Chest discomfort

Causes of chest discomfort include:

Myocardial ischemia occurs when oxygen supply to the heart is insufficient to meet
metabolic needs. This can result from a decrease in oxygen supply, a rise in demand, or
both.
o Most common cause of myocardial ischemia is obstruction of coronary
arteries by atherosclerosis; transient ischemic episodes are precipitated by
increase O2 demand on exertion.
o Ischemia can also result from psychological stress, fever, or large meals.
o Ventricular hypertrophy due to valvular disease, hypertrophic
cardiomyopathy, or hypertension can predispose myocardium to ischemia
impaired penetration of blood flow from epicardial coronary arteries to
endocardium.
1. Angina Pectoris chest discomfort of myocardial ischemia that is a visceral
discomfort that is usually described as heaviness, pressure, or squeezing. Patients
may deny pain but admit to dyspnea or anxiety.
a. Pain not localized to a small area but may radiate to neck, jaw, teeth, arms,
or shoulders.
i. Usually never below the umbilicus
b. Treatment with sublingual nitroglycerin usually resolves pain
i. Stable angina develops gradually with exertion, and pain is relieved
with nitroglycerin; pain last longer than a few seconds, but less than an
hour.
ii. Unstable angina Acute ischemic episodes that have similar
symptoms to angina, but more prolonged and severe; onset may occur
with patient at rest and nitroglycerine may lead to transient/no relief.
Pericarditis Pain associated with this is due to inflammation of adjacent parietal pleura,
since pericardium is insensitive to pain. Infectious pericarditis involves adjoining pleural
surfaces.
Pain can be experienced in shoulder, neck, back and abdomen.
Pain aggravated by coughing, deep breaths, changes in position (all move pleural
surfaces)
Pain is worse in the supine position, and relived by sitting upright.
Disease of the Aorta:
Aortic dissection potential catastrophic condition due to spread of sub intimal
hematoma within the wall of the aorta. Hematoma may begin with a tear in the
intima or rupture of the vasa vasorum within the media.
o Occurs when there is trauma to the aorta (ex: intraaortic balloon pumps)
o Non traumatic dissections due to hypertension
o Cystic medial degeneration/deterioration of elastic or muscular components
seen in Marfan syndrome and ehlers-Danlos syndrome.
o Hematomas may lead to MI or rupture into pericardial space leading to
tamponade
o Almost all patients present with:
Acute chest pain
Pain reflective of ripping and tearing

Thoracic aortic aneurysm frequently asymptomatic but can lead to chest pain by
compressing adjacent structures; pain tends to be steady, deep, and sometimes
severe.

Pulmonary Embolism sudden onset of pleuritic chest pain

Pneumonia or pleuritis Lung diseases that damage and cause inflammation of pleura
leading to a sharp pain aggrevated by inspiration or coughing.
Gastrointestinal conditions: Esophageal pain from acid reflux in the stomach, spasm,
obstruction, or injury can all lead to pain that is difficult to differentiate from myocardial
infarction.
Acid reflux causes deep burning discomfort exacerbated by alcohol, aspirin, and
foods.
Esophageal spasm leads to squeezing pain indistinguishable from angina;
prompt relief from sublingual Nifedipine further promotes confusion between these
syndromes.
Peptic ulcers, biliary disease, and pancreatitis generally cause abdominal pain
as well as chest discomfort and not associated with exertion.
o Peptic ulcers typically occurs 60-90 minutes after a meal
o Cholecystitis aching pain after meals
Neuromuscular Conditions:
Cervical disk disease causes chest pain by compression of nerve roots;
dermatome distributional pain can be caused by intercostal muscle cramps or
herpes zoster (chest pain occurs before lesions are present)
Costochondral and chondrosternal syndromes MOST common cause of anterior
chest musculoskeletal pain.
o Pain usually fleeting and sharp but may be dull and ache for hours
o Direct pressure may relieve pain
Approach to the patient:

First assess the patients respiratory and hemodynamic status.

o If either compromised, first step in management should be to stabilize the
patient before diagnostic evaluation is pursued.
o If not compromised, assess history, physical examination, and laboratory
evaluations
History should include:
o Quality and location of chest discomfort
o Nature and onset of pain, as well as duration
MI is usually associated with gradual intensification of pain over
minutes
Pain that is fleeting or last hours without being associated with ECG
changes is not likely to be ischemic in origin.
Absence of risk factors does NOT eliminate MI
Wide radiation of chest pain increases probability of MI
Radiation of chest pain to arm is common with MI
Right arm pain is common with cholecystitis (but usually also in
abdomen)

Physical examination:
o Evaluation of blood pressure in both arms and pulses in both legs
Poor perfusion of a limb could be due to aortic dissection
o Chest auscultation
Pericardial rubs
3rd and 4th heart sounds indicative of MI or cardiac problems
Diminished breath sounds evidence of pneumothorax, PE, or
pneumonia
o Palpation
Pressure on the chest wall may reproduce musculoskeletal causes
o ECG
Absence of changes does not exclude chest pain
ST wave changes may indicate MI or angina
o Cardiac markers
Troponins I and T
Creatinine kinase (CK)-MB
D-Dimer test and CT scan for PE
Stress test for angina if MI is ruled out
Chest X-ray for pulmonary disease