CHAPTER 14 - CHEST DISCOMFORT
📌 Other Cardiopulmonary Causes of Chest Discomfort
📌 Epidemiology & Natural History of Chest Discomfort 1. Pericardial & Myocardial Diseases
• Prevalence: • Pericarditis:
• Among the top 3 reasons for ED visits in the U.S. • Pain mainly from pleural inflammation (pericardium itself
largely insensitive).
• Accounts for 6–7 million ED visits/year.
• Evaluation & Outcomes:
• Pleuritic, positional pain (↑ with breathing, coughing,
position changes).
• >60% hospitalized for further testing; most others undergo • Referred pain: shoulder/neck (phrenic nerve) or upper
ED investigations.
abdomen (lateral diaphragm).
• <15% ultimately diagnosed with acute coronary syndrome
• Myocarditis:
(ACS) (10–20% in most series, as low as 5% in some).
• Most common diagnosis: gastrointestinal causes. • Chest discomfort from myocardial inflammation or ↑ wall
stress due to ventricular dysfunction.
• ~5% are other life-threatening cardiopulmonary causes.
• Takotsubo (stress) cardiomyopathy:
• Many cases remain unexplained after ACS and other major • Triggered by emotional/physical stress.
causes are excluded.
• Missed MI:
• Mimics acute MI (ST elevation, troponin rise).
• 2–6% of discharged patients with presumed nonischemic • More common in women >50 yrs.
2. Diseases of the Aorta
chest pain later found to have missed MI.
• These patients have double the 30-day mortality risk • Acute Aortic Syndromes (AAS):
compared to hospitalized patients. • Spectrum: aortic dissection, penetrating ulcer, intramural
hematoma.
• Prognosis in Low-Risk Patients:
• In >350,000 patients with unspecified, noncardiopulmonary • Pain: sudden, severe, tearing.
chest pain → <2% 1-year mortality, similar to general o Ascending aorta: anterior chest pain.
population. o Descending aorta: back pain.
• 30-day major CV events: ~2.5% in low-risk acute chest o Extension: pain radiates from chest → back
(between scapulae).
pain (excluding STEMI or definite noncardiac pain).
• Type A dissection (ascending aorta): risk of MI (coronary
ostia compromise), acute AI, tamponade.
• Risk factors: hypertension, pregnancy, bicuspid aortic
valve, Marfan, Ehlers-Danlos.
• Incidence: ~3/100,000/year.
• Aortic aneurysm: usually asymptomatic; pain if compressing
nearby structures (steady, deep).
• Aortitis: rare cause of chest/back pain.
3. Pulmonary Causes
• Pulmonary Embolism (PE):
• Incidence: ~1/1000/year.
📌 Myocardial Ischemia / Injury • Symptoms: sudden dyspnea + pleuritic pain.
• Myocardial ischemia (angina pectoris): imbalance between • Pain sources: pleural infarct, pulmonary artery distention, RV
myocardial O₂ demand vs. supply. strain/ischemia.
• O₂ demand ↑ with ↑ heart rate, wall stress, and contractility. • Small PE: lateral, pleuritic pain.
• O₂ supply depends on coronary blood flow + arterial O₂ content. • Massive PE: severe substernal pain (MI-like), may cause
syncope, hypotension, RHF.
• Severe, prolonged ischemia (>20 min) → irreversible injury →
MI. • Pneumothorax:
Causes • Primary spontaneous: young men, smokers, Marfan;
incidence 7/100,000 (men), <2/100,000 (women).
• Most common: Atherosclerotic plaque narrowing epicardial
coronary arteries. • Secondary: COPD, asthma, CF; more severe.
• Stable ischemic heart disease (SIHD): gradual narrowing → • Tension pneumothorax: emergency → trapped air →
exertional angina, relieved by rest/NTG. hemodynamic collapse.
• Unstable ischemia (ACS): • Other pulmonary diseases:
• Unstable angina (UA): ischemia without myocardial • Pneumonia, malignancy: pain via pleural/surrounding
injury. structure involvement.
• NSTEMI: ischemia with myocardial necrosis, no ST • Pleurisy: sharp, knife-like pain, worse with
elevation. inspiration/cough.
• STEMI: complete occlusion → transmural ischemia + ST • Chronic pulmonary HTN: angina-like chest pain (RV
elevation + necrosis. ischemia).
• Other triggers: ↑ demand (stress, fever), ↓ supply (anemia, • Asthma/reactive airway disease: chest tightness +
hypoxia, hypotension). dyspnea (not pleuritic).
• MI classification: 📌 Noncardiopulmonary Causes of Chest Discomfort
o Type 1 MI: due to acute coronary thrombosis. 1. Gastrointestinal Causes
• Type 2 MI: secondary to O₂ supply-demand imbalance. • Most common source of nontraumatic chest pain; often
mimics angina.
• Non-atherosclerotic causes: vasospasm, microvascular
disease, endothelial dysfunction, congenital anomalies, • Esophageal disorders:
arteritis, myocardial bridging, radiation-induced disease. • GERD & esophageal spasm → retrosternal, squeezing pain
• Structural conditions contributing: aortic stenosis, (may be relieved by nitroglycerin or CCBs, making it hard
hypertrophic or dilated cardiomyopathy. to distinguish from angina).
Characteristics of Ischemic Chest Discomfort (Angina) • Mallory-Weiss tear / Boerhaave’s syndrome (rupture after
• Typical description: aching, heavy, squeezing, crushing, severe vomiting) → acute severe chest pain.
constricting. • Peptic ulcer disease: epigastric pain radiating to chest.
Variants: vague tightness, burning, numbness. • Hepatobiliary disease (cholecystitis, biliary colic):
• Location: usually retrosternal; may radiate to left arm (ulnar side), • Pain usually RUQ or epigastrium, radiates to back, chest,
right arm, both arms, neck, jaw, or shoulders. or scapula.
• Patterns: • Steady pain lasting hours, resolves spontaneously between
o Stable angina: gradual onset, peaks in minutes, lasts attacks.
minutes, predictable with exertion/stress, relieved by • Pancreatitis: epigastric aching pain radiating to back.
📌 Other Cardiopulmonary Causes of Chest Discomfort
📌 Epidemiology & Natural History of Chest Discomfort 1. Pericardial & Myocardial Diseases
• Prevalence: • Pericarditis:
• Among the top 3 reasons for ED visits in the U.S. • Pain mainly from pleural inflammation (pericardium itself
largely insensitive).
• Accounts for 6–7 million ED visits/year.
• Evaluation & Outcomes:
• Pleuritic, positional pain (↑ with breathing, coughing,
position changes).
• >60% hospitalized for further testing; most others undergo • Referred pain: shoulder/neck (phrenic nerve) or upper
ED investigations.
abdomen (lateral diaphragm).
• <15% ultimately diagnosed with acute coronary syndrome
• Myocarditis:
(ACS) (10–20% in most series, as low as 5% in some).
• Most common diagnosis: gastrointestinal causes. • Chest discomfort from myocardial inflammation or ↑ wall
stress due to ventricular dysfunction.
• ~5% are other life-threatening cardiopulmonary causes.
• Takotsubo (stress) cardiomyopathy:
• Many cases remain unexplained after ACS and other major • Triggered by emotional/physical stress.
causes are excluded.
• Missed MI:
• Mimics acute MI (ST elevation, troponin rise).
• 2–6% of discharged patients with presumed nonischemic • More common in women >50 yrs.
2. Diseases of the Aorta
chest pain later found to have missed MI.
• These patients have double the 30-day mortality risk • Acute Aortic Syndromes (AAS):
compared to hospitalized patients. • Spectrum: aortic dissection, penetrating ulcer, intramural
hematoma.
• Prognosis in Low-Risk Patients:
• In >350,000 patients with unspecified, noncardiopulmonary • Pain: sudden, severe, tearing.
chest pain → <2% 1-year mortality, similar to general o Ascending aorta: anterior chest pain.
population. o Descending aorta: back pain.
• 30-day major CV events: ~2.5% in low-risk acute chest o Extension: pain radiates from chest → back
(between scapulae).
pain (excluding STEMI or definite noncardiac pain).
• Type A dissection (ascending aorta): risk of MI (coronary
ostia compromise), acute AI, tamponade.
• Risk factors: hypertension, pregnancy, bicuspid aortic
valve, Marfan, Ehlers-Danlos.
• Incidence: ~3/100,000/year.
• Aortic aneurysm: usually asymptomatic; pain if compressing
nearby structures (steady, deep).
• Aortitis: rare cause of chest/back pain.
3. Pulmonary Causes
• Pulmonary Embolism (PE):
• Incidence: ~1/1000/year.
📌 Myocardial Ischemia / Injury • Symptoms: sudden dyspnea + pleuritic pain.
• Myocardial ischemia (angina pectoris): imbalance between • Pain sources: pleural infarct, pulmonary artery distention, RV
myocardial O₂ demand vs. supply. strain/ischemia.
• O₂ demand ↑ with ↑ heart rate, wall stress, and contractility. • Small PE: lateral, pleuritic pain.
• O₂ supply depends on coronary blood flow + arterial O₂ content. • Massive PE: severe substernal pain (MI-like), may cause
syncope, hypotension, RHF.
• Severe, prolonged ischemia (>20 min) → irreversible injury →
MI. • Pneumothorax:
Causes • Primary spontaneous: young men, smokers, Marfan;
incidence 7/100,000 (men), <2/100,000 (women).
• Most common: Atherosclerotic plaque narrowing epicardial
coronary arteries. • Secondary: COPD, asthma, CF; more severe.
• Stable ischemic heart disease (SIHD): gradual narrowing → • Tension pneumothorax: emergency → trapped air →
exertional angina, relieved by rest/NTG. hemodynamic collapse.
• Unstable ischemia (ACS): • Other pulmonary diseases:
• Unstable angina (UA): ischemia without myocardial • Pneumonia, malignancy: pain via pleural/surrounding
injury. structure involvement.
• NSTEMI: ischemia with myocardial necrosis, no ST • Pleurisy: sharp, knife-like pain, worse with
elevation. inspiration/cough.
• STEMI: complete occlusion → transmural ischemia + ST • Chronic pulmonary HTN: angina-like chest pain (RV
elevation + necrosis. ischemia).
• Other triggers: ↑ demand (stress, fever), ↓ supply (anemia, • Asthma/reactive airway disease: chest tightness +
hypoxia, hypotension). dyspnea (not pleuritic).
• MI classification: 📌 Noncardiopulmonary Causes of Chest Discomfort
o Type 1 MI: due to acute coronary thrombosis. 1. Gastrointestinal Causes
• Type 2 MI: secondary to O₂ supply-demand imbalance. • Most common source of nontraumatic chest pain; often
mimics angina.
• Non-atherosclerotic causes: vasospasm, microvascular
disease, endothelial dysfunction, congenital anomalies, • Esophageal disorders:
arteritis, myocardial bridging, radiation-induced disease. • GERD & esophageal spasm → retrosternal, squeezing pain
• Structural conditions contributing: aortic stenosis, (may be relieved by nitroglycerin or CCBs, making it hard
hypertrophic or dilated cardiomyopathy. to distinguish from angina).
Characteristics of Ischemic Chest Discomfort (Angina) • Mallory-Weiss tear / Boerhaave’s syndrome (rupture after
• Typical description: aching, heavy, squeezing, crushing, severe vomiting) → acute severe chest pain.
constricting. • Peptic ulcer disease: epigastric pain radiating to chest.
Variants: vague tightness, burning, numbness. • Hepatobiliary disease (cholecystitis, biliary colic):
• Location: usually retrosternal; may radiate to left arm (ulnar side), • Pain usually RUQ or epigastrium, radiates to back, chest,
right arm, both arms, neck, jaw, or shoulders. or scapula.
• Patterns: • Steady pain lasting hours, resolves spontaneously between
o Stable angina: gradual onset, peaks in minutes, lasts attacks.
minutes, predictable with exertion/stress, relieved by • Pancreatitis: epigastric aching pain radiating to back.
