Chest Pain – 3

We previously addressed Coronary Artery Disease (Chest Pain – 1) and the various causes of Pleuritic Chest Pain (Chest Pain – 2).  Finishing off the topic now with our differential for Non-Pleuritic Pain.

DIFFERENTIAL DIAGNOSIS – CHEST PAIN

Pleuritic Chest Pain

Non-Pleuritic Chest Pain

We’ve already dealt with coronary artery disease, our main rule-out (see “Chest Pain – 1”).  Other causes are more benign… usually.

**  Aneurysms of the Thoracic Aorta aren’t so benign.  They can dissect within the wall, or simply rupture.  The former is more common, but both are rare.  Think of it in patients over 60 years old with cardiovascular risk factors.  Younger patients are those with Marfan’s syndrome or congenital bicuspid aortic valves.

The main parameter is sudden onset, which makes sense, since the intact aneurysm is usually asymptomatic.  Pain is described as “sharp,” “tearing” or “ripping,” as opposed to the dull, heavy ache of coronary disease.  It may radiate to the back or anywhere, or remain in the chest.

Findings may include a blood pressure >20 mmHg higher in the right arm than the left, or an absent carotid or peripheral pulse, but these are not the norm.  Various neurological manifestations rarely occur.  The chest x-ray (CXR) may reveal a wide mediastinum or tracheal deviation, but may be normal up to 1/3 of the time.

Bottom line: sudden onset of severe sharp or tearing chest pain in a patient at risk warrants CT in the ED.

**  Esophageal Disorders such as gastroesophageal reflux (GERD) mimic cardiac pain, because both organs share the same innervation.  Think of it when pain occurs after swallowing, or when supine in bed, or if it lasts hours, or is accompanied by heartburn or acid regurgitation.  Or if accompanied by dysphagia, a sense of food getting stuck when swallowing.  With dysphagia, refer for endoscopy to rule out esophageal cancer.

But primarily, think of esophageal disease in the patient without coronary risk factors.  Symptoms can be so similar, that GERD is almost a diagnosis of exclusion.  Going back to our discussion of CAD, absence of risk factors is a good reason to rule out angina or MI, especially if pain does not increase during exertion.

Duration and Chronology are also important — angina lasts under 5 minutes, and recurs.  Heavy chest pain lasting 30-60 minutes could be an MI if it began recently, but not if it’s recurred intermittently on a regular basis.

A word about “therapeutic trials,” uncontrolled, open-label, with an N of 1 — don’t place much stock in them.  But if you want to see if acid suppression works, go for a high dose of the most efficacious drug, e.g. ompeprazole 40 mg BID [or equivalent PPI], plus p.r.n. antacids.  Only do it for a couple of weeks (we’re diagnosing, after all).  If you give a typically modest starting dose, & it doesn’t help, you won’t know if it’s because the dose is too low, or diagnosis wrong.

If the patient gets better on their acid suppression, they’ll be infinitely grateful.  You’ll beam with pride, but don’t take yourself too seriously.  Sure, maybe they have GERD.  But a gold standard, like esophageal pH monitoring, and other partially-invasive tests, are only used by specialists for the most refractory cases heading toward surgery.  Above all, be happy you’ve ruled out CAD.

In the days before Pepcid & Prilosec, a superb internist I worked with described his overriding fear:  your patient returns to the ER, “DOA, with Maalox on the mouth.”  He’d nod soberly, “It happened to other residents, but never to me.”  I’d picture it — “Maalox on the mouth.”

**  Herpes Zoster (Shingles) can cause chest pain if a left thoracic nerve root is involved.  This can be tricky, if not impossible, to diagnose, since pain can precede lesions by 1-2 days.  Search the skin for even the tiniest splotches of erythema or incipient vesicles anywhere from spine to sternum.

I saw that same excellent internist tell a patient, “You have shingles — in a day or two the blisters will come out.”  And he was wrong!  No lesions appeared.  Still, I admired his guts for venturing the diagnosis.  Clinical skills improve if you stick your neck out & take risks.  [actually, I thought it was pretty dumb to tell the patient; he should’ve just bragged to me & been wrong].

If you really diagnose Zoster in a patient younger than 50, suggest an HIV test.  It’ll probably be negative, but almost everyone with HIV gets Zoster at some point, due to even very subtle immune deficiency.  Not that you can’t get HIV over 50, but age by itself is enough to cause Zoster reactivation [when it comes to Zoster, 50 is “elderly;” maybe that’s why it’s when I began to get AARP mailings.  Hemlock & Neptune Societies too!!].

**  “Chest Wall Pain” sounds like a garbage-bag diagnosis; actually, that’s just what it is.  Like esophageal spasm or GERD, there’s no useful gold standard.  I never chart “costochondritis” because it sounds too pathologic, & therefore phony.  Sure, there’s Tietze’s Syndrome, a red, hot swollen costal cartilage found in SLE & other rheumatological disorders, but I’ve never seen it.  I’ll tell the patient they strained a muscle or “bruised a rib,” & write “chest wall pain” for my assessment [I prefer at least some intellectual sincerity].

Once again, our main job is to R/O CAD or other catastrophes.  See prior posting “Chest pain – 2” to distinguish benign chest wall pain from a pathologic rib fracture.

**  Breast Disorders are sometimes perceived as “chest pain,” particularly in men and in women with small breasts.  If in doubt, breast palpation will bring out the tenderness and clarify the issue.

**  Anxiety can cause chest pain.  Patients with panic disorder may experience chest tightness, along with palpitations, diaphoresis, sensation of suffocation, nausea, lightheadedness, tremor, and/or intense fear.  Though a frank heart attack can also generate all of the above, including fear.  And any cause of chest pain can cause anxiety.

The main distinguisher is absence of CAD risk factors.  Other clues include the lack of exertional exacerbation, and presence of tingling in the hands and mouth [symptoms of hyperventilation, not pathologic dyspnea].  When caring for a patient in the midst of a possible panic attack, don’t forget to inquire about stimulant use.  Cocaine and Meth can cause panic, & infarction too.

Like GERD & chest wall pain, anxiety is a diagnosis of exclusion.  Proceed systematically through a solid history and physical exam.  You don’t necessarily need to perform stress tests or cardiac catheterization, but even if the diagnosis seems obvious, an EKG will at least reassure the patient.  In fact, if you don’t order one, it may increase the anxiety.

That’s it for chest pain.  Next time we’ll explore a related subject: “Dyspnea” (a.k.a. SOB).

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