What are the causes of chest pain?

Causes of Chest Pain

Chest pain arises from six major categories: cardiac (20-69% depending on clinical setting), musculoskeletal (5-43%), gastrointestinal (3-6%), pulmonary (4-5%), psychiatric (5-11%), and other causes (16-26%), with the distribution varying dramatically based on whether the patient presents to a general practitioner versus an emergency setting. 1

Life-Threatening Cardiac Causes

Acute coronary syndrome (including STEMI, NSTEMI, and unstable angina) represents the most critical cardiac cause, accounting for 40-66% of emergency calls for chest pain and 8-17% of hospital admissions. 1 Patients may describe severe pain or merely slight discomfort, and symptom severity does not directly correlate with outcome. 1

Aortic dissection presents with sudden onset "ripping" chest pain radiating to the back, with extremity pulse differential in 30% of cases. 1, 2, 3

Pericarditis causes sharp, pleuritic pain that improves when sitting forward and worsens when supine, with widespread ST-elevation and PR depression on ECG. 1, 3 A pericardial friction rub may be audible. 1

Myocarditis presents with fever, chest pain, heart failure signs, and S3 gallop, and can mimic musculoskeletal pain. 4, 2

Valvular heart disease, particularly stenotic lesions or acute severe regurgitation (such as from ruptured papillary muscle in AMI), can cause chest pain. 1

Life-Threatening Pulmonary Causes

Pulmonary embolism presents with tachycardia and dyspnea in >90% of patients, with pleuritic pain on inspiration. 1, 4, 2, 3 Pleural effusion develops in 46% of PE cases. 3

Pneumothorax is characterized by dyspnea, pleuritic pain on inspiration, unilateral absence of breath sounds, and hyperresonant percussion. 1, 4, 2, 3

Pneumonia causes localized pleuritic pain, fever, productive cough, regional dullness to percussion, egophony, and possible friction rub. 1, 4, 2, 3

Musculoskeletal Causes

Musculoskeletal disorders are the most common cause in general practice settings (43%), but only 5-14% in emergency settings. 1

Costochondritis/Tietze syndrome presents with tenderness of costochondral joints on palpation. 1, 4, 3 However, approximately 7% of patients with reproducible chest wall pain still have acute coronary syndrome, making this a critical pitfall. 4, 3

Gastrointestinal Causes

Gastroesophageal reflux disease is the most common gastrointestinal cause, accounting for 10-20% of outpatient chest pain. 1 The pain can mimic myocardial ischemia, described as squeezing or burning, lasting minutes to hours, often occurring after meals or at night. 1

Esophageal motility disorders (achalasia, distal esophageal spasm, nutcracker esophagus) present as squeezing retrosternal pain often accompanied by dysphagia. 1

Medication-induced esophagitis from NSAIDs, potassium supplements, iron, or bisphosphonates should be considered. 1

Psychiatric Causes

Anxiety, panic disorder, depression, and somatoform disorders account for 5-11% of chest pain presentations. 1 These conditions are more common in women and are often diagnoses of exclusion. 1 Patients with noncardiac chest pain without somatic diagnosis frequently suffer from psychiatric problems including alcohol abuse. 1

Other Causes

Herpes zoster causes pain in a dermatomal distribution triggered by touch, with characteristic unilateral dermatomal rash that does not cross the midline. 1, 4, 2, 3

Clinical Setting Determines Probability

The likelihood of each cause varies dramatically by clinical setting:

• General practice: Musculoskeletal (43%), cardiac (20%), psychiatric (11%), gastrointestinal (5%), pulmonary (4%) 1
• Emergency dispatch/ambulance: Cardiac (60-69%), other (18-19%), musculoskeletal (5-6%), gastrointestinal (3-6%), pulmonary (4%), psychiatric (5%) 1
• Emergency department: Cardiac (45%), other (26%), musculoskeletal (14%), psychiatric (8%), gastrointestinal (6%), pulmonary (5%) 1

Critical Diagnostic Approach

Obtain a 12-lead ECG within 10 minutes of patient arrival and measure cardiac troponin as soon as possible, regardless of whether pain is reproducible, unless a clearly noncardiac cause is evident. 1, 4, 3 Perform a focused cardiovascular examination to identify life-threatening causes including ACS, aortic dissection, pulmonary embolism, and esophageal rupture. 1, 4

Common Pitfalls

Never assume reproducible chest wall tenderness excludes cardiac pathology—7% of these patients have ACS. 4, 3 Nitroglycerin response should not be used as a diagnostic criterion, as relief does not confirm or exclude myocardial ischemia. 3 Sharp, pleuritic pain does not exclude cardiac ischemia—13% of ACS patients present with pleuritic pain. 3 Patients can have concurrent conditions (e.g., herpes zoster and myocardial infarction). 2