ATYPICAL CHEST PAIN
Topic: Chest Pain Management
9 minute read
Pain is a symptom, so--for you, English Majors out there--the term asymptomatic chest pain, when referring to the absence of classical ACS pain, is an oxymoron. It is also a puzzle because it can refer to non-ischemic pain in the chest.
- Other things can cause chest pain besides the ACS:
- aortic dissection,
- pericardial tamponade,
- pulmonary embolism,
- tension pneumothorax, myocarditis,
- perforating peptic ulcer, and
- esophageal rupture (mediastinitis).
- There may be no chest pain at all; alternatively, there may be unusual (non-classical) manifestations of it, such as dyspnea alone, weakness, nausea and/or vomiting, epigastric pain or discomfort, palpitations, syncope, or cardiac arrest. These are more likely to present in
Thus, it describes situations without chest pain--unusual in otherwise symptomatic angina and acute coronary syndrome or
- other non-cardiac conditions that can mimic the ischemic symptoms of cardiac conditions.
Classic Chest Pain
Classic chest pain has the following characteristics:
- Vague and diffuse: cannot be pointed out with just one finger.
It is diffusely substernal or in the left chest, with possible radiation to the arm, neck, jaw, back, abdomen, or shoulders.
- Vague in its symptoms: crushing, pressure, heaviness, tightness, fullness, or squeezing.
It does not typically present as knifelike, sharp, or pleuritic. The position of the patient makes no difference.
- It comes and goes in its intensity, especially with exertion, but not with position.
Historically, "Levine's Sign" is a clutching of the fist to the chest as a gesture of chest pain associated with cardiac events.
Atypical Chest Pain
There is considerable overlap between ACS chest pain and non-cardiac chest pain regarding symptomatology. The following share partially in some of the classic chest pain presentations:
Pulmonary conditions: pulmonary embolus, pneumonia, pleuritis, asthma, and allergic reactions, among others. Distinguishable from ACS by pain increase with deep breathing or coughing.
GI conditions: GERD (Gastroesophageal Reflux Disease), esophagitis, and other esophageal disorders. Distinguishable from ACS by onset related to meals.
Musculoskeletal conditions are the most common cause of chest pain: costochondritis, rib fracture, etc. Distinguishable from ACS by being able to reproduce the pain with palpation or movement.
Infectious conditions, specifically, herpes zoster. Distinguishable from ACS by the presence of a dermatome-confined painful skin eruption.
Referred pain to the chest: from visceral sources like the gallbladder or diaphragm; or spinal origins such as disc herniation.
Psychiatric illness: a diagnosis of exclusion after taking a history and performing a physical examination, possibly involving a nitroglycerine challenge.
Special Populations and Atypical/Absence of Chest Pain with ACS
Atypical ACS Patients: 1/3 of MI patients represent a special population as they have no chest pain but present with dyspnea, weakness, nausea/vomiting, epigastric pain, palpitations, or syncope.
Women: may have no symptoms, and the initial presentation is discovered via an abnormal ECG done for reasons unrelated to ACS or MI. In 43% of women with MIs, chest pain is absent.
An important difference is an increased likelihood of a woman's chest pain being induced by rest, sleep, or stress (mental) instead of with exertion or in addition to it.
Diabetics: diabetics may not recognize ischemic pain, presenting with atypical angina symptoms, silent ischemia, or even silent infarction.
This may be caused by diabetic autonomic denervation of the heart.
Elderly: like women and diabetics, atypical or absent chest pain in the elderly may be their initial ACS presentation.
In the Field
Any chest pain--typical or atypical--should provoke a 12-lead ECG evaluation if feasible, considering the urgency. In diabetics, women, and the elderly--in the absence of chest pain--dyspnea, weakness, nausea, epigastric pain, palpitations, and syncope call for an ECG.