Chest Pain

How we clinicians approach “Chest Pain” depends on the setting.ย  If we’re in our clinic or office, & think this may be imminently serious, we call 911.ย  Otherwise, we make our own diagnosis.ย  The following discussions overlap both scenarios, how we think in outpatient care, and in the E.R.

โ€œItโ€™s not my heart is it?โ€  Whenever a person has chest pain, thatโ€™s what theyโ€™re worried about, and we are too.  Sometimes we can tell quickly that it is or isnโ€™t; sometimes itโ€™s more complicated. “Heart” here means Coronary Artery Disease (blockage), that causes Heart Attacks (see Diagram —  Heart Anatomy).  There are other types of heart disease, but those don’t cause chest pain.  And of course there are plenty of other completely different conditions that can or do cause chest pain.

Step 1 — Determine if it may be Coronary Artery Disease  (Heart Attack, Angina)

But if we think not, we organize our thought process by whether chest pain is โ€œpleuriticโ€ or not:

2a. Pleuriticโ€ Chest Pain  (Hurts with Deep Breaths or with Coughing)

2b. Non-Pleuriticโ€ Chest Pain  (Steady Chest Pain, no change with breathing)

“Pleuriticโ€ refers to the pleura, the folded-over membrane attaching lungs to ribs (the pleura have nerve receptors for pain).  Pleuritic pain is the most important descriptor of all for us.  For example, chest pain that consistently hurts worse with coughing or breathing is never a heart attack.  Some diseases below can cause pain that is either “pleuritic” or “non-pleuritic”.

Causes of Chest Pain

zzzz Pleuritic Chest PainNon-Pleuritic Chest Pain
Pneumonia **
Pneumothorax ** (punctured lung)
Pleural Effusion ** (fluid around lung)
Pulmonary Embolism ** (clot in lung)
Pleurisy / Pleuritis (inflamed lining of lung)
Lung Cancer
Pericarditis (inflamed lining of heart)
Rib Fracture (without trauma)
Chest Wall Pain (e.g. muscle strain)
Anxiety

** = maybe imminently life-threatening
Coronary Artery Disease ** — either
xxโ€ข Angina Pectoris
xxโ€ข Myocardial Infarction ** (M.I.; heart attack)
Thoracic Aortic Aneurysm (ruptured) **
Abdominal Diseases —  especially
xxโ€ข Esophageal Reflux (GERD) (heartburn) or
xxโ€ข Dyspepsia (indigestion)
Herpes Zoster (Shingles)
Chest Wall Pain (e.g. muscle strain)
Rib Fracture (without trauma)
Breast Conditions
Anxiety

The asterisks (**) above denote possibly imminently life-threatening conditions, but the pain itself may or may not be severe.  The reverse is also true, benign conditions can cause โ€œreal bad painโ€.

The degree of Shortness of Breath is what determines if a pateint needs same-day work-up in an E.R.  We evaluate this by:

  • Respiratory Rate — Breathing 24 breaths / min. is concerning, 28 is serious
  • โ€œRetractionsโ€ — skin being sucked in with each breath, between the ribs, where the neck meets the breastbone, or the hollows above the collarbone (needs same-day diagnosis & treatment)
  • Cyanosis — if the lips / fingers / even the entire face are blue, the person likely needs to be immediately intubated, & put on a respirator (at least temporarily)
  • Oxygen Saturation (โ€œO2 Satโ€) — a sensor placed on the finger or ear lobe can estimate blood oxygen levels:  โ‰ฅ95% is fine, โ‰ค90% is bad, 91% – 94% equivocal.

FYI  —  Clinicians always abbreviate โ€œshortness of breathโ€ as โ€œSOB.โ€  We will too.  Itโ€™s one reason some providers may not want patients to read their charts, at least if unsupervised.

Of course, people in the midst of a panic attack certainly feel theyโ€™re suffocating, & often breathe very rapidly.  But they wonโ€™t have retractions, & their O2 Sat is normal.  Usually, their symptoms are worse at rest, & improve with exertion; they certainly feel like they can’t breathe, but itโ€™s not true, dangerous SOB.  A sense of needing to take a deep breath on & off, like a sigh, isnโ€™t true SOB either.  [See “true” SOB, or also our topic Shortness of Breath for a detailed discussion].

Weโ€™ll assume that the chest pain we discuss is acute (recent) & continuous.  Of all the conditions in the above Table, the only serious one which can occur on and off, intermittently, is Angina (due to Coronary Artery Disease).  With serious lung disease, if there’s chest pain present, it persists continuously until treatment or natural resolution (or death).  Pain from muscle strain or heartburn can either be continuous, or come & go.

Our topic Chest Pain is organized in 3 sections.  First we decide if it might be a symptom of Coronary Artery Disease. If the patient is in pain right now, and it could be a heart attack, we call 911, and diagnosis gets made in an ER. If we think it may be Angina, i.e. pain from blocked coronary arteries, but not occurring today, we proceed with our work-up.  If we don’t think it’s the heart, we sort through other possible causes. Again, select from below:

Step 1 — Determine if it may be Coronary Artery Disease  (Heart Attack, Angina)

But if we think not, we organize our thought process by whether chest pain is โ€œpleuriticโ€ or not:

2a. Pleuriticโ€ Chest Pain  (Hurts with Deep Breaths or with Coughing)

2b. Non-Pleuriticโ€ Chest Pain  (Steady Chest Pain, no change with breathing)



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