Chest pain

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ΕΤΥΜΟΛΟΓΙΑ

Angina pectoris. Derived from Greek, angina meaning strangle or choking and pectoris meaning chest.

Chest pain, or the type of chest pain termed angina pectoris, is a symptom.

Not all chest pain is related to the heart, in fact, probably a large majority is not. However, the default position usually in the patient's as well as the doctor's medico-legal interest is to instantly assume this to be the case in individual patients until features suggest otherwise. Harm, however, comes to patients whose hearts are not giving them pain if they are investigated too much, over too long a time to try to demonstrate this to exclusion.

Types of chest pain include:

  • Cardiac pain - the sort of pain associated with a myocardial infarction. Often experienced as a tight, crushing pain, described as like having a tight band around your chest, or being crushed by weights. The pain is often described being experienced in the centre of the chest.
  • Pleuritic pain is typically caused by inflammation of the pleura - the surface of the lungs and of the lining of the chest cavity. Typically the pain is a sharp, scratch-like pain, approximately localised to the area of inflammation, and exacerbated by breathing (as the outer surface of the lung and the lining of the chest cavity rub across each other).
  • Retrosternal (behind the sternum). While restrosternal pain can occur with cardiac causes, it is classically associated with oesphageal inflammation ("heartburn").
  • Musculoskeletal - typically associated with the ribs, intercostal muscles or costochondritic joints, or from (or referred from) the spine or muscles of the back.

Causes

  • Musculoskeletal – Tenderness over chest wall mimics pain experienced. Anxious person. May have coexisting IHD. Problematically the chest wall can be (rarely) tender to palpation in several of the causes below.
    • Trauma
    • Muscle cramps
    • Costochondritis
  • Angina – Central chest discomfort related to things that increase myocardial oxygen demand. Walking, physical exertion, eating. Relieved by rest/GTN.

If the pain is cardiac in nature, and returns reliably without progressing to worse events, then it is conventionally referred to as angina, as a diagnosis. The pain is poorly correlated to the severity of disease and outcome, and therefore investigation toward a final plan of treatment should be rapid. Treatment is with antianginals that may reduce cardiac workload and/or act as vasodilators.

A medical emergency. Admit. Investigate. Treat. Save.

  • Myocardial infarction(MI) - Classically described as central crushing chest pain. Radiating down left arm. Associated nausea, vomiting, pallor, sweating. Unrelated to exertion. Unrelieved by GTN. Relieved only by strong analgesia. Inconveniently also presents as vague discomfort of a burning sort, on one side of the chest with no radiation. If the patient looks ill, he probably is. Neither clinical assessment nor ECG are vary good at ruling out an MI.
  • Pulmonary embolism - Sudden onset chest pain – central or maybe pleuritic if some lung infarction and secondary pleurisy. Associated with acute dyspnoea and perhaps dizziness or circulatory compromise. Pre-existing risk factors – surgery, immobility etc.
  • Aortic dissection – Usually severe ripping inter-scapular pain. However can be very like an MI. Thrombolysis must be avoided.

Assessment

If the characteristics are consistent with a myocardial infarction admission for observation and formal exclusion by myocardial damage markers is now standard. Specific chest pain units have no advantage over normal acute inpatient assessment[1].

References