Non-Pleuritic Chest Pain

A patient comes in for โ€œchest pain.โ€  We determine right off that itโ€™s “non-pleuritic,” meaning that it doesn’t feel worse every time they take a breath.  We also find out if itโ€™s continuous, or comes & goes; if it’s intermittent, how long does it last, how often does it occur? We proceed as follows:

FIRST: Rule out lethal diseases (see #1 & #2 below).  May send to ER for work-up.

1.  Make sure itโ€™s not Coronary Artery Disease (Heart Attack (M.I.) or Angina):

  • Gets worse with exertion
  • Timing: Angina lasts 1-5 min. A Heart Attack pain can be ongoing.
  • Associated symptoms along with the pain (these are important):
    • shortness of breath, nausea/vomit, cold sweat, dizzy/lightheaded
  • Coronary Artery Disease Risks (older age, smoking, hypertension, diabetes, high cholesterol, strong family history, same-day coke/meth, ? HIV)
  • If suspect this, we work it up (see Diagnosing Coronary Artery Disease)
  • BUT, if the above characteristics don’t fit, we don’t do tests “just in case”

2. Rule out ruptured Thoracic Aortic Aneurysm

  • Very sudden onset severe, continuous pain
  • โ€œSharp,โ€ โ€œtearing,โ€ โ€œrippingโ€
  • >60 y.o. w/ Cardiac Risks / younger if Marfanโ€™s syndrome (rare)
  • If suspect this, send to ER for Chest CT Scan

If none of above, we seek more common, benign causes (pain may be continuous or intermittent):

  • Abdominal Diseases **   
  • Chest Wall Pain **  —  worse with movement shoulder / torso, tender to pressing at a spot
  • Herpes Zoster  —  red splotches in a stripe from spine to breastbone
  • Breast Diseases  —  breast tissue is what’s tender to palpation
  • Anxiety **  —  symptoms of hyperventilation, context of onset, life stressors, often worse at night while in bed

**  diagnosis of exclusion (no evidence for anything else, esp. any life-threatening diseases)

See also Non-Pleuritic Chest Pain — Full Text for more in-depth explanations and discussions.

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