Chest Pain

Differentiating Cardiac from Noncardiac Causes

Types of Chest Pain

• Because heart disease is the leading cause of death in the US, it is important to diagnose a cardiac etiology in patients presenting with acute chest pain. But don’t forget that certain noncardiac causes may be life threatening as well.

• Cardiac Causes: • Ischemic and Nonischemic• Noncardiac Causes: • GI, Pulmonary, Musculoskeletal, • Dermatologic Causes: Herpes Zoster

(Shingles)

Two Types of Cardiogenic Symptoms

• Ischemic: causes of chest pain include; Myocardial Infarction (MI), CAD (Angina pectoris), Aortic Stenosis, Coronary Vasospasm, Hypertrophic Cardiomyopathy.

• Nonischemic: causes of chest pain include; Pericarditis, Dissecting Aortic Aneurysm, Mitral Valve Prolapse.

Typical and Atypical Presentations of Ischemic Chest Pain

Ischemic Symptoms: Myocardial Infarction

• MI’s may go unrecognized, sometimes symptoms are delayed for many hours.

• Three main types of MI’s: Anterior, Inferior and lateral.

• Anterior MI’s often present with chest pain and dyspnea due to left ventricular involvement.

• Inferior MI’s often present with chest pain, N & V, diaphoresis and singultus (hiccups) due to possible Vagus nerve involvement.

• Lateral MI’s often present with chest pain and left arm pain.

• Symptom presentation frequency with MI:*

• Diaphoresis 78%

• Chest pain 64%

• Nausea 52%

• SOB 47%

• Unrecognized (asymptomatic) 25%• * from a study of 88 patients presenting with verified AMI

Ischemic Symptoms: Coronary Artery Disease (CAD)

• (or Angina Pectoris) Caused by insufficient myocardial oxygen supply on demand. Pain is transient or episodic. Frequently described as heavy pressure occurring after exertion or stress or emotional upset. Associated symptoms: diaphoresis, N&V and weakness. CAD chest pain is often relieved by NTG.

Typical Angina Pain Areas

Ischemic Symptoms: Aortic Stenosis

• Often caused by congenital valve abnormalities, aortic sclerosis and rheumatic fever. Frequently coexists with CAD. Chest pain is usually exertional. Signs of heart failure may be present. Assess for systolic murmur, unusual carotid pulse.

Ischemic Symptoms: Hypertrophic Cardiomyopathy

• Causes overflow obstruction of left ventricle (hypertrophied septum). Assess for dyspnea with chest pain. Syncope can be typical with postexertion. Listen for loud systolic murmur. Pain complaints are similar to angina.

Ischemic Symptoms: Coronary Vasospasm

• Also called “Prinzmetal’s angina” or “variant angina”. Caused by vasospasm of coronary arteries. More common in females younger than 50. Typically occurs early in AM. Chest pain is usually recurrent, most often while at rest. Cocaine and other stimulants can induce symptoms due to drug induced vasoconstriction.

Nonischemic Symptoms: Dissecting Aortic Aneurysm

• Typically presents with complaints of severe anterior chest pain, radiating to upper back. HTN is usually present. Listen for murmur and radial pulse inequality.

Nonischemic Symptoms: Pericarditis

• Causes; viral infection (cocksackie & echoviruses are most common), TB, autoimmune disease, uremia, radiation, and post MI complication (Dressler’s Syndrome). Chest pain is pleuritic, usually alleviated by leaning forward – exacerbated by lying down. Listen for systolic murmur. Friction rub is the hallmark for Pericarditis.

Nonischemic Symptoms: Mitral Valve Prolapse

• Can present with chest pain, usually sharp near the apex. Associated symptoms: dyspnea, fatigue and palpitations. Pain is reduced by lying down. Listen for systolic murmur, heard best at the apex. Happens most often with thin females.

Non Cardiogenic Chest Pain

Non Cardiogenic Symptoms:Gastroesophageal Pain

• Roughly 42% of patients presenting with acute chest pain, in whom MI is ruled out, suffer GE induced chest pain. Causes: Esophagitis, esophageal perforation esophageal spasm, reflux disease, PU disease, Pancreatitis, and Cholesystitis.

• Esophageal spasm pain can be relieved by NTG!

Non Cardiogenic Symptoms:Pulmonary Pain

• Chest pain from pulmonary disease is typically “pleuritic” in nature, meaning that the pain varies with the respiratory cycle. Pleuritic chest pain usually increases during inspiration and is made worse by coughing, deep breathing or movement. Pleuritic pain is most often caused by lower respiratory infections. Other causes: spontaneous pneumothorax, pulmonary embolism, pneumonitis, bronchitis or neoplasm.

Pneumonitis

Non Cardiogenic Symptoms:Gall Bladder and Pancreas

• Acute pancreatitis, perforated peptic ulcer and acute cholecystitis can mimic an MI.

Non Cardiogenic Symptoms:Musculoskeletal Pain

• Roughly 28% of patients presenting with chest pain, in whom an MI has been ruled out, suffer from musculoskeletal or chest wall pain. Causes include; costocondritis, rib fracture and myalgia. Pain is usually reproducible upon palpation. Passive extension, flexion and rotation of the cervical and thoracic spine can be helpful in reproducing musculoskeletal chest pain.

• Costochondritis, also called Tietze's Syndrome, is a form of inflammation of the cartilage where ribs attach to the breastbone, due to excessive exersize.

Non Cardiogenic Symptoms:Herpes Zoster (Shingles)

• Shingles can present as acute chest pain. The pain is usually burning and unilateral, following the dermatomes. Chest pain from Shingles can occur before the onset of vesicles thus making a reliable diagnosis difficult.

Chest Pain Assessment• It is essential to obtain a thorough assessment that

includes:• Characteristics of pain, including location, duration,

radiation, quality and accompanying symptoms.• Carefully observe for associated symptoms:Heavy

pressure or squeezing in the chest area, episodic or exertional triggers, diaphoresis, N&V, weakness, anxiety and palpitations.

• Chest pain with diaphoresis is the most common presentation with an acute MI. Often the patient will describe the pain by using the “Levine Sign” – placing a clenched fist over the sternum.

Time is of the Essence

Conclusion

• Chest pain is a common presenting problem and has many causes, of which many can be life threatening. Cardiac and noncardiac causes must be considered. A thorough assessment is vital in order to distinguish all the potential causes and determine the appropriate intervention in a timely manner.

The End

Portions of the text were exerpted from “Chest Pain: Differentiating Cardiac from Noncardiac Causes” : pp.27 – 29, 38. Hospital Physician, April 2004 by R. Karnath MD, M. Holden MD and N. Hussain MD Prepared by High Desert State Prison Medical Education Department, July 2009.