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Saturday, August 23, 2025

Chest pain


Introduction

Chest pain is discomfort felt anywhere between the base of the neck and the upper abdomen. It can be cardiac, pulmonary, gastrointestinal, musculoskeletal, or psychogenic. Its evaluation is a medical priority because some causes are immediately life-threatening.

Mechanism of Chest Pain

Pain receptors in the chest wall, pleura, pericardium, esophagus, and great vessels are activated by:

  • Ischemia (lack of blood flow).

  • Inflammation or infection.

  • Trauma or stretching.

  • Reflux of gastric acid.

  • Muscle or bone injury.

Causes of Chest Pain

1. Cardiac Causes (Most Critical)

  • Acute coronary syndrome (ACS): Angina, unstable angina, myocardial infarction.

  • Pericarditis: Inflammation of pericardium.

  • Aortic dissection: Severe tearing pain radiating to back.

  • Valvular heart disease (aortic stenosis).

2. Pulmonary Causes

  • Pulmonary embolism (PE).

  • Pneumonia, pleuritis.

  • Pneumothorax (collapsed lung).

  • Pulmonary hypertension.

3. Gastrointestinal Causes

  • Gastroesophageal reflux disease (GERD).

  • Peptic ulcer disease.

  • Esophageal spasm.

  • Gallbladder disease (biliary colic).

4. Musculoskeletal Causes

  • Costochondritis (Tietze’s syndrome).

  • Muscle strain.

  • Rib fracture.

5. Neurological/Psychological

  • Panic attacks, anxiety.

  • Herpes zoster (shingles, before rash appears).

Clinical Features

  • Cardiac (angina/MI): Central, heavy, crushing pain; radiates to arm/jaw; worsens with exertion; associated with sweating, nausea, dyspnea.

  • Pericarditis: Sharp, pleuritic, relieved by sitting forward.

  • Aortic dissection: Sudden, tearing pain radiating to back/abdomen; unequal pulses.

  • Pulmonary embolism: Sudden pleuritic pain, dyspnea, hemoptysis, tachycardia.

  • GERD: Burning retrosternal pain, worse after meals or lying down, relieved by antacids.

  • Musculoskeletal: Localized, reproducible on palpation or movement.

  • Panic attack: Chest tightness, palpitations, hyperventilation, fear of dying.

Diagnostic Approach

1. Immediate Assessment (Rule Out Life-Threatening Causes)

  • ABC (Airway, Breathing, Circulation).

  • ECG within 10 minutes (MI, arrhythmia).

  • Pulse oximetry, blood pressure.

2. History

  • Onset, location, character, radiation, duration, triggers, relieving factors.

  • Associated symptoms (dyspnea, sweating, syncope, reflux).

  • Risk factors: hypertension, diabetes, smoking, family history.

3. Examination

  • Cardiovascular: murmurs, pericardial rub, heart failure signs.

  • Respiratory: breath sounds, crackles, pleural rub.

  • GI: epigastric tenderness.

  • Musculoskeletal: chest wall tenderness.

4. Investigations

  • ECG: ST elevation/depression, arrhythmias.

  • Cardiac enzymes (troponins).

  • Chest X-ray: Pneumothorax, pneumonia, widened mediastinum.

  • CT angiography: Aortic dissection, pulmonary embolism.

  • Echocardiogram: Pericardial effusion, valve disease.

  • Endoscopy/pH monitoring: Reflux disease.

Management and Treatment

A. Cardiac Causes

1. Acute Coronary Syndrome (ACS)

  • Immediate management (“MONA”):

    • Morphine: 2–5 mg IV every 5–15 min as needed.

    • Oxygen: If SpO₂ <90%.

    • Nitrates: Nitroglycerin 0.4 mg sublingual every 5 min (max 3 doses).

    • Aspirin: 160–325 mg orally chewed immediately.

  • Antiplatelet/anticoagulants:

    • Clopidogrel 300–600 mg loading dose, then 75 mg daily.

    • Enoxaparin 1 mg/kg SC every 12 h.

  • Definitive: Percutaneous coronary intervention (PCI) or thrombolysis (Alteplase).

2. Pericarditis

  • NSAIDs: Ibuprofen 400–600 mg orally every 6–8 h.

  • Colchicine: 0.5 mg orally twice daily for 3 months.

3. Aortic Dissection

  • IV beta-blocker (Esmolol infusion or Labetalol 20 mg IV).

  • Pain control (morphine).

  • Urgent surgery for Type A dissection.

B. Pulmonary Causes

  • Pulmonary embolism:

    • Oxygen, anticoagulation.

    • Enoxaparin 1 mg/kg SC every 12 h or Apixaban 10 mg orally BID × 7 days then 5 mg BID.

  • Pneumothorax:

    • Small, stable: oxygen + observation.

    • Large/tension: needle decompression + chest tube insertion.

  • Pneumonia:

    • Amoxicillin 1 g orally three times daily × 5–7 days.

    • Severe: Ceftriaxone 1–2 g IV daily + Azithromycin 500 mg daily.

C. Gastrointestinal Causes

  • GERD:

    • Omeprazole 20–40 mg orally daily.

    • Lifestyle: avoid late meals, elevate head of bed.

  • Esophageal spasm:

    • Nitrates (isosorbide dinitrate 5–10 mg orally as needed).

    • Calcium channel blockers (Diltiazem 60 mg orally three times daily).

  • Peptic ulcer disease:

    • Omeprazole 20–40 mg orally daily.

    • Eradication therapy for H. pylori (triple therapy: PPI + Clarithromycin 500 mg BID + Amoxicillin 1 g BID × 14 days).

D. Musculoskeletal Causes

  • Costochondritis:

    • NSAIDs (Ibuprofen 400 mg TDS).

    • Heat packs, physiotherapy.

  • Rib fracture:

    • Analgesia (Paracetamol + NSAIDs ± opioids if severe).

    • Breathing exercises to prevent pneumonia.

E. Psychogenic Causes

  • Panic attack / Anxiety:

    • Reassurance, breathing techniques.

    • SSRIs (Sertraline 50–100 mg orally daily) for chronic anxiety.

    • Benzodiazepines (Lorazepam 1–2 mg orally/IV) short-term for acute severe anxiety.

Complications

  • Cardiac: Arrhythmia, heart failure, sudden death (if MI untreated).

  • Pulmonary: Hypoxia, respiratory failure.

  • GI: Bleeding ulcer, perforation.

  • Chronic pain syndrome: With musculoskeletal causes.

Prognosis

  • Depends entirely on cause.

  • Stable angina/GERD/musculoskeletal pain: Excellent with treatment.

  • MI, PE, aortic dissection: Life-threatening unless promptly treated.

  • Chronic causes (asthma, COPD, reflux): Require long-term management.

Patient Education

  • Seek urgent care for chest pain that is sudden, severe, crushing, radiating to arm/jaw, or associated with shortness of breath, sweating, or fainting.

  • Quit smoking, manage hypertension, diabetes, and cholesterol.

  • Exercise and maintain healthy weight.

  • Take prescribed heart or reflux medicines regularly.

  • Use cushions and proper posture for musculoskeletal chest pain.




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