What is the cause of chest pain (thoracic pain)?

From the Guidelines

A comprehensive chest pain questionnaire should prioritize assessing key aspects of the pain to determine its cause and severity, focusing on characteristics such as location, quality, intensity, and duration, as well as onset, aggravating and relieving factors, and associated symptoms, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. When evaluating chest pain, it is crucial to consider the nature of the pain, including whether it is anginal, sharp, or fleeting, as these characteristics can help differentiate between cardiac and non-cardiac causes. For instance, anginal symptoms are typically perceived as retrosternal chest discomfort, while sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease 1. Key aspects to assess in the questionnaire include:

• Pain characteristics: location (central chest, left side, radiating to arm/jaw/back), quality (sharp, dull, pressure, burning), intensity on a scale of 1-10, and duration (minutes, hours, constant)
• Onset: sudden or gradual
• Aggravating factors: exertion, breathing, movement, eating
• Relieving factors: rest, position changes, antacids, nitroglycerin
• Associated symptoms: shortness of breath, nausea, sweating, dizziness, palpitations, or cough
• Medical history: previous heart problems, high blood pressure, diabetes, high cholesterol, and family history of heart disease
• Current medications, smoking status, and recent physical or emotional stress This structured approach helps differentiate between cardiac causes (like angina or myocardial infarction), gastrointestinal issues (such as reflux or ulcers), musculoskeletal pain, or pulmonary conditions (like pneumonia or pulmonary embolism), as supported by the ACR Appropriateness Criteria for nontraumatic chest wall pain 1 and the task force on the management of chest pain 1. The pattern of responses guides appropriate triage and management decisions, with certain combinations of symptoms warranting immediate emergency evaluation, highlighting the importance of a thorough and comprehensive chest pain questionnaire in clinical practice.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Questionnaire for Chest Pain

• The diagnosis and management of chest pain is crucial in identifying acute coronary syndromes (ACS) 2, 3, 4, 5.
• Symptoms most predictive of ACS include chest discomfort that is substernal or spreading to the arms or jaw, while chest pain that can be reproduced with palpation or varies with breathing or position is less likely to signify ACS 5.
• Electrocardiography changes that predict ACS include ST depression, ST elevation, T-wave inversion, or presence of Q waves 4, 5.
• Elevated troponin levels without ST-segment elevation on electrocardiography suggest non-ST-segment elevation ACS 4, 5.
• Management considerations for ACS include:
  • Initiation of dual antiplatelet therapy and parenteral anticoagulation 2, 5
  • Statin therapy 2, 5
  • Beta-blocker therapy 2, 5
  • Sodium-glucose cotransporter-2 inhibitor therapy 5
  • Coronary angiography with percutaneous or surgical revascularization 4, 5
• Prehospital administration of aspirin and nitroglycerin for patients with suspected ACS may be beneficial, although the certainty of evidence is very low 6.
• Aspirin is recommended for all patients with a suspected ACS unless contraindicated, and the addition of a second antiplatelet is also recommended for most patients 2.