Chest pain – Summary

Chest pain refers to pain in the thorax.

Chest pain can be classified by:

Cause (such as cardiac versus non-cardiac).

Type (such as localized versus poorly localized, or pleuritic versus non-pleuritic).

Non-specific chest pain (no cause identified) is found in around 15% of people presenting to primary care with chest pain.

Potentially life-threatening causes of chest pain include:

Cardiac causes: acute coronary syndrome (unstable angina and myocardial infarction); dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute congestive cardiac failure, and arrhythmias.

Respiratory causes: pulmonary embolus, pneumothorax or tension pneumothorax, community-acquired pneumonia, asthma, and pleural effusion.

Gastroenterological causes: acute pancreatitis, oesophageal rupture.

Cancer (for example, lung cancer).

Non-life-threatening causes of chest pain include:

Cardiac causes: stable angina.

Musculoskeletal causes: rib fracture, costochondritis, spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction), osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia and polymyalgia rheumatica.

Gastroenterological causes: peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis.

Other causes: psychogenic or non-specific chest pain, herpes zoster, Bornholm’s disorder (Coxsackie B virus infection) and precordial catch (Texidor twinge).

To determine the cause of chest pain a medical history and examination should be performed and investigations organized (based on the suspected cause).

Admission to hospital should be arranged for people with clinical features suggesting a potentially life-threatening cause such as:

Respiratory rate of more than 30 breaths per minute.

Tachycardia greater than 130 beats per minute.

Systolic blood pressure less than 90mmHg, or diastolic blood pressure less than 60mmHg (unless this is normal for them).

Oxygen saturation less than 92%, or central cyanosis (if no history of chronic hypoxia).

Altered level of consciousness.

High temperature (especially if more than 38.5°C).

Admission to hospital is also required if acute coronary syndrome (ACS) is suspected with the following features:

Current chest pain.

Signs of complications (such as pulmonary oedema).

Pain free, but have had chest pain in the last 12 hours and have an abnormal electrocardiogram (ECG) or an ECG is not available.

If hospital admission or referral to a specialist is not required, investigations should be arranged where appropriate and the underlying cause managed.

People not requiring hospital admission should be appropriately referred:

For an urgent same-day assessment, if they have suspected ACS and are pain free with chest pain in the last 12 hours and a normal electrocardiogram (ECG) and no complications (such as pulmonary oedema); or chest pain in the last 12–72 hours and no complications.

Within 2 weeks, if they have suspected ACS and are pain free with chest pain more than 72 hours ago and no complications; a suspected underlying malignancy; a lung or lobar collapse or pleural effusion (if admission is not required), for investigation and treatment.- This suggestion needs to be applied very much based on comprehensive clinical examination.

G Mohan.