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Chest Pain
Analyzing the many causes of chest pain to arrive at a correct etiology
can vex even the most astute clinician. Although there are numerous
causes of chest pain, the most important are angina pectoris, myocardial
infarction, pericarditis, pulmonary embolus, dissection of the aorta, chest
wall distress, and the pain of gastrointestinal disorders such as hiatal
hernia, esophageal disease or spasm, cholecystitis, pancreatitis, and
peptic ulcer distress.
The features of angina pectoris are described below in detail by using
the seven basic properties that separate angina pectoris from other
causes of chest pain. The distinguishing features of other causes of
chest pain are also discussed.
Angina Pectoris
In 1772, William Heberden described the clinical disorder he called
angina pectoris:
But there is a disorder of the breast marked with strong and
peculiar symptoms, considerable for the kind of danger belonging
to it, and not extremely rare, which deserves to be mentioned
more at length. The seat of it, and sense of strangling, and
anxiety with which it is attended, may make it not improperly be
called angina pectoris.
They who are afflicted with it, are seized while they are walking
(more especially if it be uphill, and soon after eating) with a
painful and most disagreeable sensation in the breast, which
seems as if it would extinguish life, if it were to increase or to
continue; but the moment they stand still, all this uneasiness
vanishes.*
swallowing, on lying down, and with movement, as well as containment of
pain when leaning forward or breathing shallowly, is almost diagnostic.
Radiation of the pain to the left trapezial ridge or scapula and awareness
that the intensity of the pain coincides with the heartbeat is characteristic
but not always present. The pain may be sudden or gradual in onset and
may fluctuate from mild to severe. Relief of the pain with steroids but not
with narcotics is typical. Surprisingly, some patients may have pericarditis
but not experience any chest discomfort.
Pulmonary Emboius
A large pulmonary embolus that produces infarction of the lung is
usually easily diagnosed by the sudden onset of sharp, pleuritic chest
pain, dyspnea, hemoptysis, cyanosis, and tachycardia. More commonly,
pulmonary emboli do not result in pulmonary infarction and may provide a
diagnostic dilemma. The diagnosis of pulmonary emboli should be
considered if there is pleuritic pain, unexplained dyspnea (particularly if
the dyspnea is acute and episodic), atrial arrhythmias, cyanosis,
tachycardia, fever, or congestive heart failure.
The diagnosis is strongly supported by the occurrence of hemoptysis,
which is so infrequent, however, that its absence should not alter the diag-
nosis. Since pulmonary emboli usually occur in the setting of venous injury,
venous stasis, or alteration of blood coagulation, questions should be directed
to precipitating causes. The following information should be obtained:
Prior history of pulmonary emboli
Presence of leg or calf tenderness
History of heart, lung, or blood disease
Recent surgery (particularly hip surgery), pregnancy, trauma, bed rest, or
long car trip
Use of oral contraceptives
Use of constricting girdle or garter
Occupation (prolonged standing)
Presence of varicose veins or previous vein stripping
By realizing that pulmonary emboli occur in certain settings, particularly
in hospitalized patients, and that their clinical presentation is rarely classic,
the clinician may be able to make the diagnosis.
Hyperventilation. Dyspnea related to anxiety and attendant hyperventi-
lation is very common and may provide a thorny differential diagnosis,
particularly because hyperventilation often causes chest discomfort
simulating angina. Patients with breathlessness due to hyperventilation
often describe their symptoms as "The air doesn’t go all the way down..."
or "1 can’t get a full breath." The patient should be carefully observed for
signs of sighing, swallowing of air, and anxiety, and should be asked about
other symptoms of hyperventilation such as tingling or numbness in the
hands ("falling asleep") or around the mouth, dryness of the mouth, and
dizziness. When anxiety is associated with organic heart or lung disease,
determining the major contributing cause of the dyspnea may be perplexing.
Dizziness and Syncope
The symptom of dizziness may cover a multitude of sensations,
including giddiness, a fainting feeling, temporary confusion, unsteadiness,
or vertigo. The patient may substitute other descriptions such as blacking
out, swimming in the head, graying of vision, lightheadedness, or falling-
out spells. Vertigo, a spinning sensation, must be carefully differentiated
from dizziness. The term "syncope" implies a temporary loss of
consciousness and postural tone that may or may not be preceded by
dizziness. An episode of dizziness and temporary loss of postural tone
without complete loss of consciousness is referred to as "near syncope."
Since the physician rarely has the opportunity to observe the episode of
syncope, the diagnosis is almost always based on a history provided by the
patient or a witness to the event. The following questions may be useful:
Did you feel as if you would faint, or was the sensation more like spinning
or vertigo?
What was the location and time of the attack? Did it occur more than once?
Analyzing the many causes of chest pain to arrive at a correct etiology
can vex even the most astute clinician. Although there are numerous
causes of chest pain, the most important are angina pectoris, myocardial
infarction, pericarditis, pulmonary embolus, dissection of the aorta, chest
wall distress, and the pain of gastrointestinal disorders such as hiatal
hernia, esophageal disease or spasm, cholecystitis, pancreatitis, and
peptic ulcer distress.
The features of angina pectoris are described below in detail by using
the seven basic properties that separate angina pectoris from other
causes of chest pain. The distinguishing features of other causes of
chest pain are also discussed.
Angina Pectoris
In 1772, William Heberden described the clinical disorder he called
angina pectoris:
But there is a disorder of the breast marked with strong and
peculiar symptoms, considerable for the kind of danger belonging
to it, and not extremely rare, which deserves to be mentioned
more at length. The seat of it, and sense of strangling, and
anxiety with which it is attended, may make it not improperly be
called angina pectoris.
They who are afflicted with it, are seized while they are walking
(more especially if it be uphill, and soon after eating) with a
painful and most disagreeable sensation in the breast, which
seems as if it would extinguish life, if it were to increase or to
continue; but the moment they stand still, all this uneasiness
vanishes.*
swallowing, on lying down, and with movement, as well as containment of
pain when leaning forward or breathing shallowly, is almost diagnostic.
Radiation of the pain to the left trapezial ridge or scapula and awareness
that the intensity of the pain coincides with the heartbeat is characteristic
but not always present. The pain may be sudden or gradual in onset and
may fluctuate from mild to severe. Relief of the pain with steroids but not
with narcotics is typical. Surprisingly, some patients may have pericarditis
but not experience any chest discomfort.
Pulmonary Emboius
A large pulmonary embolus that produces infarction of the lung is
usually easily diagnosed by the sudden onset of sharp, pleuritic chest
pain, dyspnea, hemoptysis, cyanosis, and tachycardia. More commonly,
pulmonary emboli do not result in pulmonary infarction and may provide a
diagnostic dilemma. The diagnosis of pulmonary emboli should be
considered if there is pleuritic pain, unexplained dyspnea (particularly if
the dyspnea is acute and episodic), atrial arrhythmias, cyanosis,
tachycardia, fever, or congestive heart failure.
The diagnosis is strongly supported by the occurrence of hemoptysis,
which is so infrequent, however, that its absence should not alter the diag-
nosis. Since pulmonary emboli usually occur in the setting of venous injury,
venous stasis, or alteration of blood coagulation, questions should be directed
to precipitating causes. The following information should be obtained:
Prior history of pulmonary emboli
Presence of leg or calf tenderness
History of heart, lung, or blood disease
Recent surgery (particularly hip surgery), pregnancy, trauma, bed rest, or
long car trip
Use of oral contraceptives
Use of constricting girdle or garter
Occupation (prolonged standing)
Presence of varicose veins or previous vein stripping
By realizing that pulmonary emboli occur in certain settings, particularly
in hospitalized patients, and that their clinical presentation is rarely classic,
the clinician may be able to make the diagnosis.
Hyperventilation. Dyspnea related to anxiety and attendant hyperventi-
lation is very common and may provide a thorny differential diagnosis,
particularly because hyperventilation often causes chest discomfort
simulating angina. Patients with breathlessness due to hyperventilation
often describe their symptoms as "The air doesn’t go all the way down..."
or "1 can’t get a full breath." The patient should be carefully observed for
signs of sighing, swallowing of air, and anxiety, and should be asked about
other symptoms of hyperventilation such as tingling or numbness in the
hands ("falling asleep") or around the mouth, dryness of the mouth, and
dizziness. When anxiety is associated with organic heart or lung disease,
determining the major contributing cause of the dyspnea may be perplexing.
Dizziness and Syncope
The symptom of dizziness may cover a multitude of sensations,
including giddiness, a fainting feeling, temporary confusion, unsteadiness,
or vertigo. The patient may substitute other descriptions such as blacking
out, swimming in the head, graying of vision, lightheadedness, or falling-
out spells. Vertigo, a spinning sensation, must be carefully differentiated
from dizziness. The term "syncope" implies a temporary loss of
consciousness and postural tone that may or may not be preceded by
dizziness. An episode of dizziness and temporary loss of postural tone
without complete loss of consciousness is referred to as "near syncope."
Since the physician rarely has the opportunity to observe the episode of
syncope, the diagnosis is almost always based on a history provided by the
patient or a witness to the event. The following questions may be useful:
Did you feel as if you would faint, or was the sensation more like spinning
or vertigo?
What was the location and time of the attack? Did it occur more than once?
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