What causes chest pain in an adult with a history of cardiovascular disease?

Causes of Chest Pain in Adults with Cardiovascular Disease

In adults with a history of cardiovascular disease presenting with chest pain, acute coronary syndrome (ACS) must be assumed and ruled out first, as it accounts for only 5.1% of all ED chest pain presentations but represents the most critical life-threatening cause, followed by systematic evaluation for other cardiac causes (aortic dissection, pericarditis), pulmonary causes (pulmonary embolism, pneumothorax), and then noncardiac causes. 1

Life-Threatening Cardiac Causes (Priority Assessment)

Acute Coronary Syndrome

• ACS (including STEMI, NSTEMI, and unstable angina) is the most critical cardiac cause and must be evaluated immediately in patients with cardiovascular disease history. 1, 2
• Presents as retrosternal chest discomfort described as pressure, heaviness, tightness, squeezing, or constriction that builds gradually over several minutes. 1
• Pain typically radiates to the left arm, shoulders, jaw, neck, or upper abdomen. 1
• Critical point: Symptom severity does not correlate with outcome—even slight discomfort can represent life-threatening ACS. 2
• Women more frequently experience accompanying symptoms including nausea, fatigue, shortness of breath, palpitations, and back/jaw/neck pain. 1, 3

Aortic Dissection

• Presents with sudden onset "ripping" or tearing chest pain with radiation to the upper or lower back. 1, 2, 3
• Extremity pulse differential occurs in 30% of cases. 2
• This diagnosis is critical in hypertensive patients with cardiovascular disease. 3

Pericarditis

• Sharp, pleuritic pain that improves when sitting forward and worsens when lying supine. 2
• Pain increases with inspiration. 1
• ECG shows widespread ST-elevation and PR depression. 2

Valvular Heart Disease

• Chest pain occurs with stenotic valvular disease (aortic stenosis, mitral stenosis) due to coronary microvascular dysfunction or coexisting obstructive CAD. 1
• Acute severe valvular regurgitation (papillary muscle rupture in MI, acute aortic insufficiency with dissection) causes acute chest pain. 1

Life-Threatening Pulmonary Causes

Pulmonary Embolism

• Presents with tachycardia and dyspnea in >90% of patients. 2, 3
• Pleuritic pain on inspiration is characteristic. 2, 3
• Must be considered in patients with cardiovascular disease given overlapping risk factors. 1

Pneumothorax

• Sudden onset chest pain with dyspnea. 3
• Pleuritic pain on inspiration, unilateral absence of breath sounds, and hyperresonant percussion. 2

Tension Pneumothorax and Esophageal Rupture

• Both are immediately life-threatening and require rapid recognition. 1, 3, 4

Noncardiac Causes (After Life-Threatening Causes Excluded)

Musculoskeletal Disorders

• Most common cause in general practice (43%) but only 5-14% in emergency settings. 2, 3
• Critical caveat: Approximately 7% of patients with reproducible chest wall tenderness still have ACS. 2
• Costochondritis presents with tenderness of costochondral joints on palpation. 2
• Pain that can be localized to a very limited area is typically nonischemic. 1, 3

Gastrointestinal Causes

• Gastroesophageal reflux disease accounts for 10-20% of outpatient chest pain and 5-6% of ED presentations. 2, 3
• Esophageal motility disorders (achalasia, distal esophageal spasm, nutcracker esophagus) present as squeezing retrosternal pain with dysphagia. 2
• Sharp chest pain that increases with inspiration and lying supine is unlikely ischemic (suggests pericarditis or esophageal origin). 1

Psychiatric Causes

• Anxiety, panic disorder, depression, and somatoform disorders account for 5-11% of chest pain presentations. 2, 3
• These conditions can cause or worsen chest pain and complicate clinical assessment. 5

Immediate Diagnostic Approach

Initial Assessment (Within 10 Minutes)

• Obtain 12-lead ECG within 10 minutes of patient arrival. 2, 3, 6
• Measure cardiac troponin as soon as possible, using high-sensitivity troponin with sex-specific thresholds when available. 2, 3, 6
• Obtain focused history including: nature, onset/duration, location/radiation, precipitating factors, relieving factors, and associated symptoms. 1

Risk Stratification

• Use structured risk assessment with evidence-based diagnostic protocols (GRACE 2.0, TIMI risk score). 1, 7
• In patients ≥75 years, consider ACS when accompanying symptoms include shortness of breath, syncope, acute delirium, or unexplained falls. 1

High-Probability Ischemic Descriptors

• Central, left-sided, pressure, dull, squeezing, aching, gripping, burning, heaviness, tightness, exertional/stress-related, or retrosternal pain. 1

Low-Probability Ischemic Descriptors

• Stabbing, right-sided, fleeting (seconds duration), sharp, pleuritic, or shifting pain. 1

Critical Clinical Pitfalls

• Never describe chest pain as "atypical"—use "cardiac," "possibly cardiac," or "noncardiac" instead, as "atypical" can be misinterpreted as benign. 1
• Women are at risk for underdiagnosis—always consider cardiac causes and emphasize accompanying symptoms more common in women with ACS. 1, 3
• Fleeting chest pain of few seconds' duration is unlikely ischemic heart disease. 1
• Sudden onset of ripping pain with back radiation is suspicious for aortic dissection, not angina. 1
• Pain localized to a very limited area or radiating below the umbilicus is unlikely anginal. 1, 3