This chapter is a collection of most important causes of chest pain, with its important corresponding clinical features and diagnostic findings, it is a repition for the topics disscused in its place, so go through through this only if you have time.
Watch 👉 Chest Pain and Dyspnea
- Video
| Causes | Characteristic clinical features | Diagnostic findings |
|---|---|---|
| STEMI | 🔷 Heavy, dull, pressure/squeezing sensation | |
| 🔷 Substernal pain with radiation to left shoulder | ||
| 🔷 Nausea, vomiting | ||
| 🔷 Diaphoresis, anxiety | ||
| 🔷 Dizziness, lightheadedness, syncope | ||
| 🔷 Pain may improve with nitroglycerin. | 🔷 Labs ⇒ ↑ Troponin | |
| 🔷 ECG ⇒ ST-segment elevation/depression, T-wave inversions, Q waves | ||
| 🔷 TTE ⇒ hypokinesis, regional wall motion abnormalities | ||
| NSTEMI/UA | 🔷 Same as STEMI | 🔷 Labs ⇒ Increased or normal troponin |
| 🔷 ECG ⇒ nonspecific changes, including T-wave inversions, ST-depressions | ||
| 🔷 TTE ⇒ Regional wall motion abnormalities may be present. | ||
| Aortic dissection | 🔷 Sudden onset of severe, sharp tearing chest or abdominal pain that radiates to the back | |
| 🔷 Hypertension or hypotension | ||
| 🔷 Asymmetrical blood pressure, pulse deficit | ||
| 🔷 New diastolic murmur | ||
| 🔷 Symptoms of myocardial ischemia | ||
| 🔷 Syncope, neurological symptoms | 🔷 Labs ⇒ Elevated D-dimer | |
| 🔷 ECG ⇒ nonspecific ST-segment changes | ||
| 🔷 CXR ⇒ widening of the aorta | ||
| 🔷 CTA chest, abdomen, and pelvis ⇒ intimal flap with false lumen | ||
| 🔷 TEE ⇒ proximal aortic dissection, tamponade, aortic regurgitation | ||
| Cardiac tamponade | 🔷 Tachypnea, dyspnea | |
| 🔷 Tachycardia | ||
| 🔷 Pulsus paradoxus | ||
| 🔷 Cardiogenic shock | ||
| 🔷 Beck triad ⇒ hypotension, JVD, muffled heart sounds | 🔷 ECG ⇒ low voltage, electrical alternans | |
| 🔷 CXR ⇒ enlarged cardiac silhouette | ||
| 🔷 TTE ⇒ circumferential fluid layer, collapsible chambers , high EF, dilated IVC |
🔸 Inspiration ⇒ *Both ventricular and atrial septa move sharply to the left*.
🔸 Expiration ⇒ *Both ventricular and atrial septa move sharply to the right*. |
| Pericarditis | 🔷 Sharp, pleuritic, retrosternal chest pain 🔷 Exacerbated by lying down; improved by leaning forward 🔷 Not relieved with nitrates 🔷 High-pitched pericardial friction rub | 🔷 Labs ⇒ ↑ ESR, ↑ CRP, leukocytosis, ↑ troponin 🔷 ECG ⇒ diffuse ST-elevations without reciprocal ST-depressions, PR-segment depression, or T-wave inversions 🔷 CXR ⇒ normal 🔷 TTE ⇒ pericardial effusion may be present. | | Heart failure exacerbation | 🔷 Chest pressure 🔷 Cough, dyspnea 🔷 Hypoxemia 🔷 Crackles, JVD, peripheral edema | 🔷 Clinical diagnosis 🔷 Labs ⇒ ↑ BNP, ↑ troponin , abnormal BMP 🔷 CXR ⇒ diffuse opacities, Kerley B lines 🔷 TTE ⇒ global or focal wall abnormalities, systolic and/or diastolic dysfunction, decreased LVEF | | Takotsubo cardiomyopathy | 🔷 History of a recent stressful event 🔷 Retrosternal chest pain, dyspnea, heavy, dull, pressure/squeezing sensation 🔷 Hypotension, cardiogenic shock 🔷 Most common in older women | 🔷 Labs ⇒ ↑ Troponin, ↑ BNP 🔷 ECG ⇒ ST-elevations, T-wave inversions 🔷 TTE ⇒ decreased LVEF, regional wall motion abnormalities , apical ballooning 🔷 cMRI ⇒ myocardial edema, regional wall motion abnormalities 🔷 Coronary angiography ⇒ no acute coronary stenosis or occlusion | | Thoracic aortic aneurysm | 🔷 Feeling of pressure in the chest 🔷 Thoracic back pain 🔷 Features of mediastinal compression or obstruction (e.g., difficulty swallowing, hoarseness) 🔷 If ruptured ⇒ severe chest pain, possible loss of consciousness | 🔷 Chest x-ray ⇒ abnormal aortic contour, widened mediastinum, tracheal deviation 🔷 CTA chest ⇒ dilation of the aorta, possible mural thrombus, dissection, perforation, or rupture |
| Causes | Characteristic clinical features | Diagnostic findings |
|---|---|---|
| Pulmonary embolism | 🔷 Pleuritic chest pain | |
| 🔷 Acute onset dyspnea, hypoxemia | ||
| 🔷 Cough, hemoptysis | ||
| 🔷 Unilateral leg swelling or history of DVT | ||
| 🔷 Hypotension, shock (if massive PE) | 🔷 Labs |
🔸 Elevated D-dimer
🔸 ↑ Troponin, BNP
🔷 ECG ⇒ normal sinus rhythm (most common), sinus tachycardia, signs of right ventricular strain 🔷 CTA chest (pulmonary embolism protocol) ⇒ pulmonary artery filling defect 🔷 V/Q scan ⇒ perfusion-ventilation mismatch 🔷 TTE ⇒ right ventricle hypokinesis with normal apical movement 🔷 Clinical calculators 🔸 Wells score 🔸 PERC rule (Pulmonary embolism rule-out criteria) 🔸 PESI (Pulmonary embolism severity index score) | | Tension pneumothorax | 🔷 Severe, sharp chest pain 🔷 Dyspnea, hypoxemia 🔷 History of trauma 🔷 Hyperresonance on percussion, decreased breath sounds, tracheal deviation 🔷 Tachycardia, hypotension | 🔷 Clinical diagnosis 🔷 CXR ⇒ absent lung markings, tracheal deviation, pneumomediastinum | | Pneumonia | 🔷 Fever, chills 🔷 Cough, dyspnea 🔷 Hypoxemia 🔷 Crackles, egophony | 🔷 Labs ⇒ leukocytosis, ↑ ESR/CRP, ↑ procalcitonin 🔷 Positive sputum culture 🔷 CXR ⇒ consolidation, pleural effusion 🔷 CT chest ⇒ hyperdense consolidation | | Spontaneous pneumothorax | 🔷 Sudden, sharp unilateral chest pain 🔷 Acute dyspnea 🔷 Hypoxemia 🔷 Hyperresonance on percussion, decreased breath sounds on the affected side 🔷 Crepitus 🔷 History of lung disease or trauma | 🔷 Inspiratory CXR ⇒ increased lucency, displaced lung markings, subcutaneous emphysema 🔷 POCUS ⇒ absent lung sliding on eFAST or lung POCUS | | Asthma exacerbation | 🔷 Dyspnea, cough 🔷 Tachycardia 🔷 Tachypnea, hypoxemia 🔷 Diffuse wheezing 🔷 Decreased or absent breath sounds 🔷 Increased work of breathing | 🔷 Peak expiratory flow ⇒ decreased from predicted or personal best 🔷 ABG ⇒ ↓ pH, ↑ PaCO2, ↓ PaO2 (respiratory acidosis) | | COPD exacerbation | 🔷 Dyspnea, cough 🔷 Purulent sputum 🔷 Tachypnea, hypoxemia 🔷 Diffuse wheezing, decreased breath sounds 🔷 Increased work of breathing 🔷 Signs of imminent respiratory arrest ⇒ confusion, absent breath sounds, bradycardia | 🔷 ABG ⇒ ↓ pH, ↑ PaCO2, ↓ PaO2 (respiratory acidosis) 🔷 Labs ⇒ ↑ CRP,↑ Procalcitonin (if underlying bacterial infection) 🔷 CXR ⇒ hyperinflated lungs; signs of pneumonia, pneumothorax, and/or pleural effusion may be present | | Pleural effusion | 🔷 Unilateral, pleuritic chest pain 🔷 Dyspnea 🔷 Dry, nonproductive cough 🔷 Dullness to percussion, decreased breath sounds, decreased tactile fremitus 🔷 Pleural friction rub | 🔷 CXR ⇒ homogeneous opacity with blunting of the costophrenic angle 🔷 Lung POCUS ⇒ hypoechoic space between the parietal and visceral pleura |
| Causes | Characteristic clinical features | Diagnostic findings |
|---|---|---|
| Esophageal perforation | 🔷 Retrosternal chest pain, neck pain, epigastric pain with radiation to the back | |
| 🔷 Dyspnea, tachypnea, tachycardia | ||
| 🔷 Dysphagia | ||
| 🔷 Signs of sepsis | ||
| 🔷 Mackler triad (chest pain, vomiting, subcutaneous emphysema) | ||
| 🔷 Mediastinal crepitus | ||
| 🔷 History of recent endoscopy or severe emesis (Boerhaave syndrome) | 🔷 CXR, upright AXR ⇒ mediastinal air and/or subdiaphragmatic air, pleural effusion, pneumothorax | |
| 🔷 Lateral neck x-ray ⇒ subcutaneous emphysema | ||
| 🔷 Contrast esophagography (gold standard) ⇒ contrast leak | ||
| 🔷 CT chest (with oral contrast) ⇒ extraluminal air, esophageal thickening | ||
| GERD and erosive esophagitis | 🔷 Postprandial substernal chest pain, pressure, burning, reflux symptoms | |
| 🔷 Aggravated by lying in the supine position and certain foods (e.g., coffee, spices) | ||
| 🔷 Epigastric tenderness | 🔷 Clinical diagnosis | |
| 🔷 Definitive diagnosis requires EGD and/or 24-hour esophageal pH monitoring | ||
| Gastritis | 🔷 Dyspepsia | |
| 🔷 Postprandial fullness | ||
| 🔷 Epigastric tenderness | 🔷 Clinical diagnosis | |
| 🔷 Follow the test-and-treat strategy for Helicobacter pylori in most patients with upper GI symptoms. | ||
| 🔷 Consider EGD with biopsies in selected cases (e.g., patients aged > 60 years). | ||
| Peptic ulcer disease | 🔷 Epigastric pain | |
| 🔷 Duodenal ulcer ⇒ pain relieved with food, weight gain | ||
| 🔷 Gastric ulcer ⇒ pain exacerbated by food, weight loss | ||
| 🔷 Signs of GI bleed | ||
| 🔷 History of frequent NSAID use | 🔷 Labs ⇒ ↓ Hb, ↓ Hct, ↓ RBC count, positive FOBT or melena (in patients with a bleeding ulcer) | |
| 🔷 Urea breath test for H. pylori ⇒ positive in most cases of PUD | ||
| 🔷 EGD ⇒ mucosal erosions and/or ulcers | ||
| Acute pancreatitis | 🔷 Severe epigastric pain that radiates to the back | |
| 🔷 Nausea, vomiting | ||
| 🔷 Epigastric tenderness, guarding, rigidity | ||
| 🔷 Hypoactive bowel sounds | ||
| 🔷 History of gallstones or alcohol use | 🔷 Labs ⇒ ↑ Lipase, ↑ amylase | |
| 🔷 Abdominal ultrasound ⇒ pancreatic edema, peripancreatic fluid, gallstones | ||
| 🔷 Abdominal CT with IV contrast ⇒ pancreatic edema, peripancreatic fat stranding, gallstones | ||
| Esophageal hypermotility disorders | 🔷 Episodic retrosternal chest pain | |
| 🔷 Intermittent dysphagia, globus sensation | ||
| 🔷 Reflux symptoms | ||
| 🔷 Symptoms aggravated by stress and/or hot and cold food and drink | 🔷 Upper GI endoscopy ⇒ typically normal | |
| 🔷 Barium swallow ⇒ normal or corkscrew esophagus appearance | ||
| 🔷 Esophageal manometry ⇒ premature and/or hypertensive esophageal contractions | ||
| Mallory-Weiss syndrome | 🔷 Epigastric pain that radiates to the back | |
| 🔷 Repeated episodes of severe vomiting | ||
| 🔷 Hematemesis | ||
| 🔷 Melena, dizziness, syncope | 🔷 CBC ⇒ anemia | |
| 🔷 EGD ⇒ longitudinal mucosal tears, typically at the gastroesophageal junction |
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