From the Guidelines
Chest pain can be caused by a variety of life-threatening and benign conditions, and prompt medical evaluation is essential to determine the underlying cause and provide appropriate treatment. The most serious causes of chest pain include heart attacks (myocardial infarction), where blood flow to heart muscle is blocked, causing crushing pain often radiating to the left arm or jaw, accompanied by shortness of breath and sweating 1. Other cardiac causes include pericarditis (inflammation of the heart sac), aortic dissection (tearing of the major artery), and valvular heart disease.
Common Causes of Chest Pain
- Cardiac causes: heart attacks, angina, pericarditis, aortic dissection, and valvular heart disease
- Pulmonary conditions: pulmonary embolism, pneumonia, pleurisy, and pneumothorax
- Gastrointestinal causes: acid reflux, esophageal spasms, and peptic ulcers
- Musculoskeletal pain: costochondritis, muscle strain, or rib fractures
- Psychological conditions: panic attacks and anxiety
According to the 2024 American Heart Association and American Red Cross guidelines for first aid, the prevalence of myocardial infarction in patients presenting to the ED with nontraumatic chest pain varies by age, ranging from ≈1% in patients 18 to 44 years of age to 4% in patients ≥80 years of age 1. The 2021 ACR Appropriateness Criteria for nontraumatic chest wall pain also highlights the importance of distinguishing visceral from musculoskeletal pain in the diagnostic approach 1.
Importance of Prompt Medical Evaluation
Prompt medical evaluation is crucial for any new or concerning chest pain, especially if accompanied by shortness of breath, nausea, or lightheadedness, as immediate treatment for conditions like heart attacks can be lifesaving 1. A focused cardiovascular examination should be performed initially to aid in the diagnosis of acute coronary syndromes or other potentially serious causes of chest pain 1.
In patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in the diagnosis of ACS or other potentially serious causes of chest pain. The physical examination contributes almost nothing in diagnosing a heart attack, unless there is an associated shock, and general predictors for infarction are age, male gender, type of pain and pattern of radiation, nausea and sweating, and prior cardiovascular disease 1.
Triage and Management of Chest Pain
Triage of patients with acute chest pain is critical, and the main tools to diagnose the cause of chest pain are history and a physical examination with a stethoscope and a blood-pressure cuff 1. Severe prolonged chest pain of acute onset is rarely a decision-making problem, and immediate hospital care is needed for conditions like heart attacks, aneurysm of the aorta, pulmonary embolism, pneumothorax, and other pulmonary conditions 1.
In summary, chest pain can be caused by a variety of conditions, and prompt medical evaluation is essential to determine the underlying cause and provide appropriate treatment. A focused cardiovascular examination should be performed initially to aid in the diagnosis of acute coronary syndromes or other potentially serious causes of chest pain.
From the FDA Drug Label
Nitrate therapy may aggravate the angina caused by hypertrophic cardiomyopathy Chest pain, acute myocardial infarction, and even sudden death have occurred during temporary withdrawal of nitrates In some of these trials, an increase in the frequency of anginal attacks during the nitrate free interval was observed in a small number of patients. If chest pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than is typically experienced, prompt medical attention is recommended
The causes of chest pain in a patient may include:
- Hypertrophic cardiomyopathy which can be aggravated by nitrate therapy
- Temporary withdrawal of nitrates
- Anginal attacks which can increase in frequency during the nitrate free interval If the chest pain is different from what is typically experienced, or if it persists after treatment, prompt medical attention is recommended 2
From the Research
Causes of Chest Pain
The causes of chest pain in a patient can be diverse and may originate from various structures within the thoracic cavity 3. The possible causes can be broadly categorized into cardiac and noncardiac causes.
Cardiac Causes
Cardiac causes of chest pain typically present with anginal symptoms and may include:
- Acute coronary syndrome (ACS), which encompasses myocardial infarction and unstable angina 4, 5, 6
- Myocardial ischemia 6
- Heart failure, although this is unlikely in the absence of dyspnea 4
Noncardiac Causes
Noncardiac causes of chest pain can have a variety of characteristics and may include:
- Pulmonary causes such as:
- Musculoskeletal causes, where pain is reproducible by palpation 4
- Gastroesophageal reflux disease (GERD) 5
- Panic disorder or anxiety states 4, 5
- Acute pericarditis 5
- Acute thoracic aortic dissection 5
- Costochondritis 5
Evaluation and Diagnosis
A thorough history, physical examination, and diagnostic tests such as chest radiograph, electrocardiogram, and measurement of troponin levels are essential for evaluating chest pain 4, 5. Clinical prediction rules and risk stratification tools, like the Marburg Heart Score and the INTERCHEST clinical decision rule, can help estimate the risk of ACS and guide further evaluation and management 5. Noninvasive cardiac imaging modalities may also be used to exclude ischemia as an etiology and to establish noncoronary etiologies for chest pain 6.