Chest pain in adults

Probability diagnosis

Musculoskeletal (chest wall) incl. costochondritis

Psychogenic

Angina

Serious disorders not to be missed

Cardiovascular:

• myocardial infarction/unstable angina

• aortic dissection

• pulmonary embolism/infarction

Neoplasia/cancer:

• lung cancer

• tumours of spinal cord and meninges

Infection:

• pneumonia/pleuritis (pleurisy)

• mediastinitis

• pericarditis

• myocarditis

Pneumothorax

Pitfalls (often missed)

Mitral valve prolapse

Oesophageal spasm

Gastro-oesophageal reflux

Biliary colic

Peptic ulcer

Herpes zoster

Fractured rib (e.g. cough fracture)

Spinal dysfunction

Precordial catch (‘stitch’ in side)

Rarities:

• pancreatitis

• Bornholm disease (pleurodynia)

• cocaine inhalation (can ↑ ischaemia)

• hypertrophic cardiomyopathy

Masquerades checklist

Depression (possible)

Anaemia (indirect)

Spinal dysfunction

Is the patient trying to tell me something?

Consider functional causes, especially anxiety with hyperventilation, opioid dependency.

Key history

This needs to be meticulous because of the life-threatening causes. Analyse the pain into its usual characteristics with the SOCRATES system.

   Note family history drug history, psychosocial history and past history, especially if immunocompromised (e.g. diabetes or metabolic syndrome).

Key examination

• General appearance

• Vital signs

• Peripheral circulation

• Careful examination of cardiovascular and respiratory systems

• Upper abdominal palpation

Key investigations

• Base tests available to the GP are ECG, cardiac enzymes and CXR and in most instances help confirm the diagnosis.

• Otherwise specialist investigations including imaging are confined to hospitals and cardiology centres.

Diagnostic tips

• Consider chest pain as due to a coronary syndrome until proved otherwise.

• The history remains the most important clinical factor in the diagnosis of ischaemic heart disease and other conditions.

• With angina a vital clue is the reproducibility of the symptom.