Chest pain

• Myocardial infarction (MI): typically presents with central chest pain, often described as a crushing or heavy sensation, radiating to the left arm, neck, or jaw, and associated with diaphoresis, nausea, and shortness of breath.
• Angina pectoris: similar to MI but typically triggered by exertion or stress and relieved by rest or nitroglycerin; pain is usually less severe.
• Pericarditis: sharp, pleuritic chest pain that improves when sitting up and leaning forward; may be associated with a pericardial friction rub on auscultation.
• Aortic dissection: sudden onset of tearing or ripping chest pain, often radiating to the back; may be associated with a differential blood pressure between arms.
• Heart failure: presents with chest discomfort, typically related to fluid overload and pulmonary congestion, often accompanied by dyspnoea.

• Pulmonary embolism (PE): sudden onset pleuritic chest pain, often associated with dyspnoea, tachycardia, and sometimes haemoptysis; risk factors include immobility, recent surgery, and history of DVT.
• Pneumonia: pleuritic chest pain with productive cough, fever, and dyspnoea; may have localised crackles on auscultation.
• Pneumothorax: sudden onset of unilateral pleuritic chest pain and breathlessness; hyper-resonance and decreased breath sounds on the affected side.
• Pleuritis (pleurisy): sharp, stabbing pain that worsens with inspiration or coughing; usually associated with viral infections.
• Lung cancer: persistent chest pain, often dull and localised, may be associated with cough, weight loss, or haemoptysis.

• Gastro-oesophageal reflux disease (GORD): burning retrosternal pain, often worse after meals or when lying down; may be associated with regurgitation and dysphagia.
• Peptic ulcer disease: epigastric pain that may radiate to the chest; typically relieved by antacids or food.
• Oesophageal spasm: chest pain that mimics angina, triggered by swallowing or stress, may be relieved by nitroglycerin.
• Pancreatitis: epigastric pain radiating to the back, often associated with nausea, vomiting, and a history of alcohol use or gallstones.
• Cholecystitis: right upper quadrant pain radiating to the chest, often associated with nausea and vomiting, usually following a fatty meal.

• Costochondritis: sharp, localised pain, often exacerbated by palpation of the affected area and movements.
• Rib fracture: localised, severe pain, usually following trauma; pain worsens with breathing or coughing.
• Muscle strain: diffuse chest pain, often related to recent physical activity or heavy lifting; pain may be reproduced by certain movements.
• Tietze syndrome: similar to costochondritis but with visible swelling at the costosternal, costochondral, or costovertebral junctions.

• Panic disorder: sudden onset of intense chest pain often associated with palpitations, sweating, dizziness, and a sense of impending doom.
• Anxiety: chest pain associated with persistent worry, palpitations, and hyperventilation; often chronic and diffuse.
• Somatic symptom disorder: chest pain without an identifiable physical cause, often associated with multiple other somatic complaints.
• Depression: chest pain associated with low mood, anhedonia, and fatigue; may be chronic and less severe.

The character of chest pain can provide clues to its aetiology:

• Crushing or heavy pain: suggests myocardial infarction or angina.
• Pleuritic pain: sharp, worsens with inspiration, suggests pulmonary embolism, pneumonia, or pleuritis.
• Burning pain: often retrosternal, suggests GORD.
• Sharp, stabbing pain: suggests pericarditis, costochondritis, or pneumothorax.

Onset and duration are critical in differentiating acute from chronic causes:

• Sudden onset: suggests acute coronary syndrome, pulmonary embolism, or pneumothorax.
• Gradual onset: suggests musculoskeletal or gastrointestinal causes.
• Intermittent: typically seen in angina, oesophageal spasm, or panic attacks.
• Prolonged: may indicate more chronic conditions like GORD or anxiety.

Associated symptoms can help narrow the differential diagnosis:

• Shortness of breath: suggests cardiac or respiratory causes like MI, PE, or heart failure.
• Diaphoresis: strongly suggests an acute coronary event.
• Fever: indicates infectious causes such as pneumonia or pericarditis.
• Palpitations: seen in panic attacks, arrhythmias, or thyroid dysfunction.
• Gastrointestinal symptoms: suggest GORD, peptic ulcer disease, or pancreatitis.

Relevant background history may include:

• Past medical history: previous MI, angina, GORD, or chronic lung disease may suggest recurrent or related causes.
• Drug history: use of anticoagulants, antiplatelets, or NSAIDs may suggest a risk of bleeding or peptic ulcer disease.
• Family history: cardiovascular disease, particularly MI or sudden cardiac death in first-degree relatives, may indicate a higher risk of cardiac causes.
• Social history: smoking, alcohol use, drug use (e.g., cocaine), and occupation may provide clues to aetiology.

Initial investigations for chest pain often include:

• Electrocardiogram (ECG): essential for diagnosing MI, arrhythmias, and other cardiac conditions.
• Chest X-ray: useful in detecting pneumothorax, pneumonia, or rib fractures.
• Blood tests: including cardiac enzymes (e.g., troponins) for MI, D-dimer for PE, and full blood count for infection.
• Arterial blood gas (ABG): important in cases of suspected PE or respiratory failure.

Further investigations may be indicated based on initial findings:

• CT pulmonary angiography: the gold standard for diagnosing pulmonary embolism.
• Echocardiography: used to assess cardiac function and detect pericardial effusion or valvular disease.
• Coronary angiography: indicated in patients with high suspicion of coronary artery disease or after positive non-invasive tests.
• Endoscopy: may be considered for suspected upper GI causes, such as peptic ulcer disease or oesophagitis.
• Holter monitoring: useful in detecting intermittent arrhythmias in patients with palpitations and chest pain.