experience and the five key clinical features i.e. predisposing factors, onset, duration and character of pain, and things providing relief of pain. !o not begin by attempting to rule out specific conditions. +remature use of examination findings, laboratory studies, and ancillary testing to exclude specific diagnoses leads to excessive use of medical resources. More important, the use of some ancillary tests e.g. graded exercise tests on populations with a low probability of the disease in #uestion results in a high rate of false%positive errors in test interpretation. c. Perform #irecte# ph"sical e$amination an# la orator" assessment. complete physical examination is often not

necessary when history alone strongly suggests a specific

cause. -or example, in patients with costochondritis, reproducibility of pain on palpation can confirm the diagnosis without need for further examination or laboratory studies. d. Use follo%&up visits to reassess chest pain %hen #iagnosis is uncertain. )ime can be both a diagnostic and therapeutic agent in the primary care setting. Clinical clues to the diagnosis may only appear over time, and pain may resolve spontaneously. *pecific diagnosis and intervention is not always necessary at the initial visit. e. Consi#er empiric therap". .hen a specific diagnosis is likely but not yet proved, consider a trial of empiric therapy based on the tentative diagnosis. If therapy is successful, confirmation of the diagnosis is through laboratory studies or ancillary testing may no longer be necessary.

II. Common clinical con#itions causing nonemergent chest pain' inclu#ing their prevalence' characteristic clinical features' an# helpful tests. a. (usculos!eletal con#itions (/0'" $. (uscular chest pain' chest %all muscle pain' pectoralis strain (&1'". )his condition is most commonly seen in active young men and women. *uggestive history includes sharp pain of recent onset, associated with minor trauma or repeated use of arms and shoulders, and pain with movement, radiating to shoulder, back or arm, without associated systemic symptoms. Characteristic physical examination findings include tenderness on musculoskeletal palpation or exacerbated by movement. In this clinical setting, laboratory studies are not necessary. &. Costochon#ritis )Tiet*e+s s"n#rome, 1-.. )his condition is often seen in young women, particularly

black women. *uggestive history includes pain with the use of the chest wall muscles and sometimes chest ache at rest or pain with deep inspiration, without history or trauma. If tried, over%the 2counter anti%inflammatory agents have often provided relief. )he characteristic physical examination finding is tenderness to palpitation over the costochondral margins, often worse over the left third or fourth margin. 3aboratory studies are not helpful in establishing the diagnosis. /. nother musculoskeletal condition causing chest pain is ri fracture (&'".

. Gastrointestinal con#itions )1/.,. $. Gastroeophageal reflu$ #isease )GE01,' reflu$ esophagitis' #"spepsia' gastritis )1-.,. )his condition affects al ages and both sexes. Clinical history may vary considerably, but suggestive findings include late postrandial

discomfort (half an hour or more after food intake", pain on an empty stomach, night or morning cough or both. ssociated abdominal or epigastric discomfort, sharp retrosternal pain or pressure, dysphagia or odynophagia, hoarse voice, water brash and presence of significant external stressors. +atients may express relief with antacids or food intake. )here are few characteristic physical examination findings( epigastric tenderness is a common but nonspecific finding. 3aboratory studies helpful in establishing the diagnosis include upper gastrointestinal radiography (45I", esophagogastroduodenoscopy (65!", esophageal manometry and p7 measurement, and ,ernsteins test. &. Esophageal spasm (8'". )his condition may be more common in patients with 569!. Clinical history is #uite variable is #uite variable but may include the following( sudden onset of nonexertional s#uee:ing substernal pain or pressure, sharp susbsternal pain that can atimes be locali:ed by the patient with one finger, often relieved by antacids or

eructation, positional (worst when recumbent" but not affected by movement. )he pain can last from moments to hours and can be associated with dysphagia. )here are no characteristic physical examination findings. 3aboratory studies are often necessary to establish the diagnosis( barium swallow (nutcracker esophagus" or esophageal manometry (markedly elevated muscle tone" are especially useful, and 45I, 65! or esophageal p7 measurement may confirm associated gastroesophageal p7 measurement may confirm associated gastroesophageal reflux. !ifferential diagnosis for these patients may include angina pectoris. )he similarities of symptoms make it extremely difficult to distinguish esophageal spasm from angina without confirmatory laboratory testing. -. 2ther GI con#itions causing chest pain3 Peptic ulcer #isease )1.,' choletothiasis an# cholec"stitis )1.,' esophageal muscle an# motilit" #isor#ers )41.,

C. Car#iac con#itions )15., $. 6T"pical car#iac ischemia3 angina pectoris )17.,' unsta le )crescen#o, angina )1.8.,. )his condition is most commonly seen in middle%aged to elderly men and pos menopausal women. *uggestive history includes diffuse susternal chest tightness and discomfort with consistent level of physical exertion, sometimes with emotional exertion, often associated to radiation to jaw, left arm or back and sometimes accompanied by respiration and not relieved by dyspnea, nausea, diaphoresis or sudden fatigue. +ain is not affected by respiration and not relieved by antacids or position changes but is usually relieved by antacids or position changes but is usually relieved by rest of sublingual nitates. ,etween episodes there are no characteristics physical examination findings. !uring episodes, patients may have hypertension or hypotension, palpably displaced point of maximal cardiac impulse, systolic murmur of mitral insufficiency, transient third or fourth sound (*/ or *8", or

other signs suggestive congestive heart failure. 7elpful laboratory studies include 6C5 (*)%segment depression during episode", graded exercise testing (5;)", stress thallium scan, stress echocardiography and cardiac catheteri:ation. *erum creatine phosphokinase isoen:yme measurement (C+<" should only be performed in the inpatient setting. If clinical suspicion of (MI" is sufficiently high to warrant C+< measurement, the patient should be admitted for cardiac monitoring and consideration of thrombolytic therapy. )he clinician must differentiate between stable and unstable angina. If patient has no previous diagnosis of angina (all new%onset angina is by definition unstable until symptom pattern established" or if there is an increase in fre#uency, intensity or other change from established pattern of angina episodes, the diagnosis is unstable angina and aggressive management is indicated.

&. 6At"pical9 angina pectoris )vasospastic angina' variant angina, )41.,.)his condition primarily affects young to middle%aged women suggestive history includes diffuse substernal chest tightness or discomfort occurring at rest, sometimes radiating to the jaw, left arm, or back, occasionally accompanied with dyspnea, nausea, diaphoresis or sudden fatigue. )he pain is not associated with inspiration or expiration and is not relieved by antacids or position changes. ,etween episodes, there are usually no specific physical examination findings. !uring an episode, patients may have he examination findings listed. 7elpful laboratory studies include 6C5 (*)%segment depression during episode", 5;), stress thallium, stress achocardiography and cardiac catheteri:ation with ergonovine challenge testing. /. (ital valve prolapse s"n#rome )1.8.,. )his condition is almost exclusively seen in young to middle%aged women. +atients often report substernal chest pain of variable duration, sharp or dull, often accompanied by palpitations

that may be worse with exertion or in the presence of external stressors. )he characteristic physical examination finding is a mdsystolic click followed by systolic murmur on cardiac auscultation (click%murmur". )wo%dimensional echocardiography will confirm this diagnosis. If echocardiographyis normal, the clinician should consider alternative, diagnoses, such as anxiety%related chest pain, panic disorder or variant angina. 8. =ther cardiac conditions causing chest pain( Cardiac dysrththmias ($'" and acute and subacute pericarditis (>$'".

!. Ps"chosocial con#itions )/., $. An$iet" or stress relate# chest pain.):.,. )his condition is usually seen in healthy young men and women. Characteristic symptoms include chest tightness associated with dyspnea, difficulty in taking a deep breath, or hyperventilation, often associated with other stress%related symptoms (headache, 5I symptoms" or the presence of

significant external stressors? usual duration might be hours to days. =n physical examination, patients often exhibit distress out of proportion to objective findings. 3aboratory studies are usually not helpful, but a brief mental health screening instruments such as +9IM6%M! (@", may assist in establishing a diagnosis of anxiety disorder, depression and stomati:ation disorder. &. Panic attac!s or panic #isor#er )41.,. )hese conditions are most commonly in seen in young women, who usually presents with episodes of chest tightness accompanied by some of the following autonomic symptoms( dyspnea, AsmotheringB sensation, di::iness, palpitations, trembling, sweating, nausea, parenthesias, hot flashes, depersonali:ation, and fear of dying or going cra:y. ,etween episodes, physical examination is non%specific, sometimes characteri:ed by anxiety. !uring episodes, patients may have a rapid respiratory rate, tachycardia, and increased tremulousness. 3aboratory studies are usually not helpful, but

a brief mental health screening instrument or review of the diagnostic criteria for panic disorder with the patient may assist in establishing the diagnostic criteria for panic disorder with the patient may assist in establishing the diagnosis. !ifferential diagnosis should include mirtral valve prolapse and generali:ed anxiety disorder. f. Pulmonar" con#itions )8., $. ;ronchitis )<.,. )his condition is more likely to occur in smokers. *uggestive history includes dull chest ache often accompanied by a productive cough, with occasional sharp pain with cough. +hysical examination may reveal upper airway congestion, rhonchi clearing with cough, or diffuse whee:ing on pulmonary auscultation. 3aboratory studies are not necessary, unless chest radiography is performed to rule out pneumonia. &. Pleuris"' pleuro#"nia )1&<.,. )his condition often accompanies viral or bacterial respiratory infections

or inflammatory conditions. *uggestive history includes acute onset of sharp pain associated with breathing or movement sometimes by other symptoms of inflammation (e.g. joint stiffness or pain or rash". +hysical examination may reveal a pleural friction rub laboratory studies such as serum rheumatoid factor, antinuclear antibody screen and erythrocyte sedimentation rate may be useful to exclude underlying rheumatologic or connective tissue disease. Chest radiography may be helpful to exclude pneumonia. /. Pneumonia )1.,. )his condition affects all ages and both sexes. *uggestive history includes sharp or ArawB pain exacerbated by inspiration and cough accompanied by systemic symptoms of severe cough, fever, and dyspnea. Characteristic physical examination findings include toxic appearance, rapid respiratory rat, fever and consolidation or locali:ed

whee:ing on pulmonary auscultation. 4seful laboratory studies include chest radiograph and sputum culture. 8. 2ther pulmonar" con#itions causing chest pain3 Pulmonar" em olism )41.,' pnemothora$ )41.,.

-. 2ther con#itions )1-.,( Conspecific or atypical chest pain ($/'". )his ill%defined diagnostic label refers to the absence of an identifiable cause for chest pain, but most descriptions of this entity refer to relatively young patients with vaguely defined pain occurring with a specific pattern. +ain is often described as As#uee:ingB and not well locali:ed. +atients are usually alarmed by these symptoms? attribute them to cardiac disease and present for reassurance. )his diagnosis is often reached only after an extensive and negative evaluation for cardiac disease has been completed.