What are the potential causes of chest pain in a patient, considering factors such as age, sex, medical history (e.g. hypertension, diabetes, hyperlipidemia), and symptoms (e.g. shortness of breath, dizziness, nausea)?

Causes of Chest Pain

Chest pain etiology varies dramatically by clinical setting, with cardiac causes representing only 20% in primary care but 60-69% in emergency settings, making context-dependent risk stratification essential for appropriate evaluation. 1

Life-Threatening Causes Requiring Immediate Exclusion

The initial approach must prioritize rapid identification or exclusion of conditions with high morbidity and mortality 1:

Cardiac Causes

• Acute Coronary Syndrome (ACS) encompasses STEMI, NSTEMI, and unstable angina, presenting as retrosternal discomfort with radiation to left arm, neck, or jaw, often precipitated by physical or emotional stress 2
• Aortic dissection manifests as sudden-onset tearing or ripping chest pain with radiation to the back, particularly in hypertensive patients 2
• Patients with cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) require immediate ECG within 10 minutes and cardiac troponin measurement 1

Non-Cardiac Life-Threatening Causes

• Pulmonary embolism presents with acute chest pain accompanied by dyspnea 2
• Tension pneumothorax causes acute onset chest pain with respiratory compromise 2
• Esophageal rupture requires urgent recognition as a life-threatening nonvascular syndrome 2

Distribution by Clinical Setting

The probability of cardiac versus non-cardiac causes depends critically on where the patient presents 1:

Primary Care Setting

• Musculoskeletal disorders: 43% - most common cause in general practice 1
• Cardiac causes: 20% - less frequent but cannot be excluded 1
• Psychiatric causes: 11% - including anxiety, depression, or alcohol abuse 1
• Gastrointestinal: 5% 1
• Pulmonary: 4% 1

Emergency Department/Ambulance Setting

• Cardiac causes: 60-69% - dramatically higher prevalence 1
• Musculoskeletal: 5-14% - much less common than in primary care 1
• Among emergency calls for chest pain, 40% have confirmed myocardial ischemia or infarction 1
• Only 5.1% of ED chest pain patients ultimately have ACS, but evaluation must focus on excluding this diagnosis 1

Common Non-Life-Threatening Causes

Musculoskeletal

• Chest wall pain is reproducible with palpation, worsens with specific movements, and is usually nonischemic 1, 2
• Costochondritis presents with localized tenderness at costochondral junctions 2

Gastrointestinal

• GERD can mimic cardiac symptoms with epigastric pain that may respond to nitroglycerin, though this response is not diagnostic 2, 3
• Peptic ulcer disease causes epigastric pain that can radiate to the back with posterior penetrating ulcers 2
• Esophageal spasm can respond to nitroglycerin similar to cardiac ischemia 2

Pulmonary (Non-Life-Threatening)

• Pleurisy causes intensely painful but prognostically benign chest pain related to breathing 4
• Pneumonia with pleuritic involvement rarely poses diagnostic difficulty 4
• Pulmonary hypertension and lung cancer show constant pain unrelated to respiratory movements 4

Psychiatric

• Patients with chest pain without somatic diagnosis often suffer from anxiety, depression, or alcohol abuse 1
• Women may be overrepresented in psychiatric causes of chest pain 1

Critical Patient-Specific Considerations

Age-Related Patterns

• Young adults: Musculoskeletal causes and hyperventilation are more common, but ACS cannot be excluded based on age alone 2
• Middle age: Increasing prevalence of ACS and coronary artery disease requires balanced consideration of cardiac and non-cardiac causes 2
• Elderly (≥75 years): Age itself is a major risk factor for ACS; accompanying symptoms may include shortness of breath, syncope, acute delirium, or unexplained falls 2, 5

Sex-Based Differences

• Women are at significant risk for underdiagnosis because traditional risk scores and physician assessments often underestimate their cardiac risk 1, 5
• Women more commonly present with accompanying symptoms: jaw/neck pain, back pain, palpitations, epigastric symptoms, shortness of breath, nausea, and diaphoresis 1, 5
• Chest pain remains the dominant symptom in women with ACS, occurring with equal frequency to men 1
• Cardiac causes must always be considered in women presenting with chest pain 1

Risk Factor Profile Impact

• Patients with hypertension, diabetes, and hyperlipidemia have higher likelihood of cardiac etiology 1, 6
• Patients with non-ischemic chest pain have lower prevalence of previous MI, angina, hypertension, and diabetes 1
• Smoking is more frequent in patients with non-ischemic chest pain 1

Algorithmic Diagnostic Approach

Immediate Assessment (Within 10 Minutes)

1. Obtain 12-lead ECG to assess for STEMI, ST depression, or new T-wave inversion 1, 6
2. Measure cardiac troponin as soon as possible if ACS is suspected 1, 6
3. Focused cardiovascular examination to identify complications and assess for aortic dissection, PE, or esophageal rupture 2, 5

Symptom Characterization

Pain characteristics suggesting ischemia 1:

• Retrosternal discomfort described as pressure, tightness, heaviness, or squeezing
• Gradual build in intensity over minutes
• Radiation to left/right arm, neck, jaw, or back
• Precipitated by physical exercise or emotional stress

Pain characteristics suggesting non-ischemic causes 1:

• Sharp chest pain that increases with inspiration and lying supine
• Sudden onset of ripping pain (suggests aortic dissection)
• Fleeting pain of few seconds duration
• Pain localized to very limited area
• Positional chest pain (usually musculoskeletal)

Risk Stratification

• Use structured risk assessment tools rather than clinical gestalt alone 1
• Low-risk patients do not require urgent diagnostic testing for suspected CAD 1
• Intermediate to high-risk patients benefit most from cardiac imaging and testing 1

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as diagnostic criterion for myocardial ischemia, as GERD and esophageal spasm show comparable response 1, 2, 3
• Do not assume symptoms are noncardiac based on "atypical" presentation, especially in elderly women, as this descriptor is based on male symptom patterns 2, 5
• Do not attribute symptoms to anxiety or psychosomatic causes until comprehensive cardiac workup is negative 2, 5
• Do not delay urgent transport to ED if ACS or other life-threatening causes are suspected in office setting 2, 5
• Do not exclude cardiac causes in young patients or those without classic risk factors 2

Context-Dependent Clinical Decision-Making

For patients calling emergency dispatch or arriving by ambulance: Assume high pretest probability of cardiac etiology (60-69%) and initiate rapid ACS protocol 1

For patients in primary care setting: While musculoskeletal causes dominate (43%), maintain vigilance for the 20% with cardiac etiology, particularly in patients with risk factors 1

For emergency department presentations: Use clinical decision pathways routinely to standardize evaluation 1