Chest pain

Chest pain
Other names	Pectoralgia, stethalgia, thoracalgia, thoracodynia
Potential location of pain from a heart attack
Specialty	Emergency medicine, internal medicine, cardiology
Symptoms	Discomfort in the front of the chest [1]
Types	Cardiac, noncardiac [2]
Causes	Serious: Acute coronary syndrome (including heart attacks), pulmonary embolism, pneumothorax, pericarditis, aortic dissection, esophageal rupture [3] Common: Gastroesophageal reflux disease, psychological problems such as anxiety disorders, depression, stress etc, muscle or skeletal pain, pneumonia, shingles [3]
Diagnostic method	Medical history, physical exam, medical tests [3]
Treatment	Based on the underlying cause [1]
Medication	Aspirin, nitroglycerin [1] [4]
Prognosis	Depends on the underlying cause [3]
Frequency	~5% of ER visits [3]

Chest pain is pain or discomfort in the chest, typically the front of the chest. ^[1] It may be described as sharp, dull, pressure, heaviness or squeezing. ^[3] Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath. ^{[1] [3]} It can be divided into heart-related and non-heart-related pain. ^{[1] [2]} Pain due to insufficient blood flow to the heart is also called angina pectoris. ^[5] Those with diabetes or the elderly may have less clear symptoms. ^[3]

Serious and relatively common causes include acute coronary syndrome such as a heart attack (31%), pulmonary embolism (2%), pneumothorax, pericarditis (4%), aortic dissection (1%) and esophageal rupture. ^[3] Other common causes include gastroesophageal reflux disease (30%), muscle or skeletal pain (28%), pneumonia (2%), shingles (0.5%), pleuritis, traumatic and anxiety disorders. ^{[3] [6]} Determining the cause of chest pain is based on a person's medical history, a physical exam and other medical tests. ^[3] About 3% of heart attacks, however, are initially missed. ^[1]

Management of chest pain is based on the underlying cause. ^[1] Initial treatment often includes the medications aspirin and nitroglycerin. ^{[1] [4]} The response to treatment does not usually indicate whether the pain is heart-related. ^[1] When the cause is unclear, the person may be referred for further evaluation. ^[3]

Chest pain represents about 5% of presenting problems to the emergency room. ^[3] In the United States, about 8 million people go to the emergency department with chest pain a year. ^[1] Of these, about 60% are admitted to either the hospital or an observation unit. ^[1] The cost of emergency visits for chest pain in the United States is more than US$8 billion per year. ^[6] Chest pain accounts for about 0.5% of visits by children to the emergency department. ^[7]

Signs and symptoms

A woman clutching her chest, a common sign of a heart attack

Chest pain may present in different ways depending upon the underlying diagnosis. Chest pain may also vary from person to person based upon age, sex, weight, and other differences. ^[1] Chest pain may present as a stabbing, burning, aching, sharp, or pressure-like sensation in the chest. ^{[8] [1]} Chest pain may also radiate, or move, to several other areas of the body. This may include the neck, left or right arms, cervical spine, back, and upper abdomen. ^[9] Other associated symptoms with chest pain can include nausea, vomiting, dizziness, shortness of breath, anxiety, and sweating. ^{[8] [1]} The type, severity, duration, and associated symptoms of chest pain can help guide diagnosis and further treatment.

Differential diagnosis

Causes of chest pain range from non-serious to life-threatening. ^[10]

In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%). ^[11] Other less common causes include: pneumonia, lung cancer, and aortic aneurysms. ^[11] Psychogenic causes of chest pain can include panic attacks; however, this is a diagnosis of exclusion. ^[12]

In children, the most common causes for chest pain are musculoskeletal (76–89%), exercise-induced asthma (4–12%), gastrointestinal illness (8%), and psychogenic causes (4%). ^[13] Chest pain in children can also have congenital causes.

Cardiovascular

A blockage of coronary arteries can lead to a heart attack

• Acute coronary syndrome
  • Stable or unstable angina
  • Myocardial infarction ("heart attack"): People typically present with pressure or squeezing sensation over the chest in addition to sweating, nausea, vomiting, and weakness. ^[1] Chest pain is more commonly associated with anterior infarction because of left ventricular impairment; inferior infarction is more commonly associated with nausea, vomiting, and excessive sweating due to irritation of vagus nerve; lateral infarction is associated with left arm pain. ^[1]
• Prinzmetal's angina: Chest pain is caused by coronary vasospasm. It is more common in women younger than 50 years and has associations with tobacco, cocaine, or triptan use. People usually complain of chest pain at rest that is unrelated to stress or exertion. It is often relieved by cessation of the offending drug and the administration of nitrates or calcium channel blockers.
• Cocaine use: This condition is suspected when people with few risk factors for arteriosclerosis present with non-traumatic chest pain. Ingestion of cocaine can lead to vasoconstriction of coronary arteries, thus producing chest pain similar to heart attack. Symptoms can appear within one hour of cocaine use.
• Aortic stenosis: This condition occurs in individuals with underlying congenital bicuspid valve, aortic sclerosis, or a history of rheumatic fever. Chest pain usually happens during physical activity. Syncope is a late symptom. Signs and symptoms of heart failure may also be present. On auscultation, a loud ejection systolic murmur can be heard at the right second intercostal space with radiation to the carotid artery in the neck. Splitting of second heart sound is heard in severe stenosis.
• Hypertrophic cardiomyopathy: It is the hypertrophy of interventricular septum that causes outflow obstruction of the left ventricle. Dyspnea and chest pain commonly occur during daily activities. Syncope may also occur. On physical examination, significant findings include: loud systolic murmur and palpable triple apical impulse due to a palpable presystolic fourth heart sound.
• Aortic dissection is characterized by severe chest pain that radiates the back. It is usually associated with Marfan's syndrome and hypertension. On examination, the murmur of aortic insufficiency can be heard with unequal radial pulses. ^[14]
• Pericarditis: This condition can be the result of viral infection such as coxsackie virus and echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial infarction (Dressler syndrome). The chest pain is often pleuritic in nature (associated with respiration) which is aggravated when lying down and relieved on sitting forward, sometimes, accompanied by fever. On auscultation, pericardial friction rub can be heard.
• Cardiac tamponade: Cardiac tamponade occurs due to fluid accumulation in the pericardial space and typically presents with chest pain often accompanied by symptoms like dyspnea, hypotension, and pulsus paradoxus. Clinical signs include Beck's triad—hypotension, jugular venous distension, and muffled heart sounds. ^[15]
• Arrhythmia: Atrial fibrillation and several other arrhythmias can cause chest pain.
• Myocarditis: Myocarditis often affects young men under 45, presenting with symptoms such as chest pain, rapid heartbeat, palpitations, difficulty breathing, and early heart failure signs. Approximately one-third experience sharp, squeezing chest pain, while nonspecific symptoms like fever, fatigue, and muscle aches may also occur. Common causes range from viral infections like Coxsackie and adenovirus to bacterial, fungal, chemical exposures, and autoimmune conditions such as lupus and rheumatoid arthritis. ^[16]
• Mitral valve prolapse syndrome: Those affected are usually slim females presented with chest pain which is sharp in quality, localized at the apex, and relieved when lying down. Other symptoms include: shortness of breath, fatigue, and palpitations. On auscultation, midsystolic click followed by late systolic murmur can be heard, louder when person is in standing position.
• Aortic aneurysm: Aortic aneurysms, particularly when they rupture or dissect, cause sudden, severe chest or back pain often described as tearing or ripping. Thoracic aortic aneurysms are usually asymptomatic until they expand or rupture at which point they often have a >94% mortality rate ^[17] .

Respiratory

• Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and Bronchospasm. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. Chest pain usually happens during a strenuous activity or heavy exercise.
• Bronchitis: Bronchitis occurs due to inflammation of the bronchial tubes, often triggered by viral infections or irritants like smoke, leading to excessive mucus production and airway obstruction. Common symptoms include a productive cough, wheezing, mild chest discomfort, and fatigue. ^[18]
• Pulmonary embolism: Common signs and symptoms are shortness of breath, pleuritic chest pain, blood in sputum during cough, and lower limb swelling. Risk factors includes: recent surgery, cancer, and bedridden state. Embolus source usually comes from venous thromboembolism.
• Pneumonia: Pneumonia arises from infections that cause inflammation and fluid accumulation in the alveoli of the lungs, with bacterial pathogens like Streptococcus pneumoniae being common culprits. Clinically, it manifests as fever, persistent cough, difficulty breathing, and pleuritic chest pain that worsens with deep breaths. ^[19]
• Hemothorax: A hemothorax occurs from accumulation of blood in the pleural cavity, commonly due to trauma, vascular injury, or coagulopathies, which can disrupt lung expansion and oxygenation. Key symptoms include sharp chest pain, difficulty breathing, low blood pressure in severe cases, and diminished breath sounds accompanied by dullness to percussion over the affected area. ^[20]
• Pneumothorax: Those who are at a higher risk of developing pneumothorax are tall, slim male smokers who have had underlying lung diseases such as emphysema. Those affected can have a sharp chest pain which radiates to the shoulder of the same side. Physical examination revealed absent breath sounds and hyperresonance on the affected side of the chest.
• Pleurisy: (Pleuritic Chest Pain) The pain is sharp, localized, and is frequently exacerbated with coughing or inspiration. It can be attributed to various etiologies including pulmonary embolism, pneumothorax, pericarditis, and viral pleurisy. ^[18]
• Tuberculosis: Tuberculosis is caused by Mycobacterium tuberculosis, which primarily infects the lungs, leading to Granuloma formation as the immune system walls off the bacteria. Symptoms include chronic cough, fever, night sweats, weight loss, and pleuritic chest pain if the pleura is involved, often worsening with deep breaths or coughing. ^[21]
• Tracheitis: Tracheitis, usually a bacterial driven inflammation of the trachea, which often narrows the airway. It can present as stridor and may cause respiratory distress symptoms like tachypnea, cyanosis, and hoarseness. Clinical symptoms include a dry, painful cough that worsens at night and may progress to a productive cough, fever, and retrosternal chest pain due to irritation of tracheal mucosa. ^[22]
• Lung cancer: Hemoptysis, cough, dyspnea, chest pain, and other constitutional symptoms are commonly seen in lung cancer ^[23]

Gastrointestinal

Gastroesophageal reflux disease is a common cause of chest pain in adults

• Gastroesophageal reflux disease: The pain is aggravated when lying down or after meals. Affected individuals may describe this as a heartburn. Besides, they may also complain of tasting bitter contents from the stomach. ^[11]
• Achalasia, nutcracker esophagus, and other motility disorders of the esophagus
• Diffuse esophageal spasm: Unlike cardiac chest pain, esophageal pain is not related to activity. The pain is usually associated with swallowing of hot or cold water. ^[11]
• Esophageal rupture: Those affected usually complain of sudden, severe, and constant pain that starts from the neck to the upper abdomen. The pain is aggravated by swallowing. On examination, neck swelling and Crepitus can be felt due to subcutaneous emphysema as free air is entering from esophagus into the subcutaneous tissue.
• Esophagitis: There are many causes of esophagitis. Esophagitis caused by Candida albicans is usually found in people on chemotherapy or with HIV. Medication such as nonsteroidal anti-inflammatory drug and alendronate can induce esophagitis if not swallowed properly. ^[11]
• Functional dyspepsia: Functional dyspepsia is characterized by upper abdominal discomfort without an identifiable organic cause. Symptoms include epigastric pain or burning, postprandial fullness, early satiety, bloating, nausea, and belching; notably, chest pain can also manifest, potentially mimicking cardiac conditions ^[24]
• Hiatus hernia: A hiatal hernia occurs when a portion of the stomach pushes upward through the diaphragm into the chest cavity. While gastroesophageal reflux, presenting as heartburn and regurgitation, is the hallmark symptom, other manifestations such as dysphagia, epigastric or chest pain, and chronic iron deficiency anemia may also occur. ^[25]
• Jackhammer esophagus (hypercontractile peristalsis): Intense long-lasting esophageal muscle spasm. ^{[26] [27]}
• Acute cholecystitis: Characterized by positive Murphy's sign where the person has a cessation of inhalation when the doctor places his finger at the right subcostal region of the abdomen.
• Acute pancreatitis: History of excessive alcohol use, cholelithiasis (stones in the gallbladder), and hypertriglyceridemia are risk factors for pancreatitis. The pain is described as sharp, burning, and can worsen after eating.
• Perforated peptic ulcer: Sudden onset of severe pain in the upper abdomen which later develops into peritonitis (inflammation of tissues that lines the abdominal organs).
• Acute gastritis: Common presentations include upper gastrointestinal issues such as epigastric pain, heartburn, bloating, and a feeling of early fullness ^[28]

Chest wall

• Costochondritis or Tietze's syndrome: An inflammation of a costochondral junction. Any movements or palpation of the chest can reproduce the symptoms.
• Spinal nerve problem
• Fibromyalgia: Fibromyalgia is a chronic condition presenting with but not limited to widespread musculoskeletal pain, often accompanied by fatigue, sleep disturbances, and cognitive difficulties. Symptoms can vary widely; common reports include chest pain, muscle weakness, abdominal cramps, dizziness, insomnia, and numbness or tingling ^[29]
• Chest wall problems: Chest pain can arise from musculoskeletal issues ie scleroderma, costochondritis, cervical radiculitis, among others. ^[30]
• Radiculopathy (Cervical Angina) Cervical spondylosis presents as sharp pain traveling from the neck to the chest and can be reproduced by turning of the neck sideways. Spurling's test can help rule out this etiology. ^[31]
• Precordial catch syndrome: Another benign and harmless form of a sharp, localized chest pain often mistaken for heart disease.
• Breast conditions
• Herpes zoster (shingles): It is usually described as a burning sensation over the chest in a unilateral dermatome distribution. However, diagnosis can be difficult because the pain usually appears before the characteristic rash is visible.
• Osteoarthritis: Osteoarthritis of the manubriosternal joint is a very uncommon presentation of chest pain ^[32]
• Bornholm disease: Bornholm disease is a viral illness marked by a brief febrile episode accompanied by sharp pains in the lower chest or upper abdomen. The condition may also involve muscle tenderness and localized swelling, with chest pain being a prominent symptom. ^[33]
• Rib fracture: Rib fractures often cause pain that intensifies with deep breathing, leading people to breathe shallowly to minimize discomfort, especially after trauma. In individuals with a history of cancer, rib metastases should be considered if symptoms like tenderness, weight loss, fatigue, and reduced appetite are present. ^[31]

Psychological

• Panic attack: Chest pain is a common symptom of panic attacks, with as high as 78% of persons describing chest pain with their worst panic attacks. ^[12] Overall chest pain is a symptom of up to 48% of sudden-onset panic attacks, and 10% of gradual-onset panic attacks. ^[12]
• Anxiety: Generalized anxiety disorder (GAD) is characterized by persistent and excessive worry, often accompanied by physical symptoms such as chest pain, restlessness, fatigue, and muscle tension ^[34]
• Clinical depression: Depression, linked to chest pain through its physical and emotional effects, has been shown in studies to independently increase the long-term risk of coronary heart disease (CHD) and myocardial infarction (MI), potentially contributing to cardiovascular disease. ^[35]
• Somatization disorder: Somatization disorder can present with chronic physical symptoms without an identifiable medical cause; it often manifests as chest pain and results from underlying psychological distress ^[36]
• Hypochondria

Others

• Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth.
• Tuberculosis: Chest pain associated with tuberculosis often arises from tuberculous pericarditis, a condition caused by Mycobacterium tuberculosis affecting the pericardium. This inflammation typically results in symptoms such as chest discomfort, coughing, fever, night sweats, and unintentional weight loss ^[37]
• Da Costa's syndrome
• Carbon monoxide poisoning: Chest pain, along with symptoms like headache, dizziness, nausea, and confusion, can occur as a result of carbon monoxide poisoning, which is often mistaken for the flu due to its nonspecific presentation ^[38]
• Sarcoidosis: Cardiac sarcoidosis involves the formation of granulomas (clusters of inflammatory cells) within the heart tissue, which can lead to chest pain due to inflammation and fibrosis ^[39]
• Lead poisoning: Chest pain associated with lead poisoning may result from its impact on the cardiovascular system, including hypertension or vascular damage, often occurring in conjunction with fatigue and abdominal pain ^[40]
• Prolapsed intervertebral disc
• Thoracic outlet syndrome: Occurs when nerves or blood vessels are compressed in the space between the first rib and the collarbone, causing symptoms such as pain in the neck, shoulder, or chest, along with arm weakness or numbness ^[41]
• Adverse effect from certain medications

Diagnostic approach

History taking

Knowing a person's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors. Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of acute coronary syndrome. ^[42] Other clues in the history can help lower the suspicion for myocardial infarction. These include chest pain described as "sharp" or "stabbing", chest pain that is positional or pleuritic in nature, and chest pain that can be reproduced with palpation. ^{[43] [44]} However, both atypical and typical symptoms of acute coronary syndrome can occur, and in general a history cannot be enough to rule out the diagnosis of acute coronary syndrome. ^[44] In some cases, chest pain may not even be a symptom of an acute cardiac event. An estimated 33% of persons with myocardial infarction in the United States do not present with chest pain, and carry a significantly higher mortality as a result of delayed treatment. ^[45]

Physical examination

Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialized units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. ^[46] However, in the case of acute coronary syndrome, a third heart sound, diaphoresis, and hypotension are the most strongly associated physical exam findings. ^[47] However these signs are limited in their prognostic and diagnostic value. ^[8] Other physical exam findings suggestive of cardiac chest pain may include hypertension, tachycardia, bradycardia, and new heart murmurs. ^[8] Chest pain that is reproducible during the physical exam with contact of the chest wall is more indicative of non-cardiac chest pain, but still cannot completely rule out acute coronary syndrome. ^[48] For this reason, in general, additional tests are required to establish the diagnosis.

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided. ^[10]

Risk scores

The Global Registry of Acute Coronary Events score and the Thrombosis in Myocardial Infarction performed at time of admission may help stratify persons into low, intermediate and high risk groups for acute coronary syndrome. ^[1] However these scores do not provide management guidelines for risk-stratified persons.

The HEART score, stratifies persons into low-risk and high-risk groups, and recommends either discharge or admission based upon the score. ^[1]

HEART score ^{[49] [50]}

Criteria	Point Value
History
Highly suspicious	+2
Moderately suspicious	+1
Slightly suspicious	0
ECG
Significant ST-depression	+2
Nonspecific repolarization disturbance	+1
Normal	0
Age
≥ 65	+2
45-65	+1
≤ 45	0
Risk factors*
≥ 3 risk factors or history of atherosclerotic disease	+2
1-2 risk factors	+1
No risk factors known	0
Troponin
≥ 3× normal limit	+2
1-3× normal limit	+1
≤ normal limit	0
*include hypercholesterolemia, hypertension, diabetes mellitus, smoking, obesity

Cumulative score:

• 0-3: 2.5% risk of adverse cardiac event. Patient's can be discharged with follow-up.
• 4-6: 20.3% risk of adverse cardiac event. Patients should be admitted to the hospital for trending of troponin and provocative testing.
• ≥7: 72.7% risk of adverse cardiac event, suggesting early invasive measures with these patients and close coordination with inpatient cardiology.

If acute coronary syndrome ("heart attack") is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause.

Medical tests

Depending on the differential diagnoses made based on history and physical examination, a number of tests may be ordered: ^[51]

Blood tests:

• Complete blood count (CBC)
• Cardiac enzymes: troponin, creatine kinase, and myosin for myocardial infarction
• Electrolytes and renal function (creatinine)
• Liver enzymes
• D-dimer: when suspicion for pulmonary embolism is present but low
• Serum Lipase: to exclude acute pancreatitis

Other tests:

• Electrocardiogram (ECG)
• Chest radiograph (CXR)
• Echocardiograph: useful in patients with known cardiac disease or aortic dissection ^{[8] [52]}
• CT scan: useful in diagnosis of aortic dissection ^[52]
• V/Q scintigraphy or CT pulmonary angiogram: useful when pulmonary embolism is suspected ^[8]

Management

Management of chest pain varies with the underlying cause of the pain and the stage of care.

Prehospital care

If a chest pain patient suspects that he is suffering a myocardial infarction, he can calm down, remain in a position that is comfortable, calling emergency medical services and trying any other action of the applicable first aid process.

Chest pain is a common symptom encountered by emergency medical services. Aspirin increases survival in people with acute coronary syndrome and it is reasonable for EMS dispatchers to recommend it in people with no recent serious bleeding. ^[53] Supplemental oxygen was used in the past for most people with chest pain but is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress. ^{[54] [53]} Entonox is frequently used by EMS personnel in the prehospital environment. ^[55] However, there is little evidence about its effectiveness. ^{[53] [56]}

Hospital care

Hospital care of chest pain begins with initial survey of a person's vital signs, airway and breathing, and level of consciousness. ^{[1] [8]} This may also include attachment of ECG leads, cardiac monitors, intravenous lines and other medical devices depending on initial evaluation. ^[8] After evaluation of a person's history, risk factors, physical examination, laboratory testing and imaging, management begins depending on suspected diagnoses. ^[8] Depending upon the diagnosis, a person may be placed in the intensive care unit, admitted to the hospital, or be treated outpatient. ^[8] For persons with suspected cardiac chest pain or acute coronary syndrome, or other emergent diagnoses such as pneumothorax, pulmonary embolism, or aortic dissection, admission to the hospital is most often recommended for further treatment. ^[8]

Outpatient care

For people with non-cardiac chest pain, cognitive behavioral therapy might be helpful on an outpatient basis. A 2015 Cochrane review found that cognitive behavioral therapy might reduce the frequency of chest pain episodes the first three months after treatment. ^[57] For persons with chest pain due to gastroesophageal reflux disease, a proton-pump inhibitor has been shown to be the most effective treatment. ^[58] However, treatment with proton pump inhibitors has been shown to be no better than placebo in persons with noncardiac chest pain not caused by gastroesophageal reflux disease. ^[58] For musculoskeletal causes of chest pain, manipulation therapy or chiropractic therapy, acupuncture, or a recommendation for increased exercise are often used as treatment. ^[58] Studies have shown conflicting results on the efficacy of these treatments. ^[58] A combination therapy of nonsteroidal anti-inflammatory drugs and manipulation therapy with at-home exercises has been shown to be most effective in treatment of musculoskeletal chest pain. ^[9]

Epidemiology

Chest pain is a common presenting problem. Overall chest pain is responsible for an estimated 6% of all emergency department visits in the United States and is the most common reason for hospital admission. ^[44] Chest pain is also very common in primary care clinics, representing 1-3% of all visits. ^[59] The rate of emergency department visits in the US for chest pain decreased 10% from 1999 to 2008. ^[60] but a subsequent increase of 13% was seen from 2006 to 2011. ^[61] Less than 20% of all cases of chest pain admissions are found to be due to coronary artery disease. ^[62] The rate of chest pain as a symptom of acute coronary syndrome varies among populations based upon age, sex, and previous medical conditions. ^[45] In general, women are more likely than men to present without chest pain (49% vs. 38%) in cases of myocardial infarction. ^[45]

References

1. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline D (2016). Tintinalli's emergency medicine: a comprehensive study guide (Eighth ed.). New York: McGraw-Hill Education. pp. 325–331. ISBN   978-0-07-179476-3. OCLC   915775025.
2. Schey R, Villarreal A, Fass R (April 2007). "Noncardiac chest pain: current treatment". Gastroenterology & Hepatology. 3 (4): 255–62. PMC   3099272 . PMID   21960837.
3. Johnson, Ken (13 March 2019). "Chest pain". StatPearls. PMID   29262011 . Retrieved 22 June 2019.
4. Adams, James G. (2012). Emergency Medicine E-Book: Clinical Essentials (Expert Consult - Online and Print). Elsevier Health Sciences. p. 449. ISBN   9781455733941.
5. Alpert, Joseph S. (2005). Cardiology for the Primary Care Physician. Springer Science & Business Media. p. 47. ISBN   9781573402125.
6. Wertli MM, Ruchti KB, Steurer J, Held U (November 2013). "Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis". BMC Medicine. 11: 239. doi: 10.1186/1741-7015-11-239 . PMC   4226211 . PMID   24207111.
7. Thull-Freedman J (March 2010). "Evaluation of chest pain in the pediatric patient". The Medical Clinics of North America. 94 (2): 327–47. doi:10.1016/j.mcna.2010.01.004. PMID   20380959.
8. Marx JA, Hockberger RS, Walls RM, Biros MH, Danzl DF, Gausche-Hill M, Jagoda A, Ling L, Newton E, Zink BJ, Rosen P (2014). Rosen's Emergency Medicine: Concepts and Clinical Practice (Eighth ed.). Philadelphia, PA: Elsevier/Saunders. ISBN   978-1-4557-0605-1. OCLC   853286850.
9. Ayloo A, Cvengros T, Marella S (December 2013). "Evaluation and treatment of musculoskeletal chest pain". Primary Care. 40 (4): 863–87, viii. doi:10.1016/j.pop.2013.08.007. PMID   24209723.
10. Woo KM, Schneider JI (November 2009). "High-risk chief complaints I: chest pain--the big three". Emergency Medicine Clinics of North America. 27 (4): 685–712, x. doi:10.1016/j.emc.2009.07.007. PMID   19932401.
11. Kontos MC, Diercks DB, Kirk JD (March 2010). "Emergency department and office-based evaluation of patients with chest pain". Mayo Clinic Proceedings. 85 (3): 284–99. doi:10.4065/mcp.2009.0560. PMC   2843115 . PMID   20194155.
12. Katerndahl DA (2008). "Chest pain and its importance in patients with panic disorder: an updated literature review". Primary Care Companion to the Journal of Clinical Psychiatry. 10 (5): 376–83. doi:10.4088/PCC.v10n0505. PMC   2629063 . PMID   19158976.
13. Baren JM, Rothrock SG, Brennan JA, Brown L (2008). Pediatric Emergency Medicine. Philadelphia: Saunders/Elsevier. p. 481. ISBN   978-1-4160-0087-7.
14. Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA (August 2016). "Acute Aortic Dissection and Intramural Hematoma: A Systematic Review". JAMA. 316 (7): 754–63. doi:10.1001/jama.2016.10026. hdl: 2434/450334 . PMID   27533160.
15. Keyvanfar, Amirreza; Najafiarab, Hanieh; Ramezani, Sepehr; Tehrani, Shabnam (2024-08-29). "Cardiac tamponade in people living with HIV: a systematic review of case reports and case series". BMC Infectious Diseases. 24 (1): 882. doi: 10.1186/s12879-024-09773-4 . ISSN   1471-2334. PMC   11360758 . PMID   39210274.
16. Albarran, John W.; Tagney, Jenny, eds. (2007-01-15). Chest Pain. Wiley. doi:10.1002/9780470775127. ISBN   978-1-4051-4422-3.
17. Gouveia e Melo, Ryan; Silva Duarte, Gonçalo; Lopes, Alice; Alves, Mariana; Caldeira, Daniel; Fernandes e Fernandes, Ruy; Mendes Pedro, Luís (2022). "Incidence and Prevalence of Thoracic Aortic Aneurysms: A Systematic Review and Meta-analysis of Population-Based Studies". Seminars in Thoracic and Cardiovascular Surgery. 34 (1): 1–16. doi:10.1053/j.semtcvs.2021.02.029. ISSN   1043-0679. PMID   33705940.
18. Sydney, Elana; Weinstein, Eleanor; Rucker, Lisa M., eds. (2022). Handbook of Outpatient Medicine. doi:10.1007/978-3-031-15353-2. ISBN   978-3-031-15352-5.
19. Htun, Tha Pyai; Sun, Yinxiaohe; Chua, Hui Lan; Pang, Junxiong (2019-05-20). "Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review". Scientific Reports. 9 (1): 7600. Bibcode:2019NatSR...9.7600H. doi:10.1038/s41598-019-44145-y. ISSN   2045-2322. PMC   6527561 . PMID   31110214.
20. Masters, Barry R. (2012-05-25). "Harrisons's Principles of Internal Medicine, 18th Edition, two volumes and DVD. Eds: Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson and Joseph Loscalzo, ISBN-13: 9780071748896 McGraw Hill". Graefe's Archive for Clinical and Experimental Ophthalmology. 250 (9): 1407–1408. doi:10.1007/s00417-012-1940-9. ISSN   0721-832X.
21. GIE, R (2009), "Intrathoracic tuberculosis in childrenThe most common clinical presentations", Tuberculosis, Elsevier, pp. 361–363, doi:10.1016/b978-1-4160-3988-4.00032-9, ISBN   978-1-4160-3988-4 , retrieved 2024-12-01
22. Blot, M.; Bonniaud-Blot, P.; Favrolt, N.; Bonniaud, P.; Chavanet, P.; Piroth, L. (November 2017). "Update on childhood and adult infectious tracheitis". Médecine et Maladies Infectieuses. 47 (7): 443–452. doi:10.1016/j.medmal.2017.06.006. PMC   7125831 . PMID   28757125.
23. Okoli, Grace N.; Kostopoulou, Olga; Delaney, Brendan C. (2018-11-21). Wang, Xin Shelley (ed.). "Is symptom-based diagnosis of lung cancer possible? A systematic review and meta-analysis of symptomatic lung cancer prior to diagnosis for comparison with real-time data from routine general practice". PLOS ONE. 13 (11): e0207686. Bibcode:2018PLoSO..1307686O. doi: 10.1371/journal.pone.0207686 . ISSN   1932-6203. PMC   6248994 . PMID   30462699.
24. Feinle-Bisset, Christine; Andrews, Jane M. (2003-08-06). "Treatment of functional dyspepsia". Current Treatment Options in Gastroenterology. 6 (4): 289–297. doi:10.1007/s11938-003-0021-x. ISSN   1092-8472. PMID   12846938.
25. Sfara, Alice; Dumitrașcu, Dan L (2019-09-12). "The management of hiatal hernia: an update on diagnosis and treatment". Medicine and Pharmacy Reports. 92 (4): 321–325. doi:10.15386/mpr-1323. ISSN   2668-0572. PMC   6853045 . PMID   31750430.
26. "NIH: Jackhammer esophagus Disorder Summary". U.S.A. National Institutes of Health, Genetic and Rare Diseases Information Center (GARD). Retrieved 2020-10-29.
27. "Mayo Clinic: Chest Pain Symptoms & causes". U.S.A. Mayo Clinic: Chest Pain, Symptoms & causes. Retrieved 2020-10-29.
28. Singh, Shubhangi; Chakole, Swarupa; Agrawal, Suyash; Shetty, Nidhi; Prasad, Roshan; Lohakare, Tejaswee; Wanjari, Mayur; Yelne, Seema (2023-08-13). "A Comprehensive Review of Upper Gastrointestinal Symptom Management in Autoimmune Gastritis: Current Insights and Future Directions". Cureus. 15 (8): e43418. doi: 10.7759/cureus.43418 . ISSN   2168-8184. PMC   10496934 . PMID   37706145.
29. Kang, Ji-Hyoun; Choi, Sung-Eun; Park, Dong-Jin; Lee, Shin-Seok (2022-01-01). "Disentangling Diagnosis and Management of Fibromyalgia". Journal of Rheumatic Diseases. 29 (1): 4–13. doi:10.4078/jrd.2022.29.1.4. ISSN   2093-940X. PMC   10324920 . PMID   37476701.
30. Masters, Barry R. (2012-05-25). "Harrisons's Principles of Internal Medicine, 18th Edition, two volumes and DVD. Eds: Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson and Joseph Loscalzo, ISBN-13: 9780071748896 McGraw Hill". Graefe's Archive for Clinical and Experimental Ophthalmology. 250 (9): 1407–1408. doi:10.1007/s00417-012-1940-9. ISSN   0721-832X.
31. Katamreddy, Adarsh (2022), "Chest Pain", Handbook of Outpatient Medicine, Cham: Springer International Publishing, pp. 333–354, doi:10.1007/978-3-031-15353-2_17, ISBN   978-3-031-15352-5 , retrieved 2024-12-01
32. Parkinson, L.; Waters, D.L.; Franck, L. (2017-11-10). "Systematic review of the impact of osteoarthritis on health outcomes for comorbid disease in older people". Osteoarthritis and Cartilage. 25 (11): 1751–1770. doi:10.1016/j.joca.2017.07.008. PMID   28710026.
33. Morrison, R. J. G. (1953-09-01). "Bornholm Disease". International Journal of Clinical Practice. 7 (9): 677–680. doi:10.1111/j.1742-1241.1953.tb05643.x. ISSN   1368-5031. PMID   13098749.
34. Carter, Cameron S.; Maddock, Richard J. (1992-09-01). "Chest Pain in Generalized Anxiety Disorder". The International Journal of Psychiatry in Medicine. 22 (3): 291–298. doi:10.2190/RGC5-PJK2-7TG5-KL1B. ISSN   0091-2174. PMID   1487393.
35. Gan, Yong; Gong, Yanhong; Tong, Xinyue; Sun, Huilian; Cong, Yingjie; Dong, Xiaoxin; Wang, Yunxia; Xu, Xing; Yin, Xiaoxu; Deng, Jian; Li, Liqing; Cao, Shiyi; Lu, Zuxun (2014-12-01). "Depression and the risk of coronary heart disease: a meta-analysis of prospective cohort studies". BMC Psychiatry. 14 (1): 371. doi: 10.1186/s12888-014-0371-z . ISSN   1471-244X. PMC   4336481 . PMID   25540022.
36. Rodolico, Alessandro; Mineo, Ludovico (2020), Govoni, Stefano; Politi, Pierluigi; Vanoli, Emilio (eds.), "Distinguishing Cardiac from Psychological Somatic Symptoms", Brain and Heart Dynamics, Cham: Springer International Publishing, pp. 181–196, doi:10.1007/978-3-030-28008-6_16, ISBN   978-3-030-28008-6 , retrieved 2024-12-08
37. López-López, José Patricio; Posada-Martínez, Edith L.; Saldarriaga, Clara; Wyss, Fernando; Ponte-Negretti, Carlos I.; Alexander, Bryce; Miranda-Arboleda, Andrés Felipe; Martínez-Sellés, Manuel; Baranchuk, Adrian; the Neglected Tropical Diseases, Other Infectious Diseases Affecting the Heart (the NET-Heart Project) (2021-04-06). "Tuberculosis and the Heart". Journal of the American Heart Association. 10 (7): e019435. doi:10.1161/JAHA.120.019435. PMC   8174360 . PMID   33733808.
38. CDC (2024-10-31). "Carbon Monoxide Poisoning Basics". Carbon Monoxide Poisoning. Retrieved 2024-12-08.
39. Cheng, Richard K.; Kittleson, Michelle M.; Beavers, Craig J.; Birnie, David H.; Blankstein, Ron; Bravo, Paco E.; Gilotra, Nisha A.; Judson, Marc A.; Patton, Kristen K.; Rose-Bovino, Leonie; on behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology, and Council on Cardiovascular and Stroke Nursing (2024-05-21). "Diagnosis and Management of Cardiac Sarcoidosis: A Scientific Statement From the American Heart Association". Circulation. 149 (21): e1197–e1216. doi:10.1161/CIR.0000000000001240. PMID   38634276.
40. Navas-Acien, Ana; Guallar, Eliseo; Silbergeld, Ellen K.; Rothenberg, Stephen J. (2007-03-01). "Lead Exposure and Cardiovascular Disease—A Systematic Review". Environmental Health Perspectives. 115 (3): 472–482. Bibcode:2007EnvHP.115..472N. doi:10.1289/ehp.9785. ISSN   0091-6765. PMC   1849948 . PMID   17431501.
41. Dengler, Nora Franziska; Ferraresi, Stefano; Rochkind, Shimon; Denisova, Natalia; Garozzo, Debora; Heinen, Christian; Alimehmeti, Ridvan; Capone, Crescenzo; Barone, Damiano Giuseppe; Zdunczyk, Anna; Pedro, Maria Teresa; Antoniadis, Gregor; Kaiser, Radek; Dubuisson, Annie; Kretschmer, Thomas (2022-06-01). "Thoracic Outlet Syndrome Part I: Systematic Review of the Literature and Consensus on Anatomy, Diagnosis, and Classification of Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery". Neurosurgery. 90 (6): 653–667. doi:10.1227/neu.0000000000001908. ISSN   0148-396X. PMC   9514726 . PMID   35319532.
42. Swap CJ, Nagurney JT (November 2005). "Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes". JAMA. 294 (20): 2623–9. doi: 10.1001/jama.294.20.2623 . PMID   16304077.
43. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL (October 1998). "The rational clinical examination. Is this patient having a myocardial infarction?". JAMA. 280 (14): 1256–63. doi:10.1001/jama.280.14.1256. PMID   9786377.
44. Dezman ZD, Mattu A, Body R (June 2017). "Utility of the History and Physical Examination in the Detection of Acute Coronary Syndromes in Emergency Department Patients". The Western Journal of Emergency Medicine. 18 (4): 752–760. doi:10.5811/westjem.2017.3.32666. PMC   5468083 . PMID   28611898.
45. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, Lambrew CT, Ornato JP, Barron HV, Kiefe CI (June 2000). "Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain". JAMA. 283 (24): 3223–9. doi: 10.1001/jama.283.24.3223 . PMID   10866870.
46. Edmondstone WM (1995-12-23). "Cardiac chest pain: does body language help the diagnosis?". BMJ. 311 (7021): 1660–1. doi:10.1136/bmj.311.7021.1660. PMC   2539106 . PMID   8541748.
47. Chun AA, McGee SR (September 2004). "Bedside diagnosis of coronary artery disease: a systematic review". The American Journal of Medicine. 117 (5): 334–43. doi:10.1016/j.amjmed.2004.03.021. PMID   15336583.
48. Pereira VC, Cunha Mde L (November 2013). "Coagulase-negative staphylococci strains resistant to oxacillin isolated from neonatal blood cultures". Memórias do Instituto Oswaldo Cruz. 108 (7): 939–42. doi:10.1590/0074-0276130644. PMC   3970650 . PMID   24141968.
49. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, et al. (October 2013). "A prospective validation of the HEART score for chest pain patients at the emergency department". International Journal of Cardiology. 168 (3): 2153–8. doi: 10.1016/j.ijcard.2013.01.255 . PMID   23465250.
50. Six AJ, Backus BE, Kelder JC (June 2008). "Chest pain in the emergency room: value of the HEART score". Netherlands Heart Journal. 16 (6): 191–6. doi:10.1007/BF03086144. PMC   2442661 . PMID   18665203.
51. Hess EP, Perry JJ, Ladouceur P, Wells GA, Stiell IG (March 2010). "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome". CJEM. 12 (2): 128–34. doi: 10.1017/S148180350001215X . PMID   20219160.
52. Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y (July 2006). "Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis". Archives of Internal Medicine. 166 (13): 1350–6. doi: 10.1001/archinte.166.13.1350 . PMID   16831999.
53. O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O'Neil BJ, Travers AH, Yannopoulos D (November 2010). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S787–817. doi: 10.1161/CIRCULATIONAHA.110.971028 . PMID   20956226.
54. "Highlights of the 2010 AHA Guidelines for CPR and ECC" (PDF). American Heart Association. Archived from the original (PDF) on 2017-01-06. Retrieved 2010-11-09.
55. Castle N (February 2003). "Effective relief of acute coronary syndrome". Emergency Nurse. 10 (9): 15–9. doi:10.7748/en2003.02.10.9.15.c1090. PMID   12655961.
56. "Entonox for the Treatment of Undiagnosed Chest Pain: Clinical Effectiveness and Guidelines" (PDF). Canadian Agency for Drugs and Technologies in Health. Archived from the original (PDF) on 29 September 2011. Retrieved 12 July 2011.
57. Kisely SR, Campbell LA, Yelland MJ, Paydar A (June 2015). "Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy" (PDF). The Cochrane Database of Systematic Reviews. 2021 (6): CD004101. doi:10.1002/14651858.cd004101.pub5. PMC   6599861 . PMID   26123045.
58. Burgstaller JM, Jenni BF, Steurer J, Held U, Wertli MM (2014-08-11). "Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis". PLOS ONE. 9 (8): e104722. Bibcode:2014PLoSO...9j4722B. doi: 10.1371/journal.pone.0104722 . PMC   4128723 . PMID   25111147.
59. Stochkendahl MJ, Christensen HW (March 2010). "Chest pain in focal musculoskeletal disorders". The Medical Clinics of North America. 94 (2): 259–73. doi:10.1016/j.mcna.2010.01.007. PMID   20380955.
60. "Products - Data Briefs - Number 43 - September 2010". www.cdc.gov. Retrieved 2018-01-19.
61. Skiner HG, Blanchard J, Elixhauser A (September 2014). "Trends in Emergency Department Visits, 2006-2011". HCUP Statistical Brief (179). Rockville, MD: Agency for Healthcare Research and Quality.
62. Eslick GD, Coulshed DS, Talley NJ (July 2002). "Review article: the burden of illness of non-cardiac chest pain". Alimentary Pharmacology & Therapeutics. 16 (7): 1217–23. doi: 10.1046/j.1365-2036.2002.01296.x . PMID   12144570. S2CID   72035162.