Acute Nonpleuritic Chest Pain

Acute Nonpleuritic Chest Pain: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Chest wall pain

❑ Angina

❑ Unstable angina

❑ Myocardial infarction

❑ Gastroesophageal reflux

❑ Herpes zoster

❑ Thoracic root compression

❑ Panic disorder

❑ Aortic stenosis

❑ Aortic dissection

❑ Mediastinal mass

❑ Biliary disease

Diagnostic Approach

It is essential to maintain a high index of suspicion (low threshold for investigation) for critical problems; however, most chest pain has a benign cause. The patient with myocardial ischemia often is reluctant to label the symptom as “pain.” Instead descriptors are used such as squeezing, pressure, tightness, fullness, a heavy weight on the chest, burning (attributed to indigestion),
or a toothache (when jaw radiation is present). A closed fist held to the sternum is commonly employed to explain the symptoms. Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Recurrent episodic pain or persistent pain lasting days is unlikely to represent a critical problem. Pain lasting a few seconds or pain that is sharp or stabbing in quality is almost never ischemic, especially if reproducible by palpation
or movement.

Syncope with chest pain should raise suspicion of aortic dissection,
ruptured aortic aneurysm, pulmonary embolism, or critical aortic stenosis. “Angor anomie,” a sense of impending doom, is found in serious conditions such as myocardial infarction, pulmonary embolism, aortic dissection, and to a lesser extent, panic disorder. Sternal pain may be caused by xiphoidalgia, myelomatosis, ankylosing spondylitis, osteomyelitis, or traumatic fracture.

Clinical Findings

Chest wall pain  Pain is characteristically aggravated by deep inspiration or movement, and exactly reproduced or heightened by direct pressure. Press on the contralateral side as a control. Coughing and repetitive motion of the shoulder girdle are the typical precipitants.

Angina  Substernal chest pressure caused by exertion or emotion and relieved by rest or nitroglycerin is typical. Pain is predominantly left-sided and may radiate to the jaw, neck, or shoulder, with left arm numbness. A fourth heart sound may accompany the pain.

Unstable angina  This form of ischemia may be difficult to diagnose, as it may not have a clear relationship to exertion. A high risk for subsequent myocardial infarction is characterized by prolonged ongoing chest pain, pulmonary edema, or angina with a new or worsening S₃, mitral regurgitation, or hypotension. An intermediate risk of MI is signaled by prolonged (.20 minutes) chest pain with a high likelihood of CAD, rest angina
(.20 minutes) now resolved with nitroglycerin, nocturnal angina, and new NYHA Class III or IV angina within 2 weeks. Low-risk unstable angina includes increased frequency, severity, or duration; angina provoked
at a lower exertional threshold; and new-onset angina within 2 weeks. Vasospastic angina is a variant that occurs at rest in patients with a vasospastic substrate (e.g., Raynaud syndrome or migraine).

Myocardial infarction  Prolonged, crushing substernal pressure is the prototype. The pain is similar to established angina but more intense and prolonged. The episode is often preceded by an unstable angina pattern. Diaphoresis and hypotension are common. Nausea and bradycardia should suggest inferior ischemia but can be distractors when the pain is epigastric in location. Pain radiating to the arm, neck, or jaw suggests ischemia, and on occasion, the pain is only perceived in the distal radiation, as a toothache
or tennis elbow pain. Wide radiation, for example to both arms, increases the probability of MI. Question the patient about cocaine use—the risk of MI increases 24-fold over baseline during the first hour.

Gastroesophageal reflux  Retrosternal burning associated with belching,
a sour or acid taste in the mouth, and difficult or painful swallowing are
typical symptoms. Symptoms worsen at night when the patient is supine. Esophageal spasm, which may mimic heart disease, is usually perceived as sharp substernal pain, precipitated by swallowing.

Herpes zoster  Pain may occur as a prodrome preceding development of lesions. There will be a unilateral dermatomal distribution of a sharp, burning, or numb dysesthesia.

Thoracic root compression  Thoracic radiculopathy is unusual because of the splinting provided by the ribs. When it occurs, one must consider an expanding lesion (e.g., infection or cancer).

Panic disorder  Symptoms occur in paroxysms of substernal heaviness, accompanied by lightheadedness, palpitations, nervousness, and weakness. The patient feels a strong sense of panic and impending catastrophe. The patient’s anxiety is notable even after the symptoms resolve.

Aortic stenosis  Consider in a patient with progressive angina, dyspnea, and/or syncope. Findings on examination include a loud murmur in the upper right sternal border radiating into the carotids, weak and delayed carotid pulses, and a left ventricular heave.

Aortic dissection  Dissection presents as a tearing pain with a sudden onset at maximal severity. It travels in location with the progression of the dissection, and it often radiates between the scapulae. The patient will appear quite restless, constantly in motion in an attempt to find a comfortable position. Asymmetry of pulses is a critical clue, as is a new aortic insufficiency murmur. There may be a history of hypertension, blunt chest trauma, or Marfan
syndrome with high arched palate and long limbs. Associated complications such as cardiac tamponade, syncope, paraplegia (due to spinal cord ischemia), acute lower extremity ischemia, or Horner syndrome may provide key clues.

Mediastinal mass  Symptoms begin with a vague sense of central pressure, accompanied by dyspnea and a cough that becomes increasingly severe over time.

Biliary disease  The epicenter of the pain is in the epigastrium. Biliary colic may be relieved by nitroglycerin.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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