Chest pain
Other namesPectoralgia, stethalgia, thoracalgia, thoracodynia
Potential location of pain from a heart attack
SpecialtyEmergency medicine, internal medicine, cardiology
SymptomsDiscomfort in the front of the chest[1]
TypesCardiac, noncardiac[2]
CausesSerious: Acute coronary syndrome (including heart attacks), pulmonary embolism, pneumothorax, pericarditis, aortic dissection, esophageal rupture[3]
Common: Gastroesophageal reflux disease, psychological problems such as anxiety disorders, depression, stress etc, muscle or skeletal pain, pneumonia, shingles[3]
Diagnostic methodMedical history, physical exam, medical tests[3]
TreatmentBased on the underlying cause[1]
MedicationAspirin, nitroglycerin[1][4]
PrognosisDepends on the underlying cause[3]
Frequency~5% of ER visits[3]

Chest pain is pain or discomfort in the chest, typically the front of the chest.[1] It may be described as sharp, dull, pressure, heaviness or squeezing.[3] Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath.[1][3] It can be divided into heart-related and non-heart-related pain.[1][2] Pain due to insufficient blood flow to the heart is also called angina pectoris.[5] Those with diabetes or the elderly may have less clear symptoms.[3]

Serious and relatively common causes include acute coronary syndrome such as a heart attack (31%), pulmonary embolism (2%), pneumothorax, pericarditis (4%), aortic dissection (1%) and esophageal rupture.[3] Other common causes include gastroesophageal reflux disease (30%), muscle or skeletal pain (28%), pneumonia (2%), shingles (0.5%), pleuritis, traumatic and anxiety disorders.[3][6] Determining the cause of chest pain is based on a person's medical history, a physical exam and other medical tests.[3] About 3% of heart attacks, however, are initially missed.[1]

Management of chest pain is based on the underlying cause.[1] Initial treatment often includes the medications aspirin and nitroglycerin.[1][4] The response to treatment does not usually indicate whether the pain is heart-related.[1] When the cause is unclear, the person may be referred for further evaluation.[3]

Chest pain represents about 5% of presenting problems to the emergency room.[3] In the United States, about 8 million people go to the emergency department with chest pain a year.[1] Of these, about 60% are admitted to either the hospital or an observation unit.[1] The cost of emergency visits for chest pain in the United States is more than US$8 billion per year.[6] Chest pain accounts for about 0.5% of visits by children to the emergency department.[7]

Signs and symptoms

Chest pain may present in different ways depending upon the underlying diagnosis. Chest pain may also vary from person to person based upon age, sex, weight, and other differences.[1] Chest pain may present as a stabbing, burning, aching, sharp, or pressure-like sensation in the chest.[8][1] Chest pain may also radiate, or move, to several other areas of the body. This may include the neck, left or right arms, cervical spine, back, and upper abdomen.[9] Other associated symptoms with chest pain can include nausea, vomiting, dizziness, shortness of breath, anxiety, and sweating.[8][1] The type, severity, duration, and associated symptoms of chest pain can help guide diagnosis and further treatment.

Differential diagnosis

Causes of chest pain range from non-serious to life-threatening.[10]

In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%).[11] Other less common causes include: pneumonia, lung cancer, and aortic aneurysms.[11] Psychogenic causes of chest pain can include panic attacks; however, this is a diagnosis of exclusion.[12]

In children, the most common causes for chest pain are musculoskeletal (76–89%), exercise-induced asthma (4–12%), gastrointestinal illness (8%), and psychogenic causes (4%).[13] Chest pain in children can also have congenital causes.

Cardiovascular

Respiratory

Gastrointestinal

Chest wall

Psychological

Others

Pathophysiology

The chemical pathways involved in causing chest pain vary depending on the etiology.

Angina pectoris

In angina pectoris (cardiac chest pain), loss of blood flow to the heart causes the release of chemical mediators such as serotonin, histamine, thromboxane A2, bradykinin, reactive oxygen species, lactic acid, and especially adenosine that trigger cyclooxygenase enzymes to produce prostaglandins.[41] These prostaglandins and chemical mediators interact with nerves innervating the heart, leading to the sensation of chest pain. In addition, atherosclerotic plaques occluding the coronary arteries may break apart, thus inflaming the arterial walls and causing the release of other chemical mediators such as prostaglandins, leukotrienes and substance P that sensitize pain receptors and amplifies the magnitude of the chest pain.[41]

The activation of pain receptors innervating the heart also stimulates other converging nerves in the spinal cord.[41] These signals may be misinterpreted by the brain as pain originating from the neck, jaw, and left shoulder and hand, hence why there is often referred pain to these areas during anginal episodes.[41]

Chest pain due to gastrointestinal issues

Due to the proximity of the esophagus to the heart, many esophageal disorders cause chest pain and can even affect blood flow to and electrical activity within the heart.[41] Gastroesophageal reflux disease (GERD) is an especially common mimic of chest pain. In GERD, the presence of esophageal acid alters sensory perception and the processing of pain signals from the heart.[41]

Gallbladder disease is also notorious in causing referred chest pain, as well as pain in the abdomen and back. Studies have confirmed that there is convergence between the neurons detecting pain in the gallbladder and in the heart.[41] This overlap explains how stretching of the gallbladder wall can cause chest pain as well.

Psychosomatic chest pain

Many individuals undergoing stress or who have psychiatric disorders such as depression and anxiety can experience angina-like chest pain despite not having any heart disease. Studies have implicated an increase in glucocorticoid levels within the central nucleus of the amygdala in causing chest pain as a result of stress.[41]

Diagnostic approach

History taking

Knowing a person's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors. Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of acute coronary syndrome.[42] Other clues in the history can help lower the suspicion for myocardial infarction. These include chest pain described as "sharp" or "stabbing", chest pain that is positional or pleuritic in nature, and chest pain that can be reproduced with palpation.[43][44] However, both atypical and typical symptoms of acute coronary syndrome can occur, and in general a history cannot be enough to rule out the diagnosis of acute coronary syndrome.[44] In some cases, chest pain may not even be a symptom of an acute cardiac event. An estimated 33% of persons with myocardial infarction in the United States do not present with chest pain, and carry a significantly higher mortality as a result of delayed treatment.[45]

Physical examination

Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialized units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia.[46] However, in the case of acute coronary syndrome, a third heart sound, diaphoresis, and hypotension are the most strongly associated physical exam findings.[47] However these signs are limited in their prognostic and diagnostic value.[8] Other physical exam findings suggestive of cardiac chest pain may include hypertension, tachycardia, bradycardia, and new heart murmurs.[8] Chest pain that is reproducible during the physical exam with contact of the chest wall is more indicative of non-cardiac chest pain, but still cannot completely rule out acute coronary syndrome.[48] For this reason, in general, additional tests are required to establish the diagnosis.

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.[10]

Risk scores

Depending on healthcare provider preference, there is a variety of algorithms that can be used to classify a patient with chest pain as low-, medium-, or high-risk for an adverse cardiac event.

HEART score

The HEART (History, ECG, Age, Risk factors, Troponin) score stratifies individuals with chest pain into low-risk and high-risk groups. Based on the cumulative score and associated risk of an adverse cardiac event (such as a heart attack), it recommends either discharge or admission: [1]

HEART score[49][50]
Criteria Point Value
History
Highly suspicious +2
Moderately suspicious +1
Slightly suspicious 0
ECG
Significant ST-depression +2
Nonspecific repolarization disturbance +1
Normal 0
Age
≥ 65 +2
45–65 +1
≤ 45 0
Risk factors*
≥ 3 risk factors or history of atherosclerotic disease +2
1-2 risk factors +1
No risk factors known 0
Troponin
≥ 3× normal limit +2
1–3× normal limit +1
≤ normal limit 0
*include hypercholesterolemia, hypertension, diabetes mellitus, smoking, obesity

Cumulative score:

If acute coronary syndrome ("heart attack") is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause.

Thrombolysis in Myocardial Infarction (TIMI) and Accelerated Diagnostic Protocol for Chest Pain Trial (ADAPT) scores

As one of the earliest risk stratification scores developed for chest pain, the TIMI score estimates the chance of a major adverse cardiac event (MACE) such as a heart attack in the next 14 days. It assigns 1 point for each of the listed parameters. Patients with a score of 0 or 1 are at a lower risk for a MACE.

Parameter
Age ≥ 65
≥ 3 coronary artery disease (CAD) risk factors*
Known CAD with stenosis ≥ 50%
Aspirin use in the past 7 days
ECG ST changes ≥ 0.5 mm
Positive cardiac marker
*hypertension, diabetes, dyslipidemia,

family history of heart disease, or current smoker

The original TIMI score developed in 2000 was intended for application in patients with a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina.[51] However, when paired with cardiac lab tests such as troponin, CKMB, and/or myoglobin (ADAPT score), it can be useful in evaluating the risk of MACE in patients with chest pain of unclear etiology as well.[51]

Vancouver Chest Pain Rule (VPCR)

The VPCR focuses on risk stratifying patients with undifferentiated chest pain. An individual is considered low-risk and can be discharged to outpatient follow-up if the answer to all of the criteria are "No."[51] The VPCR criteria have since been revised and is as follows:[51]

  1. Abnormal initial ECG, positive troponin at 2 hrs, OR prior ACS or nitrate use
  2. Pain is reproducible with palpation
  3. Age ≥ 50 OR Pain radiates to neck, jaw, or left arm

Emergency Department Assessment of Cardiac Pain Score (EDACS)

The EDACS is a score developed by researchers from Australia and New Zealand in 2014 that has been gaining prominence in the medical community. It is intended to identify individuals presenting with chest pain who are low-risk for a cardiac event (such as a heart attack) so that they can be discharged for outpatient care.[52] However, unlike the HEART score, it is not intended for patients in whom a cardiac cause of chest pain is suspected or for patients who have unstable vital signs.

EDACS[53]
Criteria Point Value
Age
18–45 +2
46–50 +4
51–55 +6
56–60 +8
61–65 +10
66–70 +12
71–75 +14
76–80 +16
81–85 +18
86+ +20
Sex
Male sex +6
Male individual of age 18-50 with known coronary

artery disease or 3+ risk factors*

+4
Signs and symptoms
Diaphoresis +3
Radiation of pain to arm or shoulder +5
Pain occurs with or worsens upon inspiration -4
Pain is reproducible by palpation -6
*including dyslipidemia, diabetes, hypertension, current smoker,

or family history of premature coronary artery disease

Low-risk patients who can safely go home and seek early outpatient follow-up for their chest pain should meet the following criteria:

Patients who do not meet this low-risk criteria should undergo further observation and usual chest pain workup.[53]

Studies have shown that EDACS can correctly classify up to 50% of all patients presenting with chest pain as safe for early discharge, making it more accurate than other scales such as ADAPT, HEART, and the Vancouver Chest Pain Rule in identifying low-risk patients.[52]

Medical tests

Depending on the differential diagnoses made based on history and physical examination, a number of tests may be ordered:[54]

Blood tests:

Other tests:

Management

Management of chest pain varies with the underlying cause of the pain and the stage of care.

Prehospital care

If an individual develops chest pain and suspects that they are suffering a myocardial infarction, they can calm down, remain in a position that is comfortable, and call emergency medical services while trying any other action of the applicable first aid process.

Chest pain is a common symptom encountered by emergency medical services. Aspirin increases survival in people with acute coronary syndrome and it is reasonable for EMS dispatchers to recommend it in people with no recent serious bleeding.[56] Supplemental oxygen was used in the past for most people with chest pain but is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress.[57][56] Entonox is frequently used by EMS personnel in the prehospital environment.[58] However, there is little evidence about its effectiveness.[56][59]

Hospital care

Also see management of acute coronary syndrome

Hospital care of chest pain begins with initial survey of a person's vital signs, airway and breathing, and level of consciousness.[1][8] This may also include attachment of ECG leads, cardiac monitors, intravenous lines and other medical devices depending on initial evaluation.[8] After evaluation of a person's history, risk factors, physical examination, laboratory testing and imaging, management begins depending on suspected diagnoses.[8] Depending upon the diagnosis, a person may be placed in the intensive care unit, admitted to the hospital, or be treated outpatient.[8] For persons with suspected cardiac chest pain or acute coronary syndrome, or other emergent diagnoses such as pneumothorax, pulmonary embolism, or aortic dissection, admission to the hospital is most often recommended for further treatment.[8]

Outpatient care

Patients with low-risk cardiac chest pain may undergo a cardiac stress test, usually involving treadmill or chemical stimulation to strain the heart and reproduce the chest pain. The activity of the heart is often monitored during these exams using electrocardiography, echocardiography, or cardiac MRI. Computed tomography angiography (CTA) is another option but is not often recommended due to financial burden, radiation exposure, and variable access.[60]

For people with non-cardiac chest pain, cognitive behavioral therapy might be helpful on an outpatient basis. A 2015 Cochrane review found that cognitive behavioral therapy might reduce the frequency of chest pain episodes the first three months after treatment.[61]

For persons with chest pain due to gastroesophageal reflux disease, a proton-pump inhibitor has been shown to be the most effective treatment.[62] However, treatment with proton pump inhibitors has been shown to be no better than placebo in persons with noncardiac chest pain not caused by gastroesophageal reflux disease.[62]

For musculoskeletal causes of chest pain, manipulation therapy or chiropractic therapy, acupuncture, or a recommendation for increased exercise are often used as treatment.[62] Studies have shown conflicting results on the efficacy of these treatments.[62] A combination therapy of nonsteroidal anti-inflammatory drugs and manipulation therapy with at-home exercises has been shown to be most effective in treatment of musculoskeletal chest pain.[9]

Epidemiology

Chest pain is a common presenting problem. Overall chest pain is responsible for an estimated 6% of all emergency department visits in the United States and is the most common reason for hospital admission.[44] Chest pain is also very common in primary care clinics, representing 1–3% of all visits.[63] The rate of emergency department visits in the US for chest pain decreased 10% from 1999 to 2008.[64] but a subsequent increase of 13% was seen from 2006 to 2011.[65] Less than 20% of all cases of chest pain admissions are found to be due to coronary artery disease.[66] The rate of chest pain as a symptom of acute coronary syndrome varies among populations based upon age, sex, and previous medical conditions.[45] In general, women are more likely than men to present without chest pain (49% vs. 38%) in cases of myocardial infarction.[45]

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