Chest pain

Introduction

Chest pain is one of the most frequent reasons for emergency consultations. It refers to any pain or discomfort between the base of the neck and the diaphragm. Its causes are highly varied: cardiovascular, pulmonary, digestive, musculoskeletal or psychogenic. The challenge is to quickly distinguish benign causes (muscle pain, anxiety) from life-threatening emergencies such as myocardial infarction, pulmonary embolism, aortic dissection or pneumothorax.

If you experience new or unusual chest pain, first contact your primary care physician. If they are unavailable, Docadom offers an emergency consultation with a doctor at home : call 021 845 45 45 or use our application available on the App Store and Google Play. Any constrictive chest pain radiating to the left arm or jaw requires an immediate call to 144.

Who is at risk?

Anyone can experience chest pain. Patients with cardiovascular risk factors (smoking, hypertension, diabetes, dyslipidemia, family history of heart attack) are at high risk of acute coronary syndrome. Bedridden patients, women on estrogen-progestin contraception, travelers, and post-operative patients are at risk for pulmonary embolism. Tall, thin young men may present with a spontaneous pneumothorax. Elderly patients or those with Marfan syndrome are exposed to aortic dissection. Stress, anxiety and panic disorders are also very common causes, especially in young subjects.

Symptoms and characteristics of the pain

A detailed analysis of the pain is essential to guide the diagnosis. The consultation clarifies several key elements.

Characteristics of the pain

• Location : substernal, precordial, lateral, lower chest, back.

• Radiation : jaw, left arm, back, epigastrium.

• Type : constrictive, vice-like, stabbing, burning, throbbing.

• Onset : sudden, gradual, on exertion, at rest, after a meal.

• Duration : a few seconds, a few minutes, several hours.

• Triggering or relieving factors : exertion, stress, position, respiration, palpation, nitroglycerin.

Associated signs to look for

• Dyspnea, sweating, nausea, pallor (indicative of a heart attack).

• Cough, fever, sputum (point towards an infectious cause like pneumonia).

• Palpitations, syncope, dizziness (suggestive of an arrhythmia).

• Edema or redness of a calf (suggests deep vein thrombosis and pulmonary embolism).

• Heartburn, regurgitation (digestive cause).

• Anxiety, hyperventilation (panic disorder).

When to seek emergency consultation?

Chest pain should prompt calling 144 without delay in the following cases:

• Sudden, intense, vice-like, substernal pain, radiating to the jaw or left arm.

• Pain associated with dyspnea, sweating, nausea, dizziness or loss of consciousness.

• Sudden sharp back pain (suspicion of aortic dissection).

• Chest pain with bloody cough or sudden dyspnea (suspicion of pulmonary embolism).

• Cyanosis or respiratory distress.

• Patient with cardiovascular risk factors or a history of coronary disease.

What to do before calling Docadom? First, contact your primary care physician, who knows your cardiovascular history and treatments. If they cannot be reached and the pain does not suggest a life-threatening emergency, you can call Docadom at 021 845 45 45 or place your request directly from our smartphone application (App Store and Google Play). In case of pain suggestive of an infarction, embolism, or aortic dissection, call 144 immediately.

Causes of chest pain

Cardiovascular causes

The most feared: acute coronary syndrome (infarction, unstable angina), stable angina, aortic dissection, pulmonary embolism, acute pericarditis, myocarditis. Infarction pain is substernal, constrictive, prolonged, radiating to the jaw or left arm, accompanied by sweating and nausea.

Pulmonary causes

Spontaneous pneumothorax (tall, thin young person or COPD), acute pneumonia, pleurisy, acute asthma (chest tightness, wheezing), exacerbation of chronic bronchitis.

Digestive causes

Gastroesophageal reflux disease (ascending substernal pain, heartburn), esophageal spasm (very intense pain that can mimic a heart attack), peptic ulcer, acute pancreatitis, cholecystitis.

Chest wall and musculoskeletal causes

Tietze syndrome, intercostal neuralgia, shingles (pain in a band followed by vesicular rash), rib fractures, chest bruises.

Psychogenic causes

Panic disorder, generalized anxiety, somatization. Often associated with hyperventilation, paresthesia and a feeling of impending doom. This diagnosis must be made cautiously, after ruling out serious causes.

Diagnosis of chest pain

Diagnosis is based on the medical history, clinical examination and targeted additional tests.

Diagnostic methods

• Physical examination : vital signs (blood pressure in both arms, pulse, respiratory rate, oxygen saturation), cardiac and pulmonary auscultation, palpation, calf examination.

• Electrocardiogram (ECG) : key test, to be performed in less than 10 minutes.

• Troponin : marker of myocardial distress, elevated in infarction.

• D-dimers : useful in case of suspicion of pulmonary embolism with low or intermediate probability.

• Chest X-ray : to look for pneumothorax, pulmonary consolidation, mediastinal widening.

• Echocardiography : heart function, valves, pericardium.

• Chest CT angiogram : gold standard for pulmonary embolism and aortic dissection.

• Coronary angiography : confirms and treats acute coronary syndrome.

Alternative diagnoses

• Anxiety attack or panic disorder : diagnosis of exclusion.

• Stress cardiomyopathy (takotsubo) : mimics a heart attack, triggered by emotional stress.

• Pulmonary hypertension : predominant dyspnea, atypical pain.

• Spinal disorders referred to the chest.

Management and treatment

Management depends on the cause. Any suspicious chest pain must be evaluated emergently.

Initial emergency management

Call 144 in case of signs of infarction, dissection, or embolism. Rest, oxygen therapy if necessary, monitoring, IV access, blood tests, rapid ECG.

Treatments according to the cause

• Acute coronary syndrome : antiplatelet agents, anticoagulants, beta-blockers, statins, nitroglycerin, emergency angioplasty.

• Pulmonary embolism : immediate anticoagulation, sometimes thrombolysis.

• Aortic dissection : strict control of blood pressure, emergency surgery for proximal forms.

• Pneumothorax : observation or chest tube insertion depending on the severity.

• Pericarditis : NSAIDs, colchicine, etiological treatment.

• Gastroesophageal reflux : PPIs, dietary and lifestyle measures.

• Musculoskeletal causes : analgesics, NSAIDs, physical therapy.

• Anxiety or panic disorder : reassurance, psychological management, sometimes anxiolytics or antidepressants.

Prevention

Prevention mainly concerns cardiovascular causes:

• Smoking cessation, regular physical activity, balanced diet, maintaining a healthy weight.

• Control of blood pressure, of cholesterol, of diabetes.

• Cardiological follow-up for patients at risk.

• Preventive anticoagulation in situations with thromboembolic risk (surgery, immobilization).

• Stress management and early treatment of anxiety disorders.

• Vaccinations (flu, COVID, pneumococcus) which reduce cardiovascular complications.

Possible complications

Complications depend on the underlying cause:

• Complicated myocardial infarction : heart failure, severe rhythm disorder, sudden death.

• Massive pulmonary embolism : cardiogenic shock, cardiac arrest.

• Aortic dissection : rupture, tamponade, stroke, visceral ischemia.

• Tension pneumothorax : acute respiratory failure.

• Complicated pericarditis : tamponade, chronic constrictive pericarditis.

• Psychological impact of repeated chest pain.

When to contact a doctor for chest pain

Any unexplained chest pain warrants medical advice. Here is what you should do:

• As a first resort : contact your primary care physician, who knows your cardiovascular profile and your treatments.

• If your primary care physician is unavailable (evenings, weekends, holidays) and the pain does not suggest a life-threatening emergency, Docadom offers an emergency consultation by a doctor at home. Call 021 845 45 45 or make your request via our mobile app, available for free on the App Store and Google Play.

• In case of signs suggestive of infarction, embolism or dissection (intense vice-like pain, radiation, dyspnea, sweating, dizziness), call 144 immediately.

Conclusion: never ignore chest pain

Chest pain is a symptom to be taken seriously. Benign in many cases, it can reveal a life-threatening emergency such as myocardial infarction, pulmonary embolism or aortic dissection. It is characterized by a wide variety of presentations, which depend on the underlying cause. It can lead to very serious complications in the event of delayed diagnosis, especially in patients at cardiovascular risk.

If you have any doubt, first contact your primary care physician. If they are not available and the situation is not critical, Docadom provides an emergency doctor at home 7 days a week: call 021 845 45 45 or use our mobile app (App Store, Google Play). If you experience chest pain suggestive of acute coronary syndrome, do not hesitate: call 144.