Disease: Chest Pain

    Chest pain facts

    • There are many causes of chest pain, and while many are not serious, it may be difficult to distinguish among heart attack, pulmonary embolus or aortic dissection, and another diagnosis that is not life-threatening. For that reason, patients are routinely advised to seek medical care for most types of chest pain.
    • While each cause of chest pain has a classic presentation, there are enough variations that it may take specific testing to come to a diagnosis. These tests will depend on the patient's presentation and the health care professional's index of suspicion as to what the diagnosis might be.
    • Treatment for chest pain depends upon the cause.
    • It is best to be safe. Always seek medical care for the assessment of chest pain.

    Chest pain introduction

    Chest pain is one of the most common complaints that will bring a patient to the emergency department. Seeking immediate care may be lifesaving, and considerable public education has been undertaken to get patients to access medical care when chest pain strikes. While the patient may be worried about a heart attack, there are many other causes of pain in the chest that the health care professional will need to consider. Some diagnoses are life-threatening, while others are less dangerous.

    Deciding the cause of chest pain is sometimes very difficult and may require blood tests, X-rays, CT scans and other tests to sort out the diagnosis. Often though, a careful history taken by the health care professional may be all that is needed to find the answer.

    What are the sources of chest pain?

    The following anatomic locations can all be potential sources of chest pain:

    • the chest wall including the ribs, the muscles, and the skin;
    • the back including the spine, the nerves, and the back muscles;
    • the lung, the pleura (the lining of the lung), or the trachea;
    • the heart including the pericardium (the sac that surrounds the heart);
    • the aorta;
    • the esophagus;
    • the diaphragm, the flat muscle that separates the chest and abdominal cavities; and
    • referred pain from the abdominal cavity including organs like the stomach, gallbladder, and pancreas, as well as irritation from the underside of the diaphragm due to infection, bleeding or other types of fluid.

    There may be classic presentations of signs and symptoms for many diseases but they can also present atypically and there may also be significant overlap among the symptoms of each condition. Age, gender, and race can affect presentation and the health care professional must consider many variables before coming to a specific diagnosis.

    What are the causes of chest pain?

    Pain can be caused by almost every structure in the chest. Different organs can produce different types of pain but unfortunately the pain is not specific to each cause. Each of the following causes is explained in detail in this article:

    • Broken or bruised ribs
    • Pleuritis or pleurisy
    • Pneumothorax
    • Shingles
    • Pneumonia
    • Pulmonary embolus
    • Angina
    • Heart attack (myocardial infarction)
    • Pericarditis
    • The aorta and aortic dissection
    • The esophagus and reflux esophagitis
    • Referred abdominal pain

    How is chest pain diagnosed?

    The key to diagnosis remains the patient history. Learning about the nature of the pain will give the health care professional direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the doctor assess the probability of each potential cause and make decisions about what potential diagnoses should be considered and which should be discarded.

    Differential diagnosis is a thought process that health care professionals use to consider and then eliminate potential causes for an illness. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved. As well, the patient's response to therapy can expand or narrow the differential diagnosis list. In patients with chest pain, many potential conditions may be present, and the health care professional will want to first consider those that are life-threatening. Using laboratory and X-ray tests may not be necessary to exclude potentially lethal diseases like heart attack, pulmonary embolus, or aortic dissection when clinical skill and judgment may be all that is needed.

    The patient may be asked a variety of questions to help the health care professional understand the quality and quantity of the pain. Patients use different words to describe pain, and it is important that the health care professional get an accurate impression of the situation. The questions may also be asked in different ways.

    Questions the doctor may ask about chest pain

    • When did the pain start?
    • What is the quality of the pain?
    • How long does the pain last?
    • Does the pain come and go?
    • What makes the pain better?
    • What makes the pain worse?
    • Does the pain radiate somewhere (move to another area of the body)?
    • Has there been any preceding illness?
    • Has there been any trauma?
    • Have there been similar episodes of pain in the past?
    • Is the pain different than that of a previous condition that has been experienced, or is it similar?
    Questions about the associated symptoms
    • Is there shortness of breath?
    • Fever or chills?
    • Cough?
    • Nausea or vomiting?
    • Sweating?
    Questions about risk factors for disease Risk factors for atherosclerotic heart disease (also known as coronary artery disease)
    • Smoking
    • High blood pressure
    • High cholesterol
    • Diabetes
    • Family history
    Risk factors for pulmonary embolus (blood clot to the lung)
    • Prolonged inactivity such as bed rest, long car or airplane trips
    • Recent surgery
    • Fractures
    • Birth control pill use (particularly if the patient smokes cigarettes)
    • Cancer
    Risk factors for aortic dissection
    • High blood pressure
    • Marfan syndrome
    • Ehlers-Danlos syndrome
    • Polycystic kidney disease
    • Cocaine use
    • Pregnancy

    Physical examination helps refine the differential diagnosis. While chest pain may be the initial complaint, often the whole body needs to be examined. Example components of the physical exam may include:

    Vital signs
    • Blood pressure (BP), pulse rate (PR), respiratory rate (RR), temperature, and
    • Oxygen saturation (O2 sat) which measures the amount of oxygen being carried by red blood cells in the bloodstream.
    Head and neck
    • Looking for neck vein distension or bulging
    • Listening over the carotid arteries for bruits (abnormal sounds) or murmurs that begin in the heart and radiate to the neck
    Chest wall
    • Palpate for rib or muscle tenderness
    • Look for rashes including the rash of shingles (zoster)
    Lungs
    • Listen for abnormal lung sounds like crackle or wheeze or decreased air entry with inspiration
    • Listen for rubs (a friction sound made by two rough surfaces rubbing against each other) that may be heard in pleurisy
    Heart
    • Listen for abnormal heart sounds, murmurs or rubs (which may be heard with inflammation of the heart lining, called pericarditis)
    • Listen for muffled or indistinct heart tones that can be associated with excess fluid in the pericardium, the sac that surrounds the heart
    Abdomen
    • Palpate for tenderness or masses
    • Listen for bruits over the aorta
    Extremities
    • Feel for pulses

    What is the philosophy of the approach to chest pain diagnosis?

    While there are many causes of chest pain, the health care professional will keep those that are potentially lethal front and center in their evaluation of a patient presenting with chest pain. The big three -- heart attack (myocardial infarction), pulmonary embolus, and aortic dissection -- should be considered briefly with every patient, although most of the time their presence can be discarded based upon clinical judgment.

    History and physical examination are key in deciding which path to follow in the diagnosis of chest pain. For somebody who fell and hurt their ribs, that path is well marked. For an elderly person who presents with vague discomfort and risk factors for an illness, significant testing may need to be done to prove that a given diagnosis is not correct.

    The concept of ruling out a diagnosis is difficult for some patients to understand. Instead of proving what is happening, the health care professional is sometimes charged with proving that a life-threatening diagnosis is not present. "Proving what isn't" takes time and technology. A combination of blood tests and imaging studies may take hours to confirm or discard a potential diagnosis.

    These tests often are done emergently, and treatment may be started even without a firm diagnosis. For example, if a patient presents with chest pain that the health care professional believes may be angina (pain caused because of narrowing of coronary arteries that supply blood to the heart muscle), then the initial medications to protect the heart will be started at the same time the diagnostic tests are done. Because some heart tests will take hours to complete, the philosophy for this approach is that heart muscle should not be placed at risk while waiting for a diagnosis. If the heart proves to be normal, then the medications are stopped, and the patient can be reassured that heart disease has been ruled out. Other diagnoses are also considered at the same time the heart tests are being performed, but ruling out one diagnosis does not confirm another.

    What is the diagnosis and treatment for chest pain?

    Treatment for chest pain depends upon the cause. Many times, situations require that the evaluation, diagnosis, and treatment occur at the same time, but when there is opportunity, the sequence of history, physical examination, testing, diagnosis, and treatment should be followed. A synopsis of common chest pain presentations and treatments follows.

    The chest wall

    Broken or bruised ribs

    Bruised or broken ribs are common injuries. Symptoms of broken or bruised ribs include:

    • tenderness over the site of injury;
    • a broken rib may be palpated (the health care professional can feel the rib fracture move when pressed);
    • the pain tends to be pleuritic (it hurts to take a deep breath and can be associated with shortness of breath); and
    • because the surrounding muscles go into spasm, there is pain with any movement of the trunk.

    The health care professional will want to listen to the chest to make certain that there is no associated lung damage. Sometimes, subcutaneous emphysema can be felt, a sensation of feeling rice krispies when air leaks into the skin. A chest X-ray may be done to look for a pneumothorax (collapsed lung) or pulmonary contusion (a bruised lung). Special X-rays looking for rib fracture are not needed since the presence or absence of a fracture will not alter the treatment plan or recuperation time. Special attention will be given to the upper abdomen since the ribs protect the spleen and liver, to make certain there are no associated injuries.

    The major complication of rib injuries is pneumonia. The lungs work like bellows. Normally, when one takes a breath, the ribs swing out and the diaphragm moves down, sucking air into the lungs. Because it hurts to take a deep breath, this mechanism is altered, and the lung underlying the injury may not fully expand because the patient cannot tolerate the pain. The result is stagnant air and lung tissue that does not fully expand, causing a potential breeding ground for lung infection (pneumonia).

    Rib injury treatment may include:

    • Pain control with anti-inflammatory medications like ibuprofen and narcotic pain medications to allow deep breaths to occur.
    • Application ice to the affected area and periodically deep take breaths. An incentive spirometer may be provided to help visualize the amount of breath to take.
    • Ribs are no longer wrapped or taped to help with comfort. Wrapping ribs decreases the ability of the lung underneath the injured area to fully expand and increases the risk of developing pneumonia.
    • Whether broken or bruised, rib injuries take 3 to 6 weeks to heal.

    Costochondritis

    On occasion, the joints and cartilage where ribs attach to the sternum (breastbone) may become inflamed. The pain tends to hurt with a deep breath, and there is tenderness that can be felt when the sides of the sternum are palpated or touched. If there is swelling and inflammation associated with the tenderness, it is known as Tietze's syndrome.

    The most frequent cause for costochondritis is idiopathic or unknown, meaning there is no explanation for the pain. Other causes include trauma to the area, infection (often viral), and fibromyalgia.

    Though painful, the symptoms resolve with symptomatic care, including ice and/or warm compresses and anti-inflammatory medications (for example, ibuprofen). As with other chest wall pain, recovery may take weeks. Taking deep breaths to prevent the risk of pneumonia is very important.

    For more, please read the Costochondritis and Tietze Syndrome article.

    Pleuritis or pleurisy

    The lung slides along the chest wall when a deep breath is taken. Both surfaces have a thin lining called the pleura to allow this sliding to occur. On occasion, viral infections can cause the pleura to become inflamed, and then instead of sliding smoothly, the two linings scrape against each other, causing pain. This pain hurts with a deep breath and is described as pleuritic.

    Viral infections are a common cause of pleurisy, although there are many other infectious causes including tuberculosis. Other diseases that can inflame the pleura include:

    • collagen vascular diseases like sarcoidosis and systemic lupus erythematosus,
    • cancer,
    • kidney failure,
    • rheumatoid arthritis,
    • complications of radiation therapy,
    • complications of chemotherapy, and
    • complications of surgery.

    The physical exam may be relatively unremarkable, but a friction rub may be heard over the site of pleural inflammation. If a significant amount of fluid leaks from the inflammation, the space between the lung and the chest wall (the pleural space) can fill with fluid, known as an effusion. When listening with a stethoscope, there may be decreased air entry in the lung. As well, percussion, in which the health care professional taps on the chest wall like a drum, may reveal dullness of one side compared to the other.

    Often a chest X-ray is done to assess the lung tissue and the presence or absence of fluid in the pleural cavity.

    Pleurisy is usually treated with an anti-inflammatory medication. This will often treat an effusion as well. If the effusion is large and is causing shortness of breath, thoracentesis (thora=chest + centesis=withdrawing fluid) may be done. For thoracentesis, a needle is placed in the pleural space and the fluid withdrawn. Aside from making the patient feel better, the fluid may be sent for laboratory analysis to help with diagnosis. For more, please read the Pleurisy article.

    Pneumothorax

    The lung is held against the chest wall by negative pressure in the pleura. If this seal is broken the lung can shrink down, or collapse (known as pneumothorax). This may be associated with a rib injury or it may occur spontaneously. Though commonly seen in those who are tall and thin, other risk factors for a collapsed lung include emphysema or asthma. Small blebs or weak spots in the lung can break and cause the air leak that breaks the negative pressure seal.

    The common presentation is the acute onset of sharp chest pain associated with shortness of breath, with no preceding illness or warning. Physical examination reveals decreased air entry on the affected side. Percussion may show increased resonance with tapping. Chest X-ray confirms the diagnosis.

    Treatment is dependent upon what percentage of the lung is collapsed. If it is a small amount and vital signs are stable with a normal O2 sat, the pneumothorax may be allowed to expand on its own with close monitoring. If there is a larger collapse, a chest tube may have to be placed into the pleural space through the chest wall to suck the air out and re-establish the negative pressure. On occasion, thoracoscopy (thoraco=chest +scopy=see with a camera) may be considered to identify the bleb and to staple it shut. For more, please read the Pneumothorax article.

    Tension pneumothorax is a relatively rare life-threatening event often associated with trauma. Instead of a simple collapse of the lung, a scenario can exist in which the damaged lung tissue acts as a one way valve allowing air to enter into the pleural space but not allowing it to escape. The pneumothorax size increases with each breath and can prevent blood from returning to the heart and allowing the heart to pump it back to the body. If not corrected quickly with placement of a chest tube, it can be fatal.

    Shingles

    The rash of shingles is caused by the varicella zoster virus, the same one that causes chickenpox. Once the virus enters the body, it hibernates in the nerve roots of the spinal column, only to emerge sometime in the future. The rash is diagnostic as it follows the nerve root as it leaves the back, and circles to the front of the chest, but not crossing the midline.

    Once the rash appears, the diagnosis is relatively easy for the health care professional. Unfortunately, the pain of shingles may begin a few days before the rash emerges and can be confusing to both patient and health care professional, since the pain and burning may seem out of proportion to the findings on physical examination.

    The treatment for shingles includes antiviral medications like acyclovir (Zovirax) along with pain control medication. Since it is the nerve that has become inflamed, the pain can be quite severe. Some patients may develop postherpetic neuralgia, or chronic pain from the inflamed nerve, which may persist long after the infection has cleared. A variety of pain control strategies are available from medication to pain stimulators to surgery. For more, please read the Shingles article.

    The lungs

    Pneumonia

    An infection of the lung is called pneumonia, in which inflammation can cause fluid buildup within a segment of the lung tissue, decreasing its ability to transfer oxygen from air to the bloodstream.

    Pneumonia presents with the typical symptoms of an infection:

    • fever,
    • chills, and
    • malaise.

    There may also be:

    • cough,
    • shortness of breath, and
    • sputum production (coughing up mucus).

    The chest pain is pleuritic, hurting when taking a deep breath.

    The classic presentation of a lung infection caused by the bacteria Streptococcal pneumoniae or pneumococcus, one of the most common causes of pneumonia, is acute onset of shaking chills, fever, and a cough that produces rusty brown sputum.

    Physical examination may find the patient to have abnormal vital signs consistent with an infection. The pulse rate and respiratory rate may be elevated. A fever may be present. Listening to the chest may reveal decreased air entry in the area of the infection associated with crackles and occasionally wheezing because of inflammation and narrowing of the bronchial tubes.

    A chest X-ray helps make the diagnosis, though the X-ray image sometimes lags behind the clinical findings by a day or two. Blood tests may be used to assess the severity of illness and may include a white blood cell count (markedly elevated or abnormally low counts may indicate more severe illness). Oxygen saturation measured with a probe attached to the finger is a way of assessing oxygenation of the blood and is routinely performed on patients with chest pain or shortness of breath. An arterial blood gas can exactly measure the amount of oxygen and carbon dioxide in the bloodstream to help determine the level of lung function.

    Pneumonia may be caused by viruses or bacteria. The latter are treated with antibiotics, either by mouth or in the hospital by intravenous infusion. The general health and past medical history of the patient may guide the decision as to whether inpatient or outpatient therapy is most appropriate. For more, please read the Pneumonia article.

    Pulmonary embolism

    A blood clot to the lung can be fatal and is one of the diagnoses that should always be considered when a patient presents with chest pain.

    There is a classic presentation for pulmonary embolus with the patient complaining of pleuritic chest pain (hurts to take a deep breath), shortness of breath, and coughing up blood (hemoptysis); but more commonly patients can present with more subtle complaints, and the diagnosis may be easily and unavoidably missed.

    Risk factors for pulmonary embolus include:

    • prolonged inactivity like a long trip in a car or airplane,
    • recent surgery or fracture,
    • birth control pills (especially associated with smoking),
    • cancer, and
    • pregnancy.

    Thrombophilia (thrombo=clot + philia= attraction) comprises a host of blood clotting disorders that place patients at risk for pulmonary embolus.

    The pulmonary embolus begins in veins elsewhere in the body, usually the legs, though it can occur in the pelvis, arms, or the major veins in the abdomen. When a thrombus or blood clot forms, it has the potential to break free (now called an embolus) and float downstream, returning to the heart. The embolus can continue its journey through the heart and enter into the pulmonary circulation system, eventually becoming lodged in the branches of the pulmonary artery and cutting off blood supply to part of the lung. This decreased blood flow doesn't allow enough blood to pick up oxygen in the lung, and the patient can become markedly short of breath.

    As mentioned above, the common complaints include:

    • pleuritic chest pain from the inflamed lung,
    • bloody sputum, and
    • shortness of breath.

    The patient can also have anxiety and sweat profusely. Depending upon the size of the clot, the initial presentation may be fainting (syncope) or shock in which the patient collapses, with decreased blood pressure and altered mental function.

    Depending on the severity of the embolus and the amount of lung tissue at risk, the patient may present critically ill (in extremis) with markedly abnormal vital signs, or may appear rather normal. Physical examination may not be helpful, and the diagnostic studies are done upon clinical suspicion based on history and risk factors.

    The diagnosis may be made directly with imaging of the lungs or indirectly by finding a clot elsewhere in the body. The strategy used to make a diagnosis will depend upon each individual patient's situation, but there are some general tools available.

    D-dimer is a blood test that can measure breakdown products of blood clots in the body but cannot differentiate a pulmonary embolus from a healing scar from surgery, or a bruise from falling. If this test is negative, then a pulmonary embolus can usually be excluded if the patient is in a low risk category to form clots. Cancer and pregnancy are two other situations in which the d-Dimer test is often positive even without blood clots present.

    Lungs can be imaged with a ventilation-perfusion scan or a CT scan to look for a clot. Each test has its benefits and limitations, and use of these tests is dependent upon the clinical situation. If there are technical issues so that the lungs cannot be imaged, an ultrasound of the legs may be performed to look for a thrombus; the concept is that if the symptoms are present of a pulmonary embolus and a clot is found in the leg, then the diagnosis can be inferred. However, if the complete clot has broken free, the leg ultrasound may be normal even when a pulmonary embolism is present.

    Sometimes direct angiography of the pulmonary arteries may be performed. Catheters are placed into the pulmonary artery, and a dye is injected. This test must be performed by a specially trained radiologist or cardiologist.

    The treatment for pulmonary embolus is anticoagulation using either heparin or enoxaparin (Lovenox) initially, and then transitioning to warfarin (Coumadin) for long-term treatment. The usual treatment course for anticoagulation for a pulmonary embolus is 3 to 6 months.

    The lungs and heart can stop working if there is a large enough clot load. Thrombolytic, or clot busting, therapy may be considered in addition to the basics of oxygen, intravenous fluids, and medicines to support blood pressure. In rare and extreme cases, lytic agents may be directly injected into the area of clot.

    Pulmonary embolus should always be considered a life-threatening illness.

    For additional information, please read the Pulmonary Embolism article.

    The heart

    Angina and heart attack (myocardial infarction)

    The worry for patients and health care professionals is that any chest pain may originate from the heart. Angina is the term given to pain that occurs because the coronary arteries (blood vessels to the heart muscle) narrow and decrease the amount of oxygen that can be delivered to the heart itself. This can cause the classic symptoms of chest pressure or tightness with radiation to the arm or neck associated with shortness of breath and sweating.

    Unfortunately, many people don't present with classic symptoms, and the pain may be difficult to describe -- or in some people may not even be present. Instead of angina or typical chest pressure, their anginal equivalent (symptom they get instead of chest pain) may be indigestion, shortness of breath, or weakness and malaise. Women and the elderly are at higher risk for having an atypical presentation of heart pain.

    The narrowing of blood vessels or atherosclerosis is due to plaque buildup. Plaque is a soft amalgam of cholesterol and calcium that forms along the inside lining of the blood vessel and gradually decreases the diameter of the blood vessel and restricts the flow of blood. If the plaque ruptures, it can cause a blood clot to form and completely block the vessel.

    When a coronary artery completely occludes (becomes blocked), the muscle it supplies blood to is at risk of dying. This is a heart attack or myocardial infarction. In most circumstances, this pain is more intense than routine angina, but again, there are many variations in signs and symptoms.

    The diagnosis of angina is a clinical one. After the health care professional takes a careful history and assesses the potential risk factors, the diagnosis is either reasonably pursued or else it is considered not to be present. If angina is the potential diagnosis, further evaluation may include electrocardiograms (EKG or ECG) and blood tests.

    Cardiac enzymes can be measured in the bloodstream when heart muscle is irritated or damaged. Common enzymes to measure include troponin, CPK, and myoglobin. Unfortunately, it takes time for these chemicals to be released into the bloodstream and turn a blood test positive. Interpretation of the test results may require that blood be taken more than once over a period of observation to confirm that they are normal. If these chemicals are not present, it may be reasonable to perform imaging studies of the heart in a variety of ways depending on the patient's past history:

    • Stress tests in which the electrocardiogram is monitored during exercise. This can be done by actual exercise or by chemically stimulating the heart with injected medications. The stress test may be performed in association with an echocardiogram.
    • Echocardiography (ultrasound evaluation) of heart structure and function
    • Computerized cardiac angiography in which the CT scan can image the heart's blood vessels
    • Coronary catheterization, in which tubes are floated through a major blood vessel into the heart and dye is used to directly image heart blood vessels looking for blockage

    The purpose of making the diagnosis of angina is to restore normal blood supply to heart muscle before a heart attack occurs and permanent muscle damage results. Aside from minimizing risk factors by controlling blood pressure, cholesterol, and diabetes, and stopping smoking, medications can be used to make the heart beat more efficiently (for example, beta blockers), to dilate blood vessels (for example, nitroglycerin) and to make blood less likely to clot (aspirin).

    An acute heart attack (myocardial infarction) is a true emergency, since complete blockage of blood supply will cause part of the heart muscle to die and be replaced by scar tissue. This lessens the ability of the heart to pump blood to meet the body's needs. As well, injured heart muscle is irritable and can cause electrical disturbances like ventricular fibrillation, a condition in which the heart jiggles like Jello and cannot beat in a coordinated fashion. This is the cause of sudden death in heart attack. The cause of an acute heart attack is the rupture of a cholesterol plaque in a coronary artery. This causes a blood clot to form and occlude the artery.

    The treatment for heart attack is emergent restoration of blood supply. Two options include use of a drug like TPA or TNK to dissolve the blood clot (thrombolytic therapy) or emergency heart catheterization and using a balloon to open up the blocked area (angioplasty) and keeping it open with a mesh cage called a stent. Emergent angioplasty is preferred if the patient lives close to a hospital with that capability but many people do not. Staged treated with intial thombolytic therapy followed by angioplasty is also reasonable.

    Coronary artery bypass surgery is considered when there is diffuse artery disease that is not amenable to angioplasty and stenting.

    For more, please read the Angina and Heart Attack articles.

    What are the causes of chest pain?

    Pain can be caused by almost every structure in the chest. Different organs can produce different types of pain but unfortunately the pain is not specific to each cause. Each of the following causes is explained in detail in this article:

    • Broken or bruised ribs
    • Pleuritis or pleurisy
    • Pneumothorax
    • Shingles
    • Pneumonia
    • Pulmonary embolus
    • Angina
    • Heart attack (myocardial infarction)
    • Pericarditis
    • The aorta and aortic dissection
    • The esophagus and reflux esophagitis
    • Referred abdominal pain

    How is chest pain diagnosed?

    The key to diagnosis remains the patient history. Learning about the nature of the pain will give the health care professional direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the doctor assess the probability of each potential cause and make decisions about what potential diagnoses should be considered and which should be discarded.

    Differential diagnosis is a thought process that health care professionals use to consider and then eliminate potential causes for an illness. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved. As well, the patient's response to therapy can expand or narrow the differential diagnosis list. In patients with chest pain, many potential conditions may be present, and the health care professional will want to first consider those that are life-threatening. Using laboratory and X-ray tests may not be necessary to exclude potentially lethal diseases like heart attack, pulmonary embolus, or aortic dissection when clinical skill and judgment may be all that is needed.

    The patient may be asked a variety of questions to help the health care professional understand the quality and quantity of the pain. Patients use different words to describe pain, and it is important that the health care professional get an accurate impression of the situation. The questions may also be asked in different ways.

    Questions the doctor may ask about chest pain

    • When did the pain start?
    • What is the quality of the pain?
    • How long does the pain last?
    • Does the pain come and go?
    • What makes the pain better?
    • What makes the pain worse?
    • Does the pain radiate somewhere (move to another area of the body)?
    • Has there been any preceding illness?
    • Has there been any trauma?
    • Have there been similar episodes of pain in the past?
    • Is the pain different than that of a previous condition that has been experienced, or is it similar?
    Questions about the associated symptoms
    • Is there shortness of breath?
    • Fever or chills?
    • Cough?
    • Nausea or vomiting?
    • Sweating?
    Questions about risk factors for disease Risk factors for atherosclerotic heart disease (also known as coronary artery disease)
    • Smoking
    • High blood pressure
    • High cholesterol
    • Diabetes
    • Family history
    Risk factors for pulmonary embolus (blood clot to the lung)
    • Prolonged inactivity such as bed rest, long car or airplane trips
    • Recent surgery
    • Fractures
    • Birth control pill use (particularly if the patient smokes cigarettes)
    • Cancer
    Risk factors for aortic dissection
    • High blood pressure
    • Marfan syndrome
    • Ehlers-Danlos syndrome
    • Polycystic kidney disease
    • Cocaine use
    • Pregnancy

    Physical examination helps refine the differential diagnosis. While chest pain may be the initial complaint, often the whole body needs to be examined. Example components of the physical exam may include:

    Vital signs
    • Blood pressure (BP), pulse rate (PR), respiratory rate (RR), temperature, and
    • Oxygen saturation (O2 sat) which measures the amount of oxygen being carried by red blood cells in the bloodstream.
    Head and neck
    • Looking for neck vein distension or bulging
    • Listening over the carotid arteries for bruits (abnormal sounds) or murmurs that begin in the heart and radiate to the neck
    Chest wall
    • Palpate for rib or muscle tenderness
    • Look for rashes including the rash of shingles (zoster)
    Lungs
    • Listen for abnormal lung sounds like crackle or wheeze or decreased air entry with inspiration
    • Listen for rubs (a friction sound made by two rough surfaces rubbing against each other) that may be heard in pleurisy
    Heart
    • Listen for abnormal heart sounds, murmurs or rubs (which may be heard with inflammation of the heart lining, called pericarditis)
    • Listen for muffled or indistinct heart tones that can be associated with excess fluid in the pericardium, the sac that surrounds the heart
    Abdomen
    • Palpate for tenderness or masses
    • Listen for bruits over the aorta
    Extremities
    • Feel for pulses

    What is the philosophy of the approach to chest pain diagnosis?

    While there are many causes of chest pain, the health care professional will keep those that are potentially lethal front and center in their evaluation of a patient presenting with chest pain. The big three -- heart attack (myocardial infarction), pulmonary embolus, and aortic dissection -- should be considered briefly with every patient, although most of the time their presence can be discarded based upon clinical judgment.

    History and physical examination are key in deciding which path to follow in the diagnosis of chest pain. For somebody who fell and hurt their ribs, that path is well marked. For an elderly person who presents with vague discomfort and risk factors for an illness, significant testing may need to be done to prove that a given diagnosis is not correct.

    The concept of ruling out a diagnosis is difficult for some patients to understand. Instead of proving what is happening, the health care professional is sometimes charged with proving that a life-threatening diagnosis is not present. "Proving what isn't" takes time and technology. A combination of blood tests and imaging studies may take hours to confirm or discard a potential diagnosis.

    These tests often are done emergently, and treatment may be started even without a firm diagnosis. For example, if a patient presents with chest pain that the health care professional believes may be angina (pain caused because of narrowing of coronary arteries that supply blood to the heart muscle), then the initial medications to protect the heart will be started at the same time the diagnostic tests are done. Because some heart tests will take hours to complete, the philosophy for this approach is that heart muscle should not be placed at risk while waiting for a diagnosis. If the heart proves to be normal, then the medications are stopped, and the patient can be reassured that heart disease has been ruled out. Other diagnoses are also considered at the same time the heart tests are being performed, but ruling out one diagnosis does not confirm another.

    What is the diagnosis and treatment for chest pain?

    Treatment for chest pain depends upon the cause. Many times, situations require that the evaluation, diagnosis, and treatment occur at the same time, but when there is opportunity, the sequence of history, physical examination, testing, diagnosis, and treatment should be followed. A synopsis of common chest pain presentations and treatments follows.

    The chest wall

    Broken or bruised ribs

    Bruised or broken ribs are common injuries. Symptoms of broken or bruised ribs include:

    • tenderness over the site of injury;
    • a broken rib may be palpated (the health care professional can feel the rib fracture move when pressed);
    • the pain tends to be pleuritic (it hurts to take a deep breath and can be associated with shortness of breath); and
    • because the surrounding muscles go into spasm, there is pain with any movement of the trunk.

    The health care professional will want to listen to the chest to make certain that there is no associated lung damage. Sometimes, subcutaneous emphysema can be felt, a sensation of feeling rice krispies when air leaks into the skin. A chest X-ray may be done to look for a pneumothorax (collapsed lung) or pulmonary contusion (a bruised lung). Special X-rays looking for rib fracture are not needed since the presence or absence of a fracture will not alter the treatment plan or recuperation time. Special attention will be given to the upper abdomen since the ribs protect the spleen and liver, to make certain there are no associated injuries.

    The major complication of rib injuries is pneumonia. The lungs work like bellows. Normally, when one takes a breath, the ribs swing out and the diaphragm moves down, sucking air into the lungs. Because it hurts to take a deep breath, this mechanism is altered, and the lung underlying the injury may not fully expand because the patient cannot tolerate the pain. The result is stagnant air and lung tissue that does not fully expand, causing a potential breeding ground for lung infection (pneumonia).

    Rib injury treatment may include:

    • Pain control with anti-inflammatory medications like ibuprofen and narcotic pain medications to allow deep breaths to occur.
    • Application ice to the affected area and periodically deep take breaths. An incentive spirometer may be provided to help visualize the amount of breath to take.
    • Ribs are no longer wrapped or taped to help with comfort. Wrapping ribs decreases the ability of the lung underneath the injured area to fully expand and increases the risk of developing pneumonia.
    • Whether broken or bruised, rib injuries take 3 to 6 weeks to heal.

    Costochondritis

    On occasion, the joints and cartilage where ribs attach to the sternum (breastbone) may become inflamed. The pain tends to hurt with a deep breath, and there is tenderness that can be felt when the sides of the sternum are palpated or touched. If there is swelling and inflammation associated with the tenderness, it is known as Tietze's syndrome.

    The most frequent cause for costochondritis is idiopathic or unknown, meaning there is no explanation for the pain. Other causes include trauma to the area, infection (often viral), and fibromyalgia.

    Though painful, the symptoms resolve with symptomatic care, including ice and/or warm compresses and anti-inflammatory medications (for example, ibuprofen). As with other chest wall pain, recovery may take weeks. Taking deep breaths to prevent the risk of pneumonia is very important.

    For more, please read the Costochondritis and Tietze Syndrome article.

    Pleuritis or pleurisy

    The lung slides along the chest wall when a deep breath is taken. Both surfaces have a thin lining called the pleura to allow this sliding to occur. On occasion, viral infections can cause the pleura to become inflamed, and then instead of sliding smoothly, the two linings scrape against each other, causing pain. This pain hurts with a deep breath and is described as pleuritic.

    Viral infections are a common cause of pleurisy, although there are many other infectious causes including tuberculosis. Other diseases that can inflame the pleura include:

    • collagen vascular diseases like sarcoidosis and systemic lupus erythematosus,
    • cancer,
    • kidney failure,
    • rheumatoid arthritis,
    • complications of radiation therapy,
    • complications of chemotherapy, and
    • complications of surgery.

    The physical exam may be relatively unremarkable, but a friction rub may be heard over the site of pleural inflammation. If a significant amount of fluid leaks from the inflammation, the space between the lung and the chest wall (the pleural space) can fill with fluid, known as an effusion. When listening with a stethoscope, there may be decreased air entry in the lung. As well, percussion, in which the health care professional taps on the chest wall like a drum, may reveal dullness of one side compared to the other.

    Often a chest X-ray is done to assess the lung tissue and the presence or absence of fluid in the pleural cavity.

    Pleurisy is usually treated with an anti-inflammatory medication. This will often treat an effusion as well. If the effusion is large and is causing shortness of breath, thoracentesis (thora=chest + centesis=withdrawing fluid) may be done. For thoracentesis, a needle is placed in the pleural space and the fluid withdrawn. Aside from making the patient feel better, the fluid may be sent for laboratory analysis to help with diagnosis. For more, please read the Pleurisy article.

    Pneumothorax

    The lung is held against the chest wall by negative pressure in the pleura. If this seal is broken the lung can shrink down, or collapse (known as pneumothorax). This may be associated with a rib injury or it may occur spontaneously. Though commonly seen in those who are tall and thin, other risk factors for a collapsed lung include emphysema or asthma. Small blebs or weak spots in the lung can break and cause the air leak that breaks the negative pressure seal.

    The common presentation is the acute onset of sharp chest pain associated with shortness of breath, with no preceding illness or warning. Physical examination reveals decreased air entry on the affected side. Percussion may show increased resonance with tapping. Chest X-ray confirms the diagnosis.

    Treatment is dependent upon what percentage of the lung is collapsed. If it is a small amount and vital signs are stable with a normal O2 sat, the pneumothorax may be allowed to expand on its own with close monitoring. If there is a larger collapse, a chest tube may have to be placed into the pleural space through the chest wall to suck the air out and re-establish the negative pressure. On occasion, thoracoscopy (thoraco=chest +scopy=see with a camera) may be considered to identify the bleb and to staple it shut. For more, please read the Pneumothorax article.

    Tension pneumothorax is a relatively rare life-threatening event often associated with trauma. Instead of a simple collapse of the lung, a scenario can exist in which the damaged lung tissue acts as a one way valve allowing air to enter into the pleural space but not allowing it to escape. The pneumothorax size increases with each breath and can prevent blood from returning to the heart and allowing the heart to pump it back to the body. If not corrected quickly with placement of a chest tube, it can be fatal.

    Shingles

    The rash of shingles is caused by the varicella zoster virus, the same one that causes chickenpox. Once the virus enters the body, it hibernates in the nerve roots of the spinal column, only to emerge sometime in the future. The rash is diagnostic as it follows the nerve root as it leaves the back, and circles to the front of the chest, but not crossing the midline.

    Once the rash appears, the diagnosis is relatively easy for the health care professional. Unfortunately, the pain of shingles may begin a few days before the rash emerges and can be confusing to both patient and health care professional, since the pain and burning may seem out of proportion to the findings on physical examination.

    The treatment for shingles includes antiviral medications like acyclovir (Zovirax) along with pain control medication. Since it is the nerve that has become inflamed, the pain can be quite severe. Some patients may develop postherpetic neuralgia, or chronic pain from the inflamed nerve, which may persist long after the infection has cleared. A variety of pain control strategies are available from medication to pain stimulators to surgery. For more, please read the Shingles article.

    The lungs

    Pneumonia

    An infection of the lung is called pneumonia, in which inflammation can cause fluid buildup within a segment of the lung tissue, decreasing its ability to transfer oxygen from air to the bloodstream.

    Pneumonia presents with the typical symptoms of an infection:

    • fever,
    • chills, and
    • malaise.

    There may also be:

    • cough,
    • shortness of breath, and
    • sputum production (coughing up mucus).

    The chest pain is pleuritic, hurting when taking a deep breath.

    The classic presentation of a lung infection caused by the bacteria Streptococcal pneumoniae or pneumococcus, one of the most common causes of pneumonia, is acute onset of shaking chills, fever, and a cough that produces rusty brown sputum.

    Physical examination may find the patient to have abnormal vital signs consistent with an infection. The pulse rate and respiratory rate may be elevated. A fever may be present. Listening to the chest may reveal decreased air entry in the area of the infection associated with crackles and occasionally wheezing because of inflammation and narrowing of the bronchial tubes.

    A chest X-ray helps make the diagnosis, though the X-ray image sometimes lags behind the clinical findings by a day or two. Blood tests may be used to assess the severity of illness and may include a white blood cell count (markedly elevated or abnormally low counts may indicate more severe illness). Oxygen saturation measured with a probe attached to the finger is a way of assessing oxygenation of the blood and is routinely performed on patients with chest pain or shortness of breath. An arterial blood gas can exactly measure the amount of oxygen and carbon dioxide in the bloodstream to help determine the level of lung function.

    Pneumonia may be caused by viruses or bacteria. The latter are treated with antibiotics, either by mouth or in the hospital by intravenous infusion. The general health and past medical history of the patient may guide the decision as to whether inpatient or outpatient therapy is most appropriate. For more, please read the Pneumonia article.

    Pulmonary embolism

    A blood clot to the lung can be fatal and is one of the diagnoses that should always be considered when a patient presents with chest pain.

    There is a classic presentation for pulmonary embolus with the patient complaining of pleuritic chest pain (hurts to take a deep breath), shortness of breath, and coughing up blood (hemoptysis); but more commonly patients can present with more subtle complaints, and the diagnosis may be easily and unavoidably missed.

    Risk factors for pulmonary embolus include:

    • prolonged inactivity like a long trip in a car or airplane,
    • recent surgery or fracture,
    • birth control pills (especially associated with smoking),
    • cancer, and
    • pregnancy.

    Thrombophilia (thrombo=clot + philia= attraction) comprises a host of blood clotting disorders that place patients at risk for pulmonary embolus.

    The pulmonary embolus begins in veins elsewhere in the body, usually the legs, though it can occur in the pelvis, arms, or the major veins in the abdomen. When a thrombus or blood clot forms, it has the potential to break free (now called an embolus) and float downstream, returning to the heart. The embolus can continue its journey through the heart and enter into the pulmonary circulation system, eventually becoming lodged in the branches of the pulmonary artery and cutting off blood supply to part of the lung. This decreased blood flow doesn't allow enough blood to pick up oxygen in the lung, and the patient can become markedly short of breath.

    As mentioned above, the common complaints include:

    • pleuritic chest pain from the inflamed lung,
    • bloody sputum, and
    • shortness of breath.

    The patient can also have anxiety and sweat profusely. Depending upon the size of the clot, the initial presentation may be fainting (syncope) or shock in which the patient collapses, with decreased blood pressure and altered mental function.

    Depending on the severity of the embolus and the amount of lung tissue at risk, the patient may present critically ill (in extremis) with markedly abnormal vital signs, or may appear rather normal. Physical examination may not be helpful, and the diagnostic studies are done upon clinical suspicion based on history and risk factors.

    The diagnosis may be made directly with imaging of the lungs or indirectly by finding a clot elsewhere in the body. The strategy used to make a diagnosis will depend upon each individual patient's situation, but there are some general tools available.

    D-dimer is a blood test that can measure breakdown products of blood clots in the body but cannot differentiate a pulmonary embolus from a healing scar from surgery, or a bruise from falling. If this test is negative, then a pulmonary embolus can usually be excluded if the patient is in a low risk category to form clots. Cancer and pregnancy are two other situations in which the d-Dimer test is often positive even without blood clots present.

    Lungs can be imaged with a ventilation-perfusion scan or a CT scan to look for a clot. Each test has its benefits and limitations, and use of these tests is dependent upon the clinical situation. If there are technical issues so that the lungs cannot be imaged, an ultrasound of the legs may be performed to look for a thrombus; the concept is that if the symptoms are present of a pulmonary embolus and a clot is found in the leg, then the diagnosis can be inferred. However, if the complete clot has broken free, the leg ultrasound may be normal even when a pulmonary embolism is present.

    Sometimes direct angiography of the pulmonary arteries may be performed. Catheters are placed into the pulmonary artery, and a dye is injected. This test must be performed by a specially trained radiologist or cardiologist.

    The treatment for pulmonary embolus is anticoagulation using either heparin or enoxaparin (Lovenox) initially, and then transitioning to warfarin (Coumadin) for long-term treatment. The usual treatment course for anticoagulation for a pulmonary embolus is 3 to 6 months.

    The lungs and heart can stop working if there is a large enough clot load. Thrombolytic, or clot busting, therapy may be considered in addition to the basics of oxygen, intravenous fluids, and medicines to support blood pressure. In rare and extreme cases, lytic agents may be directly injected into the area of clot.

    Pulmonary embolus should always be considered a life-threatening illness.

    For additional information, please read the Pulmonary Embolism article.

    The heart

    Angina and heart attack (myocardial infarction)

    The worry for patients and health care professionals is that any chest pain may originate from the heart. Angina is the term given to pain that occurs because the coronary arteries (blood vessels to the heart muscle) narrow and decrease the amount of oxygen that can be delivered to the heart itself. This can cause the classic symptoms of chest pressure or tightness with radiation to the arm or neck associated with shortness of breath and sweating.

    Unfortunately, many people don't present with classic symptoms, and the pain may be difficult to describe -- or in some people may not even be present. Instead of angina or typical chest pressure, their anginal equivalent (symptom they get instead of chest pain) may be indigestion, shortness of breath, or weakness and malaise. Women and the elderly are at higher risk for having an atypical presentation of heart pain.

    The narrowing of blood vessels or atherosclerosis is due to plaque buildup. Plaque is a soft amalgam of cholesterol and calcium that forms along the inside lining of the blood vessel and gradually decreases the diameter of the blood vessel and restricts the flow of blood. If the plaque ruptures, it can cause a blood clot to form and completely block the vessel.

    When a coronary artery completely occludes (becomes blocked), the muscle it supplies blood to is at risk of dying. This is a heart attack or myocardial infarction. In most circumstances, this pain is more intense than routine angina, but again, there are many variations in signs and symptoms.

    The diagnosis of angina is a clinical one. After the health care professional takes a careful history and assesses the potential risk factors, the diagnosis is either reasonably pursued or else it is considered not to be present. If angina is the potential diagnosis, further evaluation may include electrocardiograms (EKG or ECG) and blood tests.

    Cardiac enzymes can be measured in the bloodstream when heart muscle is irritated or damaged. Common enzymes to measure include troponin, CPK, and myoglobin. Unfortunately, it takes time for these chemicals to be released into the bloodstream and turn a blood test positive. Interpretation of the test results may require that blood be taken more than once over a period of observation to confirm that they are normal. If these chemicals are not present, it may be reasonable to perform imaging studies of the heart in a variety of ways depending on the patient's past history:

    • Stress tests in which the electrocardiogram is monitored during exercise. This can be done by actual exercise or by chemically stimulating the heart with injected medications. The stress test may be performed in association with an echocardiogram.
    • Echocardiography (ultrasound evaluation) of heart structure and function
    • Computerized cardiac angiography in which the CT scan can image the heart's blood vessels
    • Coronary catheterization, in which tubes are floated through a major blood vessel into the heart and dye is used to directly image heart blood vessels looking for blockage

    The purpose of making the diagnosis of angina is to restore normal blood supply to heart muscle before a heart attack occurs and permanent muscle damage results. Aside from minimizing risk factors by controlling blood pressure, cholesterol, and diabetes, and stopping smoking, medications can be used to make the heart beat more efficiently (for example, beta blockers), to dilate blood vessels (for example, nitroglycerin) and to make blood less likely to clot (aspirin).

    An acute heart attack (myocardial infarction) is a true emergency, since complete blockage of blood supply will cause part of the heart muscle to die and be replaced by scar tissue. This lessens the ability of the heart to pump blood to meet the body's needs. As well, injured heart muscle is irritable and can cause electrical disturbances like ventricular fibrillation, a condition in which the heart jiggles like Jello and cannot beat in a coordinated fashion. This is the cause of sudden death in heart attack. The cause of an acute heart attack is the rupture of a cholesterol plaque in a coronary artery. This causes a blood clot to form and occlude the artery.

    The treatment for heart attack is emergent restoration of blood supply. Two options include use of a drug like TPA or TNK to dissolve the blood clot (thrombolytic therapy) or emergency heart catheterization and using a balloon to open up the blocked area (angioplasty) and keeping it open with a mesh cage called a stent. Emergent angioplasty is preferred if the patient lives close to a hospital with that capability but many people do not. Staged treated with intial thombolytic therapy followed by angioplasty is also reasonable.

    Coronary artery bypass surgery is considered when there is diffuse artery disease that is not amenable to angioplasty and stenting.

    For more, please read the Angina and Heart Attack articles.

    Source: http://www.rxlist.com

    The key to diagnosis remains the patient history. Learning about the nature of the pain will give the health care professional direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the doctor assess the probability of each potential cause and make decisions about what potential diagnoses should be considered and which should be discarded.

    Differential diagnosis is a thought process that health care professionals use to consider and then eliminate potential causes for an illness. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved. As well, the patient's response to therapy can expand or narrow the differential diagnosis list. In patients with chest pain, many potential conditions may be present, and the health care professional will want to first consider those that are life-threatening. Using laboratory and X-ray tests may not be necessary to exclude potentially lethal diseases like heart attack, pulmonary embolus, or aortic dissection when clinical skill and judgment may be all that is needed.

    The patient may be asked a variety of questions to help the health care professional understand the quality and quantity of the pain. Patients use different words to describe pain, and it is important that the health care professional get an accurate impression of the situation. The questions may also be asked in different ways.

    Source: http://www.rxlist.com

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