In medicine, chest pain is a symptom of a number of conditions and is generally considered a medical emergency, unless the patient is a known angina pectoris sufferer and the symptoms are familiar (appearing at exertion and resolving at rest, known as "stable angina"). When the chest pain is not attributed to heart disease, it is termed non-cardiac chest pain.
As in all medicine, a careful medical history and physical examination is essential in separating dangerous and trivial causes of disease, and the management of chest pain is often done on specialised units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection). Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.
An emergency medicine doctor will also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking, diabetes and other risk factors.
Features of the pain suggest of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; the pain coming upon exertion; dizziness; shortness of breath and a "sense of impending doom."
On the basis of the above, a number of tests may be ordered:
X-rays of the chest and/or abdomen (CT scanning may be better but is often not available)
In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analyses are not sensitive enough (Chun & McGee 2004). The physician's typical approach is to rule-out the most dangerous causes of chest pain first (e.g., heart attack, blood clot in the lung, aneurysm). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient. If acute coronary syndrome ("unstable angina") is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (CK-MB, troponin or myoglobin). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.
Chun A, McGee S (2004). "Bedside diagnosis of coronary artery disease: a systematic review.". Am J Med117 (5): 334-43. PMID 15336583.
Ringstrom E, Freedman J (2006). "Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines.". Mt Sinai J Med73 (2): 499-505. PMID 16568192. Full text (PDF)
Butler K, Swencki S (2006). "Chest pain: a clinical assessment.". Radiol Clin North Am44 (2): 165-79, vii. PMID 16500201.
Haro L, Decker W, Boie E, Wright R (2006). "Initial approach to the patient who has chest pain.". Cardiol Clin24 (1): 1-17, v. PMID 16326253.
Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain.". Clin Med6 (5): 445-9. PMID 17080889.