Differential diagnosis of chest pain

Some features differentiating cardiac from noncardiac chest pain Favoring ischemic origin Against ischemic origin Chracter of pain ConstrictingDull ache Squeezing “ knife like ”, sharp, stabbling Burning “ Jabs ” aggravated by respiration “ Heaviness ”, “ heavy feeling ” Factors Provoking Pain ExercisePain after completion Excitementof exercise Other forms of stressProvoked by a specific Cold weather body motion After meals

Some features differentiating cardiac from noncardiac chest pain Favoring ischemic origin Against ischemic origin Location of Pain SubsternalIn the left submammary area Across mid-thorax, anteriorlyIn the left hemithorax In both arms, shoulders In the neck, cheeks, teeth In the forearms, fingers In the interscalpular region

Effort angina Quality : visceral(pressure) first episode vivid Duration : 5-15 minutes Location : substernal, radiates Provocation: during effort or emotion Relief : rest, nitroglycerin

Resting angina Quality : visceral(pressure) often nocturnal Duration : 5-15 minutes Location : substernal, radiates Provocation: spontaneous(? with exercise) Relief : nitroglycerin

Distinguishing Features of Esophageal Pain from Angina Location : high epigastric, behind xiphoid process or in low retrosternal area Nature : burning pain or spasm, heartburn increased salivation, dysphagia Radiation: tend to ascend or to radiate down to epigastrium no radiation to left side Precipitation: certain foods (alcohol, coffee, spices) less likely by exertion Duration : may last hours; wax and wane

Esophageal Reflux/Peptic Ulcer Quality : visceral, burning Duration : 10 minutes to 1 hour Location : substernal, epigastric no radiation Provocation: recumbency, after meals, lack of food, “ acid foods ” Relief : food, antacid

Esophageal Spasm Quality : visceral(mimic angina) Duration : 5-60 minutes Location : substernal with radiation to the back Provocation: spontaneous, cold liquids, exercise Relief : NTG

Biliary disease Quality : visceral(waxes and wanes) colic Duration : hours Location : epigstric, ? radiates Provocation: spontaneous food Relief : time, analgesia

Pulmonary Quality : visceral(pressure), dyspneic Duration : 30 minutes + Location : substernal Provocation: often spontaneous Relief : rest, time, bronchodilator

Hyperventilation Quality : visceral(facial paresthesia) Duration : 2-3 minutes Location : substernal Provocation: emotion, tachypnea Relief : stimulus removal

Musculoskeletal Quality : superficial(tenderness) Duration : variable Location : multiple Provocation: movement, palpation Relief : time, analgesia

Cervical disc Quality : superficial Duration : variable(gradually subside) Location : arm, neck Provocation: hand and neck movement palpation Relief : time, analgesia (not relieved by rest)