Chest pain and other forms of discomfort are common symptoms that can occur as a result of pulmonary, pleural, or musculoskeletal disease, esophageal or other gastrointestinal disorders, or anxiety states, as well as many cardiovascular diseases. Myocardial ischemia is a frequent cause of cardiac chest pain and the most important to identify to prevent complications, but it is often experienced more as a sensation of discomfort than actual pain, thereby increasing the potential for being ignored by the patient
or misdiagnosed by the physician. This is usually described as dull, aching, or as a sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather than as sharp or spasmodic. Ischemic symptoms usually subside within 5–20 minutes but may last longer. Progressive symptoms or symptoms at rest may represent unstable angina due to coronary plaque rupture and thrombosis. Protracted episodes often represent myocardial infarction, although one third of patients with acute myocardial infarction do not have chest pain. When present, the pain is commonly accompanied by a sense of anxiety or uneasiness. The location is usually retrosternal or left precordial. Because there are not the appropriate sensory nerves on the heart, the central nervous system (CNS) interpretation of pain location often results in pressure or “heaviness” being referred to the throat, lower jaw, shoulders, inner arms, upper abdomen, or back. Ischemic pain may be precipitated by exertion, cold temperature, meals, stress, or combinations of these factors and is usually relieved by rest, but many episodes do not conform to these patterns. It is not related to position or respiration and is usually not elicited by chest palpation. In myocardial infarction, a precipitating factor is frequently not apparent. One clue that the pain may be ischemic is other symptoms associated with the pain, such as shortness of breath, dizziness, a feeling of impending doom, and vagal symptoms, such as nausea and diaphoresis. Hypertrophy of either ventricle or stenotic aortic valvular disease may also give rise to ischemic pain or pain with less typical features. Myocarditis, pulmonary hypertension, and mitral valve prolapse are also associated with chest pain atypical for angina pectoris. Pericarditis may produce pain that is greater supine than upright, and may increase with respiration, or swallowing. Pleuritic chest pain is not ischemic, and pain on palpation should signal a musculoskeletal etiology. Aortic dissection classically produces an abrupt onset of tearing pain of great intensity that often radiates to the back.
Source: - Canto JG et al: Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223. - Lee TH et al: Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187.