Chest pain Flashcards
What are the challenges of chest pain?
It is a common symptom
Any structure in the chest can produce pain
Several causes of chest pain are life-threatening
Misdiagnosis may have serious consequences •
Exclusion of life-threatening causes is a large part of our task
Patients are aware of the significance of chest pain and are not always readily reassure
What structures in the chest can cause pain?
- Cardiac (e.g. muscle death / infarction, ischaemia, infection)
- Pericardial (e.g. inflammation, infection)
- Oesophageal (e.g. spasm, inflammation, rupture, varices)
- Pleural (e.g. infection, infarction, embolism, rupture / collapse)
- Vascular (e.g. rupture, inflammation [vasculitis], infection)
- Musculoskeletal (e.g. strain, spasm, tear, rupture, fracture)
- Neural (e.g. ‘precordial catch, referred pain, neuropathy)
What 4 causes of chest pain are life-threatening?
Myocardial infarction
Massive pulmonary embolus & infarction
Ruptured aortic aneurysm
Ruptured oesophagus
What different types of pain are there?
Stabbing, knife-like, sharp
Gnawing, burning, numbing
Strangling, tightness, crushing, squeezing, constricting
Tearing, piercing
What are possible worsening triggers for chest pain?
Eating
exercise [‘exertional’]
breathing in / out [‘pleuritic’]
position or movement
What are possible associated symptoms with chest pain?
sweating
nausea and / or vomiting
cough
weight loss
‘sense of impending doom’
What are possible relieving factors for chest pain?
position, medication [e.g. GTN], rest
What makes chest pain cardiac in nature?
Front of the chest, mid or upper sternum (‘central’)
Radiating to left arm, both arms, round the chest or into the jaw
Described as tight, heavy, constricting, crushing, numbing or burning
What is a silent MI?
Autonomic neuropathy (e.g. diabetes) can reduce cardiac sensation, and often women do not experience these classic symptoms (more likely to describe cardiac chest pain without squeezing / pressure, pain and pressure in the upper back, SOB, or dizziness), which means that they can often have a ‘silent MI’ where some symptoms and signs (e.g. nausea, abdominal pain, tachycardia) may allude to something ‘serious’ underlying, but not conforming to the stereotypical pattern described above.
What is the presentation of an MI?
MI: myocardial infarction – ischaemia that is so severe, permanent cardiac myocyte damage occurs. Can occur with classical ECG changes (STEMI) but can more commonly occur with other patterns of changes, only detected by comparing serial traces.
What is acute coronary syndrome?
ACS: spectrum (acute coronary syndrome) that is often used to refer to STEMI, non-ST elevation MI (NSTEMI) and unstable angina.
What is the clinical presentation of an NSTEMI?
Unstable angina is less predictable, and less closely related to exacerbating and relieving factors (e.g. may present at rest, may not be relieved / fully relieved by nitrates)…clinically indistinguishable from NSTEMI in a ‘snapshot’
How do ECG’s change in acute coronary syndrome?
ECG can change in all, and can be normal in all (STEMI is characterised by ST elevation, though)
How can you differentiate between angina and stable angina?
The experience can often include pain in a similar pattern to that described above, but of a limited duration (some suggest an arbitrary ‘15 minute’ cut-off between stable and unstable angina. Although usually not as severe, and not usually associated with vomiting or diaphoresis.
What tests can be done to differentiate between the different acute coronary syndromes?
serial ECG, serum cardiac enzyme markers
What is pericarditis chest pain like?
Mediastinal (central) pain, referred to shoulder & back
Often sharp in nature, but can be dull
Made worse by breathing, coughing, sneezing
Influenced by posture, typically relieved by sitting forward
What can pericarditis be caused by?
Can happen after an MI (Dressler’s)
Viral infection
- in context of ‘flu like illness
- Coxsackie virus, mumps, herpes, HIV
What are the features of oesophageal reflux disease?
Pain can be burning, crushing, sharp, continuous, wave-like, or acute.
Can mimik cardiac pain.
Relieved by more alkaline substances (e.g. milk) and antacids (alginates, H2 antagonists and PPIs being available OTC now).
Worse after eating, on bending forward / lying flat. Raising head of bed nad smoking cessaiont
Chronic, often not sinister, but some features that would make you consider cancer risk (e.g. sudden onset / worsening in older age [NICE guidance = >55yrs])
What conditions are included in oesophageal reflux disease?
GORD, oesophagitis, oesophageal spasm
What are the features of oesophageal rupture?
Rare but serious, can result in mediastinitis - ~5 in 10,000 complication rate from OGD - Can be spontaneous (e.g. following violent vomiting)
What are the possible causes of lung pain?
Most of lower respiratory tract is insensitive to pain, but pleura are sensitive (visceral = general, parietal = specific…mirroring peritoneum)
Infection (pneumonia = radiological diagnosis = LRTI with CXR changes)
Can get effusion, empyaema or pleurisy (often considered ‘inflammation of pleura’ but is actually any pain arising from any disease of the pleura, so is non-specific term) as complication
Carcionma, pneumothroax, trauma, thrombus (PE) and immunological (e.g. vasculitic) causes also contribute to chest pain presentaitons
What is pleuritic pain?
Severe ‘sharp’, ‘stabbing’ or ‘knife-like’
Usually one sided
Worse on inspiration
Mode of onset & associated symptoms gives clue to aetiology
What are the features of a pulmonary embolism?
Venous thrombi (usually from DVT) passes into the pulmonary circulation & blocks flow to lung
Risk factors – include immobility, pregnancy, oestrogen therapy, obesity
Dyspnoea is commonest symptom of PE
Massive pulmonary embolism causes severe central chest pain due to cardiac ischaemia
Pleuritic chest pain & haemoptysis occur with infarction
Be aware of unilateral leg swelling, haemoptysis, recent surgery / trauma, prior DVT / PE, hormone use
What are the clinical features of aortic dissection?
Most life-threatening = aortic dissection -
‘One in a thousand’ hospital admissions with chest pain (no accurate figures or estimates of prevelance, but it is rare)
Difficult to diagnose, but always consider as successful surgical repair may be possible
Ways in which pain differs from MI more sudden onset -
- described as ‘tearing’
- moves from front to back as the dissection extends
- more common in men vs. women (incidence ration 1.55:1)
- other risk factors include hypertension, atherosclerosis, age >60
What are other vascular causes of chest pain apart from aortic dissection?
Technically, PE could be considered a vascular cause of chest pain
Vasculitides (e.g. Wegner’s) do affect the lower respiratory tract, but tend to be painless.
Aortitis (a complication of tertiary syphillis, for example) can be (a now, thankfully, very rare) cause of chest pain
What are the features of musculoskeletal chest pain?
Induced or relieved by postural change
Highly localised
Reproduced by pressure
What are the features of Tietze’s Syndrome?
(a specific type of costochondritis)
M>F, 20-30 years old
Pain localised to costal cartilage, usually palpable (tender) nodularities
Exacerbated by coughing, sneezing, motion
Usually post-viral URTI
What are the 2 causes of neuralgia and neuropathy in chest pain?
Herpes zoster (‘shingles’), which is usually accompanied by a blistering rash along a dermatomal distribution – classically not passing the midline.
Nerve roots can become compressed or irritated by: vertebral body collapse (# secondary to trauma or metastases), metastatic growth and invasion, infection (including discitis)
What other factors should be considered when diagnosing chest pain?
Mastitis (pain localised to structures of the breast): infection
Mastalgia (hormonally mediated breast pain) -
Gynaecomastia (often physiological, but can be pathological – caused by hormonal changes / problems / abuse, iatrogenic [e.g. H2 antagonists] or physiological [e.g. puberty]).
Cysts (usually benign) or malignancy (does not usually present with pain)
Chest pain can also be related to anxiety / underlying psychological factors, usually accompanied by (but not always / necessarily): - Headache, dizziness, low back pain, hyperventilation, fatigue (TATT), dysmenorrhoea, aggression
