Chest pain can be cardiac or non-cardiac in origin. Cardiac causes include myocardial ischemia, angina, and acute coronary syndromes which present with characteristic dull, squeezing pain in the center of the chest that may radiate to the arms and is exacerbated by exertion. Non-cardiac causes include pulmonary embolism, pneumonia, gallbladder disease and musculoskeletal disorders which typically cause localized, sharp pains. A thorough history and physical exam is needed to differentiate cardiac from non-cardiac chest pain and determine appropriate treatment or need for further testing.

1. CHEST DISCOMFORTS (PAIN)
MUKESH SUNDARARAJAN

2. Learning Outcome
DEFINITION TYPE OF CHEST PAIN ETIOLOGY CHARACTERISTIC OF
CARDIAC CHEST PAIN
ISCHAEMIC CARDIAC
PAIN VS NON-
CARDIAC CHEST PAIN
DIFFERENTIAL
DIAGNOSIS

3. Chest Pain
Definition:
• A general term for any dull, aching pain in the thorax. It can be
cardiac or non-cardiac related.

4. ETIOLOGY
Cardiac
• Myocardial ischemia & trauma
• Angina pectoris
• Acute Coronary Syndromes
Non-Cardiac
• Aortic stenosis
• Aortic dissection
• Pericarditis
• Pulmonary embolism
• Pulmonary hypertension
• Pneumonia/pleuritis
• Spontaneoushypertension
• Esophageal reflux
• Esophageal spasm
• Peptic ulcer
• Gallbladder disease
• Musculoskeletal disease
• Herpes zoster
•Emotional & psychiatric conditions

5. Types Of Chest Pain
Pleuritic
Sharp
Burning
Pressure
Tightness
Heaviness
Burning
Tearing/ripping
Burning
Pressure
Angina, unstable
angina, acute MI
Pericarditis
Aortic dissection
Gallbladder disease
Pul. Embolism,
Pneumonia,
Pleuritis,
Spontaneous
hypertension
Esophageal reflux,
peptic ulcer, herpes
zoster
Pressure
Tightness
Burning
Variable
Aching
Emotional &
psychiatric
conditions
Esophageal spasm
Musculoskeletal
disease

6. Evaluate a chest pain
1. Could the chest discomfort be due to an acute, potentially life-threatening
condition that warrants immediate hospitalization and aggressive
evaluation?
-Acute ischemic heart disease
-Aortic dissection
-Pulmonary embolism
-Spontaneous pneumothorax
2. If not, could the discomfort be due to a chronic condition likely to lead to
serious complication?
-Stable angina -Aortic stenosis -Pulmonary hypertension
3. If not, could the discomfort be due to an acute condition that warrants
specific treatment?
-Pericarditis -Pneumonia/pleuritis -Herpes zoster
4. If not, could the discomfort be due to another treatable chronic condition?
-Oesophagel reflux, oesophageal spasm, peptic ulcer disease, other GI
condition, cervical disc disease, arthritis of the shoulder or spine,
costochondritis, other musculoskeletal disorders, anxiety state

7. Initial Evaluation of Suspected Cardiac
Pain
Importance of initial evaluation:-
• Crucial process
• Determine the:-
– Nature and extent of any underlying heart disease
– Risk of serious adverse event
– Management

8. Characteristics of ISCHAEMIC cardiac
Pain
• Characteristic of pain
• Site
• Radiation
• Provocation
• Onset
• Associated features

9. Character
• Dull, constricting, choking or heavy
• Squeezing, crushing, burning or aching
• Breathlessness
• Discomfort > pain

10. Site
• Centre of the chest
• Derivation of the nerve supply to the heart & mediastinum
(sensory sympathetic cardiac nerves; T1-T5, mostly dorsal root
ganglion Lt.)
Radiation
• Radiate to neck, jaw & upper or even lower arms
• Occasionally, at the sites of radiation or in the back

12. Provocation
• Angina pain: during exertion and promptly
relieved by rest (<5 minutes), pain may
exacerbated by emotion but occur more
readily by exertion; large meal, cold wind
• Crescendo/Unstable angina: similar pain can
be precipitated by minimal exertion or at rest
• Decubitus angina: increase venous
return/preload by lying down can provoke
pain in vulnerable patients

13. Onset
• Myocardial infarction (MI): Pain
of MI takes several minutes or
longer to develop
• Angina: Pain builds up gradually in
proportion to the intensity of
exertion
• Aortic dissection, massive
pulmonary embolism or
pneumothorax : Pain is very
sudden or instantaneous
• Musculoskeletal or psychological:
Pain occur after exertion

14. Associated features
• Autonomic disturbance;
sweating, nausea, vomiting
• Breathlessness: pulmonary
congestion from transient
ischaemic Lt. ventricular
dysfunction

15. CHARACTERISTIC
ISCHAEMIC CARDIAC
CHEST PAIN
NON-CARDIAC CHEST
PAIN
LOCATION Central, diffuse Peripheral, localised
RADIATION
Jaw/neck/shoulder/arm
(occasionally back) Other or no radiation
CHARACTER Tight, squeezing, choking Sharp, stabbing, catching
PRECIPITATION Exertion and/or emotion
Spontaneous, provoked by
posture,respiration or
palpitation
RELIEVING FACTOR
Rest, quick response to
nitrates
Not relieved by rest, slow
or no response to nitrates
ASSOCIATED FEATURES Breathlessness
Respiratory, gastrointestinal,
locomotor or psychological

16. Differential
Diagnosis of
Chest Pain
• Anxiety/emotion
• Cardiac
• Aortic
• Oesophageal
• Lungs/pleura
• Musculoskeletal
• Neurological

17. Anxiety
• Common cause for atypical chest pain
• Lack of relationship with exercise
• Receiving bad news
Cardiac
• Myocardial ishaemia (angina), MI, myocarditis,
pericarditis, mitral valve prolapse
• Myocarditis & pericarditis:
– Pain felt retrosternally, to the Lt. of the sternum, or in
the Lt./Rt. Shoulder
– Intensity varies with movement and phase of
respiration. ‘sharp’ and may ‘catch’ during inspiration,
coughing or lying flat.
– Occasionally, history of prodromal viral illness

18. Aortic
• Aortic dissection, aortic aneurysm
• Aortic dissection:
– Pain is severe, sharp and tearing
– Penetrating through to the back
– Abrupt in onset
– Pain follows path of the dissection

19. Aortic aneurysm
Aortic dissection

20. Oesophageal
• Oesophagitis, oesophageal spasm,
Mallory-Weiss syndrome
• Pressure, tightness, burning
• Retrosternal
• Mimic angina very closely
– Sometimes precipitated by exercise
– Sometimes relieved by nitrates
• Elicit history of chest pain to supine posture or
eating, drinking or oesophageal reflux
• Radiates to the back

21. Lungs/Pleura
• Bronchospasm, pulmonary infarct,
pneumonia, tracheitis, pneumothorax,
pulmonary embolism, malignancy,
tuberculosis
• Bronchospasm:
– Reversible airways obstruction (e.g. asthma):
exertional chest tightness that is relieved by rest.
Difficult to distinguish from ischaemic chest
tightness
• Pneumonia, pleuritis and pulmonary
embolism:
– Pleuritic pain (sharp pain when breathing)

22. Musculoskeletal
• Osteoarthritis, rib fracture/injury, costochondritis
(Tietze’s syndrome), intercostal muscle injury,
epidemic myalgia (Bornholm disease-by
coxsackievirus)
• Aching
• Very variable in site and intensity
• Vary with posture and movement of upper body
• Can be accompanied by local tenderness over a
rib or costal cartilage
• Injuries related to everyday activities or viral
infection

23. Neurological
• Prolapsed intervertebral disc
• Herpes zoster (Sharp or burning)
• Thoracic outlet syndrome

24. Stable Angina VS Acute Coronary Syndrome

25. STABLE ANGINA ACUTE CORONARY
SYNDROMES
(unstable angina, STEMI,
NSTEMI)
•Effort-related chest or
‘choking in the chest’
•Relationship to physical
exertion (and occasionally
emotion) of the chest pain
•The duration of symptoms
should be noted because
patients with recent-onset
angina are at greater risk
• Urgent evaluation
•Prolonged, severe cardiac
chest pain

26. STABLE ANGINA ACUTE CORONARY SYNDROMES
(unstable angina, STEMI, NSTEMI)
•Physical examination: often
normal but may reveal evidence of
risk factors (eg xanthoma indicate
hyperlipidaemia),
Lt. ventricular dysfunction
(dyskinetic, apex beat, gallop
rhythm), other manifestations
of arterial disease (eg bruits,
signs of peripheral vascular
disease) and unrelated
conditions that may
exacerbate angina (eg
anaemia, thyroid disease)
•Physical examination: signs of
important comorbidity, such as
peripheral or cerebrovascular
disease, autonomic disturbance
(pallor or sweating) and
complications (arrhythmia or heart
failure)

27. STABLE ANGINA ACUTE CORONARY SYNDROMES
(unstable angina, STEMI, NSTEMI)
•Coronary artery disease, aortic
valve disease and hypertrophic
cardiomyopathy
•Angina+murmur=
echocardiography
•A full blood count, fasting blood
glucose, lipids, TFT, 12-lead ECG,
exercise testing
• CT Coronary angiography
•Signs of haemodynamic
compromise (hypotension,
pulmonary oedema)
•ECG changes: ST segment
elevation or depression)
•Biochemical markers: elevated
troponin I or T (short-term)
•A 12-lead ECG
•New ECG changes or
an elevated plasma troponin
concentration confirm the
diagnosis of an acute coronary
syndrome. exercise test or CT
coronary angiogram to diagnose
underlying coronary artery
disease.

29. Types Of Chest Pain
Pleuritic
Sharp
Burning
Pressure
Tightness
Heaviness
Burning
Tearing/ripping
Burning
Pressure
Angina, unstable
angina, acute MI
Pericarditis
Aortic dissection
Gallbladder disease
Pul. Embolism,
Pneumonia,
Pleuritis,
Spontaneous
hypertension
Esophageal reflux,
peptic ulcer, herpes
zoster
Pressure
Tightness
Burning
Variable
Aching
Emotional &
psychiatric
conditions
Esophageal spasm
Musculoskeletal
disease

30. TYPICAL CLINICAL FEATURES OF MAJOR
CAUSES OF ACUTE CHEST DISCOMFORT

31. Condition Duration Quality Location
Associated
features
Angina 2 min <t< 10 min Pressure, Retrosternal, Precipitated by
tightness, often with exertion,
heaviness, radiation to or exposure to cold,
burning isolated psychologic stress
discomfort in
neck, jaw,
S4 gallop or mitral
regurgitation
sholders, or murmur during
arms- freq. left pain
Unstable 10-20 min Similar to Similar to angina Similar to angina
angina angina but but occurs with
>severe low levels of
exertion or even
at rest
Acute MI Variable; often Similar to Similar to angina Unrelieved with
>30 min angina but nitroglycerin
>severe May be
associated with
heart failure or
arrhythmia

32. Condition Duration Quality Location Associated features
Aortic
stenosis
Recurrent
episodes
Same as angina Same as angina Late-peaking systolic
murmur radiating to
carotid arteries
Pericarditis Hours-days;
may be
episodic
Sharp Retrosternal or
toward cardiac apex;
may radiate to Lt.
shoulder
May be relieved by sitting
up and leaning forward
Pericardial friction rub
Aortic
dissection
Abrupt onset
of unrelenting
pain
Tearing or
ripping
sensation
; knifelike
Anterior chest offten
radiating to
back,between
shoulder blades
Hypertension and/or
underlying connective
tissue disorder,e.g.,
Marfan syndrome
Pulmonary
embolism
Abrupt onset;
several min-
few hours
Pleuritic Often lateral, on the
side of the
embolism
Dyspnea, tachypnea,
tachycardia and
hypotension
Pulmonary
hypertension
Variable Pressure Substernal Dyspnea,signs of increased venous
pressure including edema & jv
distension

33. Condition Duration Quality Location
Associated
features
Pneumonia/
pleuritis
Variable Pleuritic Unilateral,often
localized
Dyspnea, cough,
fever, rales,
occasional rub
Spontaneous
hypertension
Sudden
onset;
several
hours
Pleuritic Lateral to side of
pneumothorax
Dyspnea,
decreased breath
sounds on side of
pneumothorax
Esophageal
reflux
10-60 min Burning Substernal,
epigastric
Worsened by
postprandial
recumbency
Relieved by
antacids
Esophageal
spasm
2-30 min Pressure,
tightness,
burning
Retrosternal Can closely mimic
angina
Peptic ulcer Prolonged Burning Epigastric,
substernal
Relieved with
food or antacids

34. Condition Duration Quality Location
Associated
features
Gallbladder
disease
Prolonged Burning,
pressure
Epigastric, Rt.
Upper quadrant,
substernal
May follow meal
Musculoskeletal
disease
Variable Aching Variable Aggravated by
movement
May be
reproduced by
localized pressure
one examination
Herpes zoster Variable Sharp or
burning
Dermatomal
distribution
Vesicular rash in
area of discomfort
Emotional &
psychiatric
conditions
Variable;
may be
fleeting
Variable Variable; may be
retrosternal
Situational factors
may precipitate
symptoms
Anxiety or
depression often
detectable with
careful history

35. Conclusion
Topics which are covered:-
• Define chest pain
• Types of chest pain
• Characteristic of cardiac chest pain
• Ischaemic cardiac pain vs non-cardiac
chest pain
• Differential diagnosis

36. References
• Davidson’s Principles & Practice of Medicine
23rd Edition
• Harrison’s Internal Medicine 18th Edition
• Hutchinson’s Clinical Method 22nd Edition