Cardiovascular chest pain - Clinical Symptoms

Clinical

Symptoms

Cardiovascular chest pain

Chest pain can arise from the cardiovascular system, the respiratory system, the oesophagus or the musculoskeletal system. The major causes of chest pain in the cardiovascular system include ischaemia, pericarditis and aortic dissection.

Enquire about chest pain ask about the site, nature (constricting, sharp, burning, tearing), radiation, pre-cipitating/relieving factors and any associated symptoms. Ask also about the time course, i.e. onset, duration, constant or episodic. SOCRATES may be used as a mnemonic:

·        Site

·        Onset

·        Character Radiation

·        Alleviating factors Time course

·        Exacerbating factors

·        Symptoms associated with the pain

Ischaemic heart pain is classically a central aching chest pain, often described as a tightness or heaviness, constricting or crushing in nature, radiating into the arms (particularly the left) and jaw. However, this varies between individuals and therefore the pattern of pain is very significant.

·        The pain of chronic stable angina is brought on by exercise or emotion, and it is usually relieved within 2–3 minutes by rest and relaxation. It tends to be worse in cold weather or after meals. It may be associated with shortness of breath. Sublingual glyceryl trinitrate (GTN), which dilates the coronary arteries, should also rapidly relieve it.

·        Angina that occurs at rest or is provoked more easily than usual for the patient is due to acute coronary syndrome. It often persists for longer and although it may respond to GTN, it tends to recur. In acute coronary syndrome it is not possible to differentiate angina from myocardial infarction without further investigations.

·        In myocardial infarction the pain bears no relationship to exertion. Typically the pain has the same character, but it is more severe and unrelieved except by opiate analgesia. Features suggestive of myocardial infarction rather than angina include pain, which lasts longer than 30 minutes, associated symptoms due to the release of catecholamines including sweating, dizziness, nausea and vomiting. Some patients describe a feeling of impending doom (angor animi).

Pericarditis causes a sharp or aching pain. It is a retrosternal or epigastric pain that radiates to the neck, back or upper abdomen. The pain is usually altered in severity in relation to posture, typically exacerbated by deep inspiration or lying flat and relieved by leaning forwards. The pain of pericarditis may last days or even 2–3 weeks.

Aortic dissection causes a very severe central tearing chest or abdominal pain that radiates through to the back. Its onset is abrupt and of greatest intensity at the time of onset.

Chest pain associated with tenderness is suggestive of musculoskeletal pain. Pleuritic pain (e.g. pneumonia, pulmonary embolism) is usually sharp and made worse by inspiration and coughing. Oesophageal pain is a retrosternal sensation often related to eating and may be associated with dysphagia. Oesophageal reflux causes a retrosternal burning pain, often exacerbated by bending forwards. Pain from the gallbladder or stomach can often mimic cardiac pain. Equally, pain arising from structures in the chest may present as abdominal pain, e.g. myocardial infarction, pneumonia.