Chest pain is one of the most common complaints that will bring patients to emergency department. The causes include cardiac and non cardiac. Careful medical examination and history is necessary for management of chest pain. ECG is the basic investigation for chest pain, based on ECG treatment is continued further.

 

Sources of chest pain

While each source of chest pain may have a classic presentation of signs and symptoms, there is significant overlap among the symptoms of each condition

 

• Chest wall including the ribs, the muscles, and the skin
• Back region including the spine, the nerves, and the back muscles
• Lung, the pleura or the trachea
• Heart including the pericardium
• Great vessel - aorta
• Esophagus
• Diaphragm
• Referred pain from abdominal organs like the stomach, gallbladder, and pancreas

 

Causes of chest pain

Cardiac causes

• Myocardial infarction
• Angina
• Acute coronary syndrome
• Pulmonary embolus
• Pericarditis
• Arrhythmias
• Mitral valve prolapse
• Aortic stenosis
• Aortic dissection
• Cardiac tamponade

Pulmonary/lung causes

• Pneumonia
• COPD
• Asthma
• Pneumothorax
• Tension pneumothorax
• Hemothorax
• Empyema
• Pneumomediastinum
• Lung cancer

Gastrointestinal causes

• Esophagitis/GERD
• Gastritis
• Peptic ulcer disease
• Perforated ulcer
• Esophageal spasm
• Pancreatitis
• Esophageal rupture

Musculoskeletal causes

• Muscle strain or spasm
• Intercostal muscle spasm
• Costochondritis
• Trauma (e.g., rib fracture)

Other causes include Tietze's syndrome, Pott's disease (tuberculosis of the sp, cholecystitis, peritonitis, liver cancer, and hepatitis zoster, cancer (e.g., lymphoma) panic disorder

Symptoms of chest pain

• Heart attack- left sided heavy chest pain, radiating to left shoulders, arm, back and abdomen. Associated with dyspnea, nausea, vomiting and sweating
• Angina- chest pain or tightness starts with exertion/stress or worsens with exertion or exercise. Rest and nitroglycerine relives chest pain.
• Pericarditis- sharp/stabbing pain in the chest worsened by deep breaths. The pain get worsened on lying flat and relieved on leaning forwards.
• Aortic dissection- sudden chest pain described as ripping or tearing. Pain radiates to back and shoulder blades, associated with giddiness or fainting, shortness of breath, and symptoms and stroke
• Mitral valve prolapse- sharp chest pain, does not radiate, and not related to physical exertion associated with palpitations
• Pulmonary embolism- sudden onset of shortness of breath, hurried and rapid respiration, and pain get worsened on deep breathes.
• Pneumothorax- sudden onset of shortness of breath, hurried and rapid respiration, sharp chest pain, giddiness and lightheadedness.
• Pneumonia- usually pain on one side, worsened by coughing, associated with expectoration, shortness of breath, and hurried respiration.
• Esophagus related symptoms- heart burn, squeezing or burning sensation in the chest, water brash, nausea, vomiting, and bloating or belching.

Test and diagnosis

Careful history regarding the signs and symptoms of chest is necessary to rule out cardiac and non cardiac causes.

• ECG
• Stress ECG/Treadmill
• 2D-echo
• Cardiac enzymes- troponin- T and I and creatine kinase
• CT (spiral) – angiogram
• Chest X-ray
• Upper GI endoscopy

Treatment

Cardiac care

Myocardial infarct (MI) and angina

If you suspect that your may be having a heart attack, call for emergency ambulance or go to emergency department.

Chewing 2 tablets of Asprin 150 mg, it reduces the risk of death by as much as 24% if taken in early stage of heart attacks.

Nitroglycerin tablets under the tongue or transdermal patch over the chest will reduce the chest pain and improve the blood supply to heart.

• Oxygen 5-6 lts by facial mask.
• Morphine sulphate may be administered for relief of pain and anxiety.
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• Antithrombotic agent- aspirin 325 mg (if not taken) should be administered immediately. Use clopidogrel in case of aspirin allergy.
• Thrombolytic therapy- with Streptokinase, Alteplase, Reteplase.
• Platelet aggregation inhibitors- Abciximab, Tirofiban, and Eptifibatide.
• Heparin and low molecular weight heparin.
• ACE inhibitors and beta blockers also form main management of myocardial infarct.
• A good control on hypertension, diabetes mellitus, obesity, smoking, cholesterol/triglycerides levels and tackling other risk factors is very important.

Surgical management

• Angioplasty is a way of unblocking an artery. Metallic stent is placed in the artery to keep it expanded.
• Cardiac bypass surgery is done in triple vessel block, if medical treatment is unsuccessful

Aortic dissection

• Medications that slow the heart rate and dilate the arteries are most widely used.
• Close monitoring of blood pressure is required as low blood pressure can be life threatening.
• Surgical management is required if ascending aorta is required.

Pulmonary embolism- Oxygen, heparin, and thrombolytic agents are first line drugs in management.

Pericarditis- Viral Pericarditis usually subsides in7-15 days, anti-inflammatory drugs (ibuprofen and indomethacin) is the mainstay of treatment

Non- cardiac causes

Pneumothorax

• Insert wide bore needle in left 2 nd intercostal space in mid axillary line.
• Cather aspiration or chest tube inserted to restore negative pressure in the lung sac.

Pneumonia - Antibiotics, oxygen, expectorants, and bronchodilators mainstay of treatment.

Costochondritis- Nonsteroidal anti-inflammatory drugs- Ibuprofen

Esophageal disorder

• Acid reflux and acidity - antacids- Proton pump inhibitors, H2 antagonists. Syrup. Mucaine, Sucrafil
• Esophagitis- Antibiotics, antifungals and antiviral medications

Panic attacks- Anxiolytics, counseling and relaxation techniques.