Chest pain

Question 1

What are the challenges of chest pain?

Answer 1

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

Question 2

What structures in the chest can cause pain?

Answer 2

• 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)

Question 3

What 4 causes of chest pain are life-threatening?

Answer 3

Myocardial infarction

Massive pulmonary embolus & infarction

Ruptured aortic aneurysm

Ruptured oesophagus

Question 4

What different types of pain are there?

Answer 4

Stabbing, knife-like, sharp

Gnawing, burning, numbing

Strangling, tightness, crushing, squeezing, constricting

Tearing, piercing

Question 5

What are possible worsening triggers for chest pain?

Answer 5

Eating

exercise [‘exertional’]

breathing in / out [‘pleuritic’]

position or movement

Question 6

What are possible associated symptoms with chest pain?

Answer 6

sweating

nausea and / or vomiting

cough

weight loss

‘sense of impending doom’

Question 7

What are possible relieving factors for chest pain?

Answer 7

position, medication [e.g. GTN], rest

Question 8

What makes chest pain cardiac in nature?

Answer 8

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

Question 9

What is a silent MI?

Answer 9

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.

Question 10

What is the presentation of an MI?

Answer 10

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.

Question 11

What is acute coronary syndrome?

Answer 11

ACS: spectrum (acute coronary syndrome) that is often used to refer to STEMI, non-ST elevation MI (NSTEMI) and unstable angina.

Question 12

What is the clinical presentation of an NSTEMI?

Answer 12

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’

Question 13

How do ECG’s change in acute coronary syndrome?

Answer 13

ECG can change in all, and can be normal in all (STEMI is characterised by ST elevation, though)

Question 14

How can you differentiate between angina and stable angina?

Answer 14

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.

Question 15

What tests can be done to differentiate between the different acute coronary syndromes?

Answer 15

serial ECG, serum cardiac enzyme markers

Question 16

What is pericarditis chest pain like?

Answer 16

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

Question 17

What can pericarditis be caused by?

Answer 17

Can happen after an MI (Dressler’s)

Viral infection

• in context of ‘flu like illness
• Coxsackie virus, mumps, herpes, HIV

Question 18

What are the features of oesophageal reflux disease?

Answer 18

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])

Question 19

What conditions are included in oesophageal reflux disease?

Answer 19

GORD, oesophagitis, oesophageal spasm

Question 20

What are the features of oesophageal rupture?

Answer 20

Rare but serious, can result in mediastinitis - ~5 in 10,000 complication rate from OGD - Can be spontaneous (e.g. following violent vomiting)

Question 21

What are the possible causes of lung pain?

Answer 21

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

Question 22

What is pleuritic pain?

Answer 22

Severe ‘sharp’, ‘stabbing’ or ‘knife-like’

Usually one sided

Worse on inspiration

Mode of onset & associated symptoms gives clue to aetiology

Question 23

What are the features of a pulmonary embolism?

Answer 23

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

Question 25

What are the clinical features of aortic dissection?

Answer 25

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

Question 26

What are other vascular causes of chest pain apart from aortic dissection?

Answer 26

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

Question 27

What are the features of musculoskeletal chest pain?

Answer 27

Induced or relieved by postural change

Highly localised

Reproduced by pressure

Question 28

What are the features of Tietze’s Syndrome?

Answer 28

(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

Question 29

What are the 2 causes of neuralgia and neuropathy in chest pain?

Answer 29

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)

Question 30

What other factors should be considered when diagnosing chest pain?

Answer 30

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