There is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it. The seat of it, and sense of strangling, and anxiety with which it is attended, may make it not improperly be called angina pectoris. WILLIAM HEBERDEN (1710–1801)
The presenting problem of chest pain is common yet very threatening to both patient and doctor because the underlying cause in many instances is potentially lethal, especially with chest pain of sudden onset. These patients require rapid evaluation with a 12-lead ECG. The causes of acute chest pain are summarised and presented in FIGURE 30.1.
Causes of acute chest pain
Key facts and checkpoints
Chest pain represents an acute coronary event until proved otherwise.
Immediate life-threatening causes of spontaneous chest pain are:
The main differential diagnoses of ACS include aortic dissection, pericarditis, oesophageal reflux and spasm, biliary colic and hyperventilation with anxiety and Takotsubo stress-related cardiomyopathy.
The history remains the most important clinical factor in the diagnosis of ischaemic heart disease. With angina, a vital clue is the reproducibility of the symptom.
Consider unstable angina = pre-myocardial infarction.
Unrecognised MI is roughly equally divided into atypical or silent. More common with diabetes, hypertension, elderly and females.
The diagnostic strategy model (see TABLE 30.1) can be used to analyse chest pain according to the five self-posed questions.
Table 30.1Chest pain: diagnostic strategy model ||Download (.pdf) Table 30.1 Chest pain: diagnostic strategy model
Musculoskeletal (chest wall)
Gastro-oesophageal reflux disease
Serious disorders not to be missed
Pneumothorax, esp. tension
Pitfalls (often missed)
Mitral valve prolapse
Biliary colic/acute cholecystitis
Fractured rib (e.g. cough fracture)
pancreatitis; gall bladder disease
Bornholm disease (pleurodynia)
cocaine inhalation (can ↑ ischaemia)
Seven masquerades checklist
Drugs (e.g. cocaine)
Is the patient trying to tell me something?
Consider functional causes, especially anxiety or panic with hyperventilation (e.g. Takotsubo syndrome), opioid dependency.
The commonest causes encountered in general practice are musculoskeletal or chest wall pain and psychogenic disorders. The former is a very important yet often overlooked cause and sometimes inappropriately referred to as fibrositis or neuralgia. Causes include costochondritis, muscular strains, dysfunction of the sternocostal joints and dysfunction of the lower cervical spine or upper ...