Chest Pain

Question 1

What is the proportion of chest pain that are non-cardiovascular?

Answer 1

75%

Question 2

Where is the anatomical site of chest pain secondary to MI?

Answer 2

Centre of the chest radiating to neck, jaw, and upper or even lower arms. The pain may be felt at sites of radiations only.

Question 3

Where is the anatomical site of chest pain secondary to myocarditis or pericarditis?

Answer 3

Felt retrosternally or in the shoulders.

Question 4

Where is the anatomical site of chest pain secondary to aortic dissection?

Answer 4

Typically central radiating to the back (intrascapular)

Question 5

What might be the cause of left anterior chest pain radiating laterally?

Answer 5

Causes include lung disorders, anxiety and musculoskeletal problems.
Unlikely to be MI.
May be mitral valve prolapse (rare)

Question 6

What are the causes of sharp or catching pain aggravated by deep breathing or coughing (pleuritic pain)?

Answer 6

Usually indicative of respiratory pathology, particularly infection or infarction.
Myocarditis or pericarditis.
Pulmonary embolism
Pneumonia

Question 7

What are the characteristics of MI pain?

Answer 7

The pain is often dull, choking or heavy.
Usually described as squeezing, crushing, burning or aching pain.
Patients tend to say it’s a discomfort

Question 8

Which pathology can cause a gnawing, continuous localised pain?

Answer 8

Malignant tumour invading the chest wall.

Question 9

What is the characteristics of asthmatic chest pain?

Answer 9

Chest tightness that gets better with rest.

Question 10

How do you differentiate between MI and GORD chest pain?

Answer 10

GORD chest pain mostly occurs after eating

ACS and peptic ulcer pain may also occur after eating

Question 11

What are the associated features of MI pain?

Answer 11

Autonomic disturbances such as nausea, vomiting and sweating.
Dyspnoea due to pulmonary congestion arising from left ventricular dysfunction.
Hypotension/syncope (also seem in massive PE and aortic stenosis)

Question 12

What is the associated feature of respiratory causes of chest pain?

Answer 12

Dyspnoea accompany ANY respiratory causes of chest pain and can be associated with cough/wheeze

Question 13

If a patient is in pain during history taking, what do you do?

Answer 13

Offer analgesia

Question 14

How do you assess chest pain?

Answer 14

History > Examination > ECG.
ECG is most valuable in ACS.
Initial evaluations also include FBC, Lipids, Blood glucose, resting and exercise ECGs

Question 15

What are the differential diagnoses of chest pain?

Answer 15

Psychological- anxiety
Myocarditis and pericarditis
Mitral valve prolapse- sharp left-sided pain
Aortic dissection- severe, sharp and tearing, often felt in the back
GORD- mimics MI
Bronchospasm- there’s associated wheeze, cough and symptoms of atopy
Musculoskeletal chest pain- local tenderness
PE
Pancreatitis, peptic ulcer, gallstones, ACS- epigastric pain
Cholecystitis- radiates to right shoulder

Question 16

How long does it take for MI pain to build to maximal intensity?

Answer 16

It takes several minutes.

T in SOCRATES
Seconds- musculoskeletal, non-cardiac 
Minutes- ACS, GORD, musculoskeletal 
Hours- All 
Days- dull persistent pain- not ACS