chest pain chest pain chest pain is pain or discomfort in the chest, typically the front of the chest. it may be described as sharp, dull, pressure, heaviness or squeezing. associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath. it can be divided into heart-related and non-heart-related pain. pain due to insufficient blood flow to the heart is also called angina pectoris. those with diabetes or the elderly may have less clear symptoms. chest painother namespectoralgia, stethalgia, thoracalgia, thoracodyniapotential location of pain from a heart attackspecialtyemergency medicine, internal medicine, cardiologysymptomsdiscomfort in the front of the chesttypescardiac, noncardiaccausesserious: acute coronary syndrome (including heart attacks), pulmonary embolism, pneumothorax, pericarditis, aortic dissection, esophageal rupturecommon: gastroesophageal reflux disease, psychological problems such as anxiety disorders, depression, stress etc, muscle or skeletal pain, pneumonia, shinglesdiagnostic methodmedical history, physical exam, medical teststreatmentbased on the underlying causemedicationaspirin, nitroglycerinprognosisdepends on the underlying causefrequency~5% of er visits serious and relatively common causes include acute coronary syndrome such as a heart attack (31%), pulmonary embolism (2%), pneumothorax, pericarditis (4%), aortic dissection (1%) and esophageal rupture. other common causes include gastroesophageal reflux disease (30%), muscle or skeletal pain (28%), pneumonia (2%), shingles (0.5%), pleuritis, traumatic and anxiety disorders. determining the cause of chest pain is based on a person's medical history, a physical exam and other medical tests. about 3% of heart attacks, however, are initially missed. management of chest pain is based on the underlying cause. initial treatment often includes the medications aspirin and nitroglycerin. the response to treatment does not usually indicate whether the pain is heart-related. when the cause is unclear, the person may be referred for further evaluation. chest pain represents about 5% of presenting problems to the emergency room. in the united states, about 8 million people go to the emergency department with chest pain a year. of these, about 60% are admitted to either the hospital or an observation unit. the cost of emergency visits for chest pain in the united states is more than us$8 billion per year. chest pain accounts for about 0.5% of visits by children to the emergency department. signs and symptoms chest pain may present in different ways depending upon the underlying diagnosis. chest pain may also vary from person to person based upon age, sex, weight, and other differences. chest pain may present as a stabbing, burning, aching, sharp, or pressure-like sensation in the chest. chest pain may also radiate, or move, to several other areas of the body. this may include the neck, left or right arms, cervical spine, back, and upper abdomen. other associated symptoms with chest pain can include nausea, vomiting, dizziness, shortness of breath, anxiety, and sweating. the type, severity, duration, and associated symptoms of chest pain can help guide diagnosis and further treatment. differential diagnosis causes of chest pain range from non-serious to serious to life-threatening. in adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%). other less common causes include: pneumonia, lung cancer, and aortic aneurysms. psychogenic causes of chest pain can include panic attacks; however, this is a diagnosis of exclusion. in children, the most common causes for chest pain are musculoskeletal (76-89%), exercise-induced asthma (4-12%), gastrointestinal illness (8%), and psychogenic causes (4%). chest pain in children can also have congenital causes. cardiovascular a blockage of coronary arteries can lead to a heart attack acute coronary syndrome stable or unstable angina myocardial infarction ("heart attack"): people usually complained of a pressure or squeezing sensation over the chest. other associated symptoms are: excessive sweating, nausea, vomiting, and weakness. chest pain is more commonly associated with anterior infarction because of left ventricular impairment; inferior infarction is more commonly associated with nausea, vomiting, and excessive sweating due to irritation of vagus nerve; lateral infarction is associated with left arm pain. prinzmetal's angina: chest pain is caused by coronary vasospasm. more common in women younger than 50 years. person usually complain of chest pain at rest. it may occur early in the morning which awaken person from sleep. cocaine use: this condition is suspected when a person with few or no risk of arteriosclerosis presented with non-traumatic chest pain. ingestion of cocaine can cause vasoconstriction of coronary arteries, thus producing chest pain similar to heart attack. symptoms can appear within one hour of cocaine use. aortic stenosis: this condition happens when the person has underlying congenital bicuspid valve, aortic sclerosis, or history of rheumatic fever. chest pain usually happens during physical activity. syncope is a late symptom. signs and symptoms of heart failure may also present. on auscultation, loud ejection systolic murmur can be best heard at the right second intercostal space and radiates to the carotid artery in the neck. splitting of second heart sound is heard in severe stenosis. hypertrophic cardiomyopathy: it is the hypertrophy of interventricular septum that causes outflow obstruction of left ventricle. dyspnea and chest pain commonly occurs during daily activities. sometimes, syncope (fainting) may happen. on physical examination, significant findings include: loud systolic murmur and palpable triple apical impulse due to palpable presystolic fourth heart sound. aortic dissection is characterized by severe chest pain that radiates the back. it is usually associated with marfan's syndrome and hypertension. on examination, murmur of aortic insufficiency can be heard with unequal radial pulses. pericarditis: this condition can be the result of viral infection such as coxsackie virus and echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial infarction (dressler syndrome). the chest pain is often pleuritic in nature (associated with respiration) which is aggravated when lying down and relieved on sitting forward, sometimes, accompanied by fever. on auscultation, pericardial friction rub can be heard. cardiac tamponade arrhythmia: atrial fibrillation and a number of other arrhythmias can cause chest pain. myocarditis mitral valve prolapse syndrome: those affected are usually slim females presented with chest pain which is sharp in quality, localized at the apex, and relieved when lying down. other symptoms include: shortness of breath, fatigue, and palpitations. on auscultation, midsystolic click followed by late systolic murmur can be heard, louder when person is in standing position. aortic aneurysm respiratory asthma is a common long-term inflammatory disease of the airways of the lungs. it is characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. chest pain usually happens during a strenuous activity or heavy exercise. bronchitis pulmonary embolism: common signs and symptoms are shortness of breath, pleuritic chest pain, blood in sputum during cough, and lower limb swelling. risk factors includes: recent surgery, malignancy, and bedridden state. source of embolus usually comes from venous thromboembolism. pneumonia hemothorax pneumothorax: those who are at a higher risk of developing pneumothorax are tall, slim male smokers who have had underlying lung diseases such as emphysema. those affected can have a sharp chest pain which radiates to the shoulder of the same side. physical examination revealed absent breath sounds and hyperresonance on the affected side of the chest. pleurisy tuberculosis tracheitis lung cancer gastrointestinal gastroesophageal reflux disease is a common cause of chest pain in adults gastroesophageal reflux disease: the pain is aggravated when lying down or after meals. persons may describe this as a heartburn. besides, they may also complain of tasting bitter contents from the stomach. achalasia, nutcracker esophagus, and other motility disorders of the esophagus diffuse esophageal spasm: unlike cardiac chest pain, esophageal pain is not related to activity. the pain is usually associated with swallowing of hot or cold water. esophageal rupture: those affected usually complain of sudden, severe, and constant pain that starts from the neck to the upper abdomen. the pain is aggravated by swallowing. on examination, neck swelling and crepitations can be felt due to subcutaneous emphysema as free air is entering from esophagus into the subcutaneous tissue. esophagitis: there are many causes of esophagitis. esophagitis caused by candida albicans is usually found in chemotherapy or hiv patients. medication such as nonsteroidal anti-inflammatory drug and alendronate can induce esophagitis if not swallowed properly. functional dyspepsia hiatus hernia jackhammer esophagus (hypercontractile peristalsis): intense long-lasting esophageal muscle spasm. acute cholecystitis: characterized by positive murphy's sign where the person has a cessation of inhalation when the doctor places his finger at the right subcostal region of the abdomen. acute pancreatitis: history of excessive alcohol use, cholelithiasis (stones in the gallbladder), and hypertriglyceridemia are risk factors for pancreatitis. it is a constant, boring pain in the upper abdomen. perforated peptic ulcer: sudden onset of severe pain in the upper abdomen which later develops into peritonitis (inflammation of tissues that lines the abdominal organs). acute gastritis chest wall costochondritis or tietze's syndrome: an inflammation of a costochondral junction. any movements or palpation of the chest can reproduce the symptoms. spinal nerve problem fibromyalgia chest wall problems radiculopathy precordial catch syndrome: another benign and harmless form of a sharp, localized chest pain often mistaken for heart disease. breast conditions herpes zoster (shingles): it is usually described as a burning sensation over the chest in a unilateral dermatome distribution. however, diagnosis can be difficult because the pain usually appears before the characteristic rash is visible. tuberculosis osteoarthritis bornholm disease rib fracture psychological panic attack: chest pain is a common symptom of panic attacks, with as high as 78% of persons describing chest pain with their worst panic attacks. overall chest pain is a symptom of up to 48% of sudden-onset panic attacks, and 10% of gradual-onset panic attacks. anxiety clinical depression somatization disorder hypochondria others hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth. da costa's syndrome carbon monoxide poisoning sarcoidosis lead poisoning prolapsed intervertebral disc thoracic outlet syndrome adverse effect from certain medications diagnostic approach history taking knowing a person's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. for example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors. chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of acute coronary syndrome. other clues in the history can help lower the suspicion for myocardial infarction. these include chest pain described as "sharp" or "stabbing", chest pain that is positional or pleuritic in nature, and chest pain that can be reproduced with palpation. however, both atypical and typical symptoms of acute coronary syndrome can occur, and in general a history cannot be enough to rule out the diagnosis of acute coronary syndrome. in some cases, chest pain may not even be a symptom of an acute cardiac event. an estimated 33% of persons with myocardial infarction in the united states do not present with chest pain, and carry a significantly higher mortality as a result of delayed treatment. physical examination careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialized units (termed medical assessment units) to concentrate the investigations. occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as levine's sign in cardiac ischemia. however, in the case of acute coronary syndrome, a third heart sound, diaphoresis, and hypotension are the most strongly associated physical exam findings. however these signs are limited in their prognostic and diagnostic value. other physical exam findings suggestive of cardiac chest pain may include hypertension, tachycardia, bradycardia, and new heart murmurs. chest pain that is reproducible during the physical exam with contact of the chest wall is more indicative of non-cardiac chest pain, but still cannot completely rule out acute coronary syndrome. for this reason, in general,