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Doctor’s Tip: Some causes of chest pain

Chest pain is a common concern of patients visiting primary care providers. Sometimes chest pain can be associated with serious — even life-threatening — conditions, other times not. Following are some common causes of chest pain:

Heart attacks occur when atherosclerotic plaque in walls of coronary arteries ruptures, resulting in a clot that completely blocks off the blood flow to part of the heart muscle. Typical symptoms include left chest pressure (“like an elephant sitting on my chest”), often with discomfort radiating to the left neck, shoulder and/or jaw. Associated symptoms include shortness of breath, sweating, nausea and light-headedness. About a third of heart attack patients — especially women, diabetics and the elderly — don’t experience chest pain, so lack of this symptom doesn’t rule out a heart attack. And sometimes the location of heart attack pain is atypical, such as the right chest or arm.

Angina is chest pain or tightness that occurs with exertion, often with radiation to the left neck, jaw, shoulder and/or arm. It is caused by insufficient blood supply to part of the heart muscle due to a partial blockage of a coronary artery, and it goes away with rest. Unstable angina is when chest pain that previously occurred only with exertion occurs at rest, in which case urgent medical attention is indicated.

Pneumonia is often associated with chest pain. Usually there are other symptoms, such as fever, chills and cough.

Pleurisy is a sharp pain with inspiration caused by an inflammation of part of the sac that surrounds the lungs. It is usually viral, although it can be a complication of bacterial pneumonia.

Heartburn is a misnomer because it has nothing to do with the heart. When gastric acid refluxes up into the esophagus, where it doesn’t belong, the irritation causes a burning pain in the area of the sternum (breast bone). It is usually relieved by antacids.

Anxiety and depression can cause chest pain, usually in the breastbone area. The phrase “a broken heart” comes from chest discomfort that occurs with grieving, even though the source of the pain isn’t actually the heart.

Pulmonary embolus (blood clot to the lungs) is often associated with chest pain with deep inspiration. Often there are other symptoms, such as a rapid pulse and shortness of breath.

Costochondritis is an inflammation where a rib attaches to the cartilage on one side of the sternum (breast bone). The inflamed area is tender to firm touch and sometimes hurts with a deep breath. A similar condition can occur with the xyphoid process, which protrudes downward an inch or so below the sternum.

Chest wall strain: There are muscles in the chest wall, which can become strained just like any other muscles. A common cause is heavy repetitive lifting, such as starting a new upper body resistance program.

Herpes zoster (shingles) is caused by the chickenpox virus, which lies dormant but can break out later along a nerve root, causing a painful, red, raised rash. When the involved nerve root is in the chest area, the pain and rash occur in a band-like distribution on one side of the chest. When the pain precedes the rash by a few days, the diagnosis is difficult, but once the rash breaks out, it is obvious.

Fleeting chest pains: It’s not unusual for patients to complain of sharp, transient pains in various areas of their chest, lasting for a second or two. Studies have followed patients with this complaint for years, and there does not seem to be any correlation with any serious health problem.

The take-home message is: If you think you could be having a heart attack or unstable angina, call 911 immediately. If you have another potentially serious cause of chest pain, or if you aren’t sure, seek medical attention urgently.

Dr. Feinsinger is a retired family physician with special interest in disease prevention and reversal through nutrition. Free services through Center For Prevention and The People’s Clinic include: one-hour consultations, shop-with-a-doc at Carbondale City Market and cooking classes. Call 970-379-5718 for appointment or email [email protected]

Chest Pain | La Plata Pediatrics & Family Health

Is this your symptom?

  • Uncomfortable pressure, fullness, squeezing, or other pain in the chest
  • This includes the area from the collar-bone to the bottom of the rib cage

Some Basics…

  • Not all chest pain is serious. But it is safer to assume that chest pain is serious until seen by a doctor.
  • Serious causes of chest pain include angina, aortic dissection (tear in aorta), myocardial infarction (heart attack), pericarditis (inflammation of heart), pneumonia, and pneumothorax (collapsed lung).
  • Less serious cause of chest pain include costochondritis (arthritis of ribs), gastro-esophageal reflux (GERD or acid reflux), and muscle strain.
  • Pain felt in the chest can come from things besides the heart. The ribs, spine, lungs, and other organs in the upper abdomen can also cause chest pain.

Pain Scale

  • None: no pain. Pain score is 0 on a scale of 0 to 10.
  • Mild: the pain does not keep you from work, school, or other normal activities. Pain score is 1-3 on a scale of 0 to 10.
  • Moderate: the pain keeps you from working or going to school. It wakes you up from sleep. Pain score is 4-7 on a scale of 0 to 10.
  • Severe: the pain is very bad. It may be worse than any pain you have had before. It keeps you from doing any normal activities. Pain score is 8-10 on a scale of 0 to 10.

What Are the Symptoms of a Heart Attack?

  • Chest pain or discomfort: this is normally felt in the center of the chest. It may feel like pressure, squeezing, or heaviness. It lasts for more than a few minutes.
  • Upper body pain or discomfort: felt in the upper arms, jaw, neck, or back.
  • Shortness of breath
  • Other symptoms: these can include sweating more than normal, nausea, and feeling lightheaded.

If you think you are having a heart attack, call 911 (an ambulance) right away!

When to Call for Chest Pain

Call 911 Now

  • Passed out (fainted)
  • Very weak (can’t stand)
  • Sweat on or dripping down face
  • Severe trouble breathing (struggling for each breath or can’t speak)
  • Lips or face are blue
  • Severe chest pain
  • Chest pain lasting more than 5 minutes and any of these:
    • Pain is crushing, pressure-like, or heavy
    • History of heart disease (angina, heart attack, bypass surgery, angioplasty)
    • More than 50 years old
    • More than 30 years old and have one or more cardiac risk factors (high blood pressure, diabetes, high cholesterol, obesity, smoker, or strong family history of heart disease)
  • Took nitroglycerin and chest pain did not go away
  • You think you have a life-threatening emergency

Call Doctor or Seek Care Now

  • Fever
  • You feel weak or very sick
  • You think you need to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

  • Rash or blisters in same area as pain
  • You think you need to be seen, but the problem is not urgent

Contact Doctor During Office Hours

  • Chest pain that comes and goes for a few seconds each time, and lasts more than 3 days
  • Chest pain only when coughing, and lasts more than 3 days
  • You have other questions or concerns

Self Care at Home

  • Chest pains come and go for a few seconds each time
  • Mild chest pain only when coughing

Care Advice

Mild Chest Pain

  1. What You Should Know:
    • Not all chest pain is serious. But it is safer to assume that your chest pain is serious until you see a doctor.
    • Pain felt in the chest can come from things besides the heart. The ribs, spine, lungs, and other organs in the upper abdomen can also cause chest pain.
    • You can treat mild chest pain at home.
    • Here is some care advice that should help.
  2. Fleeting Chest Pain: These pains last only a few seconds and then go away. They are usually not serious. They may be from pinched muscles or nerves in your chest wall.

  3. Chest Pain Only When Coughing: Pain comes from the chest wall and airway irritation. This pain is most often not serious.

  4. Cough Medicines:
    • Over-the-Counter (OTC) Cough Syrups: Some people find that cough syrups help decrease coughing. Dextromethorphan is the most common cough suppressant in OTC cough syrups. Often the letters “DM” appear in the name.
    • OTC Cough Drops: Cough drops can help a lot. They work best for mild coughs. They soothe the tickling feeling in the back of the throat. Cough drops are easy to carry with you.
    • Home Remedy – Hard Candy: Hard candy works just as well as OTC cough drops. People who have diabetes should use sugar-free candy.
    • Home Remedy – Honey: Honey has been shown to help decrease coughing at night. The adult dose is 2 teaspoons (10 mL) at bedtime.
  5. What to Expect: These mild chest pains most often go away within 3 days.

  6. Call Your Doctor If:
    • Severe chest pain
    • Constant chest pain lasts more than 5 minutes
    • Trouble breathing occurs
    • Fever occurs
    • You think you need to be seen
    • You get worse

Internet Resources

  1. Heart Attack Symptoms and Warning Signs:
    • The American Heart Association has helpful information about heart attack, stroke, and other diseases.
    • You can find this online at: Heart Attack and Stroke Symptoms
  2. Women and Heart Disease:

And remember, contact your doctor if you develop any of the ‘Call Your Doctor’ symptoms.

Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.

Last Reviewed: 11/8/2021 1:00:38 AM
Last Updated: 10/21/2021 1:00:42 AM

Copyright 2021 Amazon.com, Inc., or its affiliates.

Chest Pain | Circulation

All that glitters is not gold” is a familiar saying. Similarly, all that is called chest pain is not necessarily a result of heart disease. The association between chest pain (angina pectoris*) and heart disease goes back to its initial description by Heberden in 1772. His description was of a “strangling sensation in the chest. ” Although angina pectoris is not the only symptom of heart disease, it is the most common one and is a good place to begin a brief discussion of cardiac pain.

Chest Pain and Heart Disease

An intriguing question that has puzzled both physicians and the lay public concerns the relationship between injury to an internal organ and the sensation of that injury perceived by patients as arm, chest, back, or jaw pain. The transmission of the pain impulse from the heart to the brain via the spinal cord is still not completely understood. Because the location in the spinal cord area in which pain signals from the heart are received is located near areas in which similar pain signals for the chest wall and arms are received, it is believed that “spillover” in these spinal cord areas is responsible for the perception of the cardiac discomfort in the arms, chest, and occasionally the back.

Patients usually are not aware of injuries to internal organs unless the affected organ swells, causing pressure on nerve endings, and these nerve fibers then transmit pain impulses to the brain. This neurological pathway is true of the liver, lung, intestines, and heart. In the case of the heart, inflammation of its outer lining surface, the pericardium, causes sharp pain while breathing in and with certain body movements, similar in many ways to pleurisy, an inflammation of the outer lining of the lungs. Chest pain caused by inadequate blood supply to the heart muscle (a condition called ischemia) is usually different: Common phrases used by patients to describe the pressure sensation they feel are “vise-like” and “an elephant standing on my chest.” Sharp stabbing pains are not typical of angina or of the most severe form of ischemia (a heart attack, also known as myocardial infarction), though, as previously noted, this type of pain sometimes indicates inflammation of the lining of the heart (pericarditis). Interestingly, women with heart disease are more likely to experience atypical symptoms such as shortness of breath and fatigue for reasons that are not well understood.

Each patient must know his or her symptoms and recognize them when they occur. This sounds simple, but we know a physician who experienced anginal discomfort in the form of back pain (this was his anginal equivalent) and eventually underwent bypass surgery. Yet when the back pain returned several years later, he again ascribed it to a muscular sprain and denied it was cardiac in origin until a stress test confirmed that this was the case.

Diagnosis of Chest Pain

If all chest pains are not caused by heart disease, what are their origins and how can we tell the difference? This question is the basis for the physician’s system of diagnosing the cause of chest pain. If the chest wall is tender to the touch, or if the pain occurs with movement of the shoulder, arm, etc, then a musculoskeletal cause is suspected. If the chest discomfort is related to eating, then gall bladder disease is suggested. If an empty stomach causes symptoms, then reflux of stomach acid or ulcer disease can be the culprit. It may seem strange that these examples of gastrointestinal disease can be experienced as chest discomfort, but it is not at all unusual. Other causes of chest pain are referred nerve pain from conditions such as arthritis of the cervical spine.

The key distinctive point in diagnosing chest pain caused by atherosclerotic blockages in the blood vessels of the heart (coronary artery disease) is in its relation to physical exertion. If the chest discomfort is not precipitated by physical exertion, it is highly unlikely that coronary artery disease of any significant degree is present. Thus, the doctor will recommend a key diagnostic test (the stress test or exercise test) in which an attempt is made to reproduce the chest pain while electrocardiographic (ECG) leads are attached to the patient, thereby recording alterations in the heart’s electrical activity. Some of these alterations can suggest that there are supply and demand imbalances in blood flow and oxygen delivery to the heart muscle (ischemia, as noted earlier). The treadmill exercise test is less reliable in women and there may therefore be a need for alternative stress tests in women, as described in the next section.

Major Causes of Chest Pain
  • • Cardiac diseases

  •  (1) Resulting from blockages in coronary arteries

  •  (2) Resulting from other cardiac problems (such as pericarditis)

  • • Musculoskeletal diseases of the chest wall, shoulders, etc.

  • • Gastrointestinal diseases (especially gall bladder, acid reflux, ulcer)

  • • Cervical arthritis or other neurological conditions

Types of Stress Tests

Various types of stress tests are used depending on whether the patient is capable of walking on a treadmill, if there is an abnormal ECG at rest, or other factors. These tests are not only helpful in diagnosing coronary artery disease, but they yield important data to predict the possible development of additional complications. For example, the presence or absence of electrocardiographic and other stress test abnormalities provides important clues about the possibility that future cardiovascular incidents such as severe chest pain (unstable angina) will occur. In addition to electrocardiographic changes, stress tests that involve nuclear scans may also show areas of heart muscle that are underperfused with blood, suggesting the presence of a blockage in the blood supply. Similarly, the echocardiographic (ultrasound) stress test may reveal an area of heart muscle that is not contracting properly because of a blood supply problem.

When the stress test is abnormal, the next step in diagnosing coronary artery disease is the cardiac catheterization procedure, also known as the coronary angiogram. This is a procedure that carries a small but definite risk of serious complications. Nevertheless, the coronary angiogram represents the best means available for diagnosis and is also used in contemporary medical practice to treat symptoms. For example, angioplasty and/or stent procedures can eliminate blockages shown on the angiogram and can be performed at the same time as the diagnostic procedure.

Types of Stress Tests That Can Be Used for Diagnostic Purposes
  • • Routine treadmill exercise test

  • • Treadmill test with nuclear scan*

  • • Nontreadmill chemical test with nuclear scan*

  • • Echocardiographic stress test with exercise or chemicals*

*Preferred for women.


Chest pain can be a clue to underlying coronary artery disease, but it can also be caused by noncardiac conditions, most of which are less serious. Proper attention to the quality of the pain and the factors that preceded it can be used as a tool to determine whether the origin is cardiac or not. A stress test is indicated when there is doubt.

No discussion of chest pain is complete without mentioning the well-known observation that serious heart disease can exist without the usual symptoms (silent ischemia, a form of silent heart disease). If readers seek a more detailed explanation of cardiac pain mechanisms, silent ischemia, or drug therapy for coronary artery disease, they are referred to 2 books written expressly by the authors for the lay public. These are entitled Heart Talk1 and an updated version Fighting the Silent Killer2.

For additional information, see the following web sites:

  1. Ornato JP, Hand MM. Warning signs of a heart attack. Circulation. 2001;104:1212–1213. Available at: http://circ.ahajournals.org/cgi/content/full/104/11/1212. Accessed July 1, 2002.

  2. American Heart Association. Angina Pectoris. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4472. Accessed July 1, 2002.

*Patients often ask about the correct pronunciation of this word. The word “angina” is like “Caribbean”: It can be pronounced correctly with emphasis on either the first or second syllables.


Correspondence to Peter F. Cohn, MD, Stony Brook University Health Sciences Center, Stony Brook, NY 11794. E-mail [email protected]


  • 1 Cohn PF, Cohn JK. Heart Talk: Preventing and Coping with Silent and Painful Heart Disease. Boston, Mass: Harcourt Brace Jovanovich; 1986.Google Scholar
  • 2 Cohn PF, Cohn JK. Fighting the Silent Killer: How Men and Women can Prevent and Cope With Heart Disease Today. Boston, Mass: A.K. Peters; 1993.Google Scholar

Thoracic Pain | UCI Health

Not all chest pain is because of heart problems.

Dysfunction of the muscles and nerves in your chest and upper back may be the cause of your pain. Your pain may be due to narrowing of the thoracic spine, fractures or post-surgical pain.

Some common causes of thoracic pain include:

Thoracic vertebral compression fracture

This is a common cause of middle to upper back pain, as well as chest wall pain. This pain is often the result of osteoporosis combined with trauma, falls or sometimes even just sneezing. These fractures can be extremely painful and can cause nerve damage. This is a condition that is best treated early after its initial occurrence.

Post-herpetic neuralgia

This is a painful disorder often seen in elderly patients who have had chicken pox or a shingles outbreak in the past. The pain is often described as burning and constant, and can last long after the initial shingles outbreak has healed. Typically, the pain is confined to areas of the body where the shingles lesions have erupted.

Post-thoracotomy pain syndrome

This syndrome is common in patients after chest wall or lung surgery. Surgical irritation of the nerves running along the ribs can cause both electric shock-like pains to the chest wall as well as upper abdominal pain. This pain can originate at the site of incision or anywhere along the length of the ribs.


This condition involves a weakening and inflammation of the connective tissue of the chest wall. It is often seen in smokers and people with arthritis. It can also be the result of inflammatory disease or follow viral and bacterial infections. Pain occurs with deep breathing and slight pressure and can be easily reproduced on medical examination.

Costosternal syndrome

This condition involves a weakening and inflammation of the connective tissue between the rib joints. This condition is often brought on by trauma to the chest. Pain occurs with deep breathing and slight pressure, and can be easily reproduced on medical examination.

To be seen by one of our specialists, call 949-UCI-PAIN (949-824-7246) or request an appointment online ›

Chest Wall Pain – Comprehensive Pain Phyicians – Doctors Ajakwe, Tatevossian & Mameghani

What is Chest Wall Pain?

Chest wall pain (Costochondritis) is an inflammation of the cartilage that connects a rib to the breastbone (sternum). Pain caused by costochondritis may mimic that of a heart attack or other heart conditions.

What are the Symptoms?

Chest pain associated with costochondritis is usually occurs after exercise, minor trauma, or an upper respiratory infection.

Specific symptoms include:

  • Sharp or dull pain on your front chest wall. It may radiate to your back or abdomen and is more common on your left side.
  • Pain with a deep breath or cough.
  • Pain in 4th, 5th and 6th ribs that increases as you move your trunk or take deep breaths. Conversely, it decreases as your movement stops or with quiet breathing.
  • Reproducible tenderness when pressing on the rib joints (costochondral junctions). Without this tenderness, a diagnosis of costochondritis is unlikely.
  • When costochondritis occurs as a result of infection after surgery, you will see redness, swelling, or pus discharge at the site of the surgery.

Comparison to Tietze Syndrome

A related condition, tietze syndrome, typically exhibits swelling at the rib-cartilage junction, whereas ostochondritis has no noticeable swelling. Neither condition involves pus or abscess formation.

Tietze syndrome usually affects the junctions at the second and third ribs, and the swelling may last for several months. The syndrome can develop as a complication of surgery on your sternum months to years after the operation.

What are the Treatments?

The treatments for costochondritis are painkillers and anti-inflammatory medications. Often, just simple painkillers such as paracetamol or codeine are needed.

Ibuprofen is an anti-inflammatory medication (also called a non-steroidal anti-inflammatory drug, or NSAID) that is often effective for costochondritis. Other NSAIDs are available on prescription.

For severe cases of costochondritis not responding to painkillers and anti-inflammatory medication, injections of steroids or local anaesthetic medicines may be used.

In extreme cases, an intercostal nerve block can be performed (usually by a doctor specializing in acute pain and/or anaesthetics). This involves injection of a local anaesthetic medicine around the painful ribs, to block the nearby intercostal nerve. The intercostal nerves transmit the painful sensation in costochondritis. This sort of injection temporarily disrupts nerve impulses to stop the pain. Nerve blocks can last several weeks or months. In repeated, severe cases of costochondritis, a series of these injections can be given to permanently destroy the nerve causing the pain.

Non-medicinal measures can be tried for relief of pain in costochondritis. Examples of such techniques include:

  • Heat pads.
  • Ice application.
  • Transcutaneous electrical nerve stimulation (TENS).
  • Acupuncture.
  • Gentle stretching exercises.
  • Avoidance of sports or activities that worsen the pain.
  • Physiotherapy or chiropractic therapy.

Chest Pain in Young Adults | 2018-04-20 | AHC Media – Continuing Medical Education Publishing | Relias Media

Chest pain is one of the most common reasons that patients present to the emergency department (ED). The underlying disease processes can range from benign to life-threatening. It is critical for the provider to thoroughly evaluate and risk-stratify patients who present with this complaint to reduce the chances of missing a potentially serious condition.

The purpose of this article is to discuss the diagnosis, treatment, and management of the common causes of chest pain that can present in a young adult.


About 8 million people are seen in the United States every year for chest pain.1 In contrast to the population of elderly adults typically seen for chest pain in EDs, an increasing number of young men and women are evaluated for symptoms of acute chest pain every day.2 Many of these patients have no cardiac risk factors. The prevalence of acute coronary syndrome has been found to be around 1% in people younger than 40 years of age, and the prevalence is about 5-10% in those younger than 50 years of age.3 Therefore, ED providers must be aware of the various other causes of chest pain in the young population.

Chest pain can be caused by a variety of disease processes that can range from benign to life-threatening. Although protocols have been developed to consider every patient who presents with chest pain as a potentially serious condition based on acuteness, duration, and intensity of pain, these factors do not necessarily correlate with a life-threatening disorder. Providers often dismiss chest pain in the younger population because of the rare occurrence of significant morbidity and mortality. Patients who are evaluated for chest pain in the ED must undergo a thorough history and physical examination with proper diagnostic testing to avoid inappropriate patient evaluation, treatment, and disposition.

Evaluation of Chest Pain

In patients presenting to the ED with chest pain, the provider must perform a thorough history and physical examination to help guide the plan of care and treatment. It is imperative that the provider ask the proper questions and pay attention to key information obtained in the history, as this can assist with developing a broad differential diagnosis.4 In addition, being aware of the characteristics of the pain also can be beneficial. The differential for chest pain involves noncardiac causes as well, so asking questions about the symptoms, pain quality, and other characteristics can differentiate between cardiac and noncardiac causes. 2 After gaining the necessary information, the provider can identify risk factors that will place the patient in a high-risk category.

On diagnostic evaluation, an electrocardiogram (ECG) is recommended within 10 minutes of arrival.5 If the provider is concerned about potential acute coronary syndrome, the laboratory evaluation should include cardiac troponins. However, elevations in troponin T can be seen in other diseases, such as renal dysfunction, pulmonary embolism, heart failure, myocarditis, pericarditis, and septic shock.6 A chest X-ray should be included for patients with chest pain to assist with the diagnosis. Chest radiography also is beneficial in life-threatening causes of chest pain, such as a pneumothorax, for which immediate intervention may be required. Other laboratory testing or specific imaging, such as CT or ultrasound, should be considered based on the suspected diagnosis. Disposition depends on either determining a specific cause or excluding potentially serious conditions to a reasonable degree. Thus, a majority of young adults with chest pain are sent home after an ED assessment. Some EDs have created observation units, where patients with fewer comorbidities and risk factors may be monitored and have additional testing performed before discharge.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a frequent cause of chest pain in young people. It is caused by transient relaxation of the lower esophageal sphincter (LES) complex.7 It can be seen in a wide variety of age groups, including neonates and the elderly. If GERD develops in childhood, the risk of developing it in adolescence and adulthood increases.8

When the LES relaxes, the acidic gastric contents enter the lower esophagus, causing irritation of the mucosa.7 In turn, this causes a burning sensation to the substernal chest. Patients also may complain of dysphagia, odynophagia, nausea, vomiting, unrelenting cough, and increased discomfort with meals. 7

Although usually harmless, the sensation often may be mistaken by patients for ischemia. This is due to the variability in the nature of the chest pain itself. Specifically, GERD can present with squeezing or pressure-like chest pain, radiation of pain to the arms and back, and diaphoresis.7 Patients also may describe worsening pain while lying flat.

Because of the similar presentations of GERD and acute coronary syndrome, patients must be risk-stratified for a safe disposition. This includes a careful and thorough history and physical exam. If there is suspicion for acute coronary syndrome based on the patient’s history, symptoms, and risk factors, a more aggressive approach may be taken, including lab testing, ECG, and radiologic studies.

Patients with suspected GERD may be treated in the ED with a variety of interventions. The goal of these treatments is to decrease acid production and risk factors.7 The two most commonly prescribed medications for acute GERD include histamine-2 (h3) blockers and proton pump inhibitors (PPIs), which decrease acid production. 7

Baclofen is a GABA-B agonist that also can be used. This has been shown to work by inhibiting the relaxation of the lower esophageal sphincter.9 However, this medication has multiple side effects, including sleepiness, fatigue, and lightheadedness. A recent trial showed that baclofen may be beneficial for patients on PPI therapy who have frequent episodes of nighttime heartburn.10 Prokinetic drugs, like mosapride, in combination with a PPI have shown no clear role in the treatment of GERD.11

In addition, it is important to counsel patients on lifestyle modifications, including weight loss and decreasing consumption of caffeine, alcohol, fatty foods, and chocolate.7,11 It also may prove beneficial for patients to sleep with the head of the bed elevated at 30 degrees and to avoid eating within three hours of bedtime.7,11 In patients who are refractory to drug therapy, surgical options such as laparoscopic antireflux surgery have been shown to be beneficial. 11 In patients with normal vital signs and who are well appearing, outpatient referral to a gastroenterologist for ambulatory pH monitoring or non-emergent endoscopy is appropriate. If left untreated, complications from GERD may develop. These include esophageal strictures, inflammatory esophagitis, and Barrett’s esophagus.

Acute Pericarditis

Acute pericarditis is caused by inflammation of the pericardial sac. In one study it was found to occur in 4.4% of patients presenting to the ED with chest pain, and frequently is seen in young adults.12 One study of 1,361 patients admitted to the hospital for chest pain showed that pericarditis was a significant cause for admission in young adults and was seen more frequently in males of younger age groups than in females.12

The inflammation from pericarditis results from an increase in lymphocytes and granulocytes around the pericardium, usually caused by infection, malignancy, drugs, or systemic rheumatic diseases. 13,14 (See Table 1.) Patients typically present with sharp, pleuritic chest pain, which is worse when the patient is lying flat.13 Oftentimes, patients will lean forward to alleviate their symptoms. They may be febrile and complain of myalgias, and a friction rub may be heard on physical exam.13 Although the affected area may be generalized in the anterior chest wall, there may be referral of pain to the left trapezial ridge.15

Infections: viral (coxsackie virus, echovirus), bacterial (staphylococcus and streptococcus)

Malignancy (i.e., breast or lung cancer, leukemia, lymphoma)

Drugs: procainamide, hydralazine

Systemic rheumatic diseases: systemic lupus erythematosus, rheumatoid arthritis, scleroderma

Miscellaneous: post-myocardial infarction, uremia, radiation, myxedema

Unfortunately, ancillary tests available in the ED lack accuracy for detecting acute pericarditis. For patients in whom the disease is suspected, an ECG should be ordered to look for specific patterns that correlate with the diagnosis. A single ECG may not be that helpful, but serial ECGs performed over several days may show serial changes in a characteristic pattern. The first changes will be seen in the initial hours to days after onset of the disease.13 This includes ST segment elevation in leads I, II, and III, aVL, aVF, and V2 to V6 with reciprocal depressions in aVR and V1.13 PR segment depression also frequently is seen in leads II, aVF, and V4-V6.13 After the initial stage, the ST and PR segments normalize, T waves flatten, and there is development of deep inverted symmetrical T waves.13 Lastly, the ECG normalizes, but T wave inversions may become permanent.13

Although not required, a chest X-ray can be performed to rule out other causes if the diagnosis is unclear initially. Bedside echocardiogram may be used to rule out the presence of a pericardial effusion.14 If present, admission may be warranted to investigate the underlying cause, and treatment may be necessary if the patient is hemodynamically unstable.

Laboratory studies generally are nonspecific and may be ordered to determine non-idiopathic causes of pericarditis.14 If there is suspicion for associated myopericarditis, cardiac biomarkers may be ordered to assess for elevation.14

Treatment should be directed at the underlying cause. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy in patients with idiopathic or viral pericarditis for up to one to three weeks.14 Ibuprofen is recommended in the acute phase, and colchicine has been found to prevent recurrence.15 In patients with resistance to colchicine, anakinra has been shown to reduce the risk of recurrence over a median of 14 months.16

Glucocorticoids have not been shown to be beneficial in patients with acute idiopathic pericarditis, as there is a high risk for recurrence when the steroids are stopped or tapered. These should be used only in patients with idiopathic pericarditis who are refractory to treatment or are unable to tolerate NSAIDs plus colchicine.17

Patients with acute pericarditis may be discharged home safely unless there is a high suspicion for myocarditis or the presence of a large effusion, fever, or immunosuppression.14


Myocarditis is a condition that occurs as a result of inflammation of the myocardium.18 The pathophysiology involves invasion of the myocardium by various cells, including lymphocytes, plasma cells, and histiocytes.18 It is caused most commonly by an infectious process.18 (See Table 2.) Although Chagas disease is the most common cause worldwide, viruses such as parvovirus B19, human herpes virus 6, and coxsackie B are responsible for the majority of cases in the United States.19 Other common causes include toxins, drugs, and immunologic conditions. Sometimes myocarditis is associated with pericarditis; myocarditis is seen in an estimated 12% of patients with pericarditis. 20

Chagas disease (Trypanosoma cruzi)


  • Parvovirus B19
  • Human herpes virus 6
  • Coxsackie B


  • Corynebacterium diphtheriae
  • Neisseria meningitidis
  • Rheumatic fever
  • Lyme disease (Borrelia burgdorferi)

Toxins: ethanol, arsenic, iron, copper

Drugs: anthracycline chemotherapeutic agents (doxorubicin), antipsychotics (clozapine)

Immunologic conditions: scleroderma, systemic lupus, sarcoidosis

Patients diagnosed with myocarditis can present with a wide range of symptoms, varying from nonspecific chest pain to cardiogenic shock. Myocarditis and acute coronary syndrome share similar characteristics, and both must be considered in a young patient who presents with chest pain. 21 Patients generally complain of retrosternal chest pain, myalgias, and fever with disproportional sinus tachycardia. As with pericarditis, a friction rub may be auscultated on exam. The patient’s appearance may help differentiate between myocarditis and pericarditis, as patients with myocarditis generally appear ill, as opposed to those with pericarditis, who often do not look ill.

Diagnosis in the ED usually is clinical and is supported by clues on traditional cardiac workup. These include elevations in cardiac biomarkers, ECG abnormalities, and cardiomegaly on chest X-ray. The ECG may show nonspecific ST wave changes, and PR depression as is seen in pericarditis.18

Definitive diagnosis typically was done by cardiac catheterization and endomyocardial biopsy. The approach has fallen out of favor because of the risk of that invasive procedure and the advent of newer diagnostic strategies. These strategies include nuclear imaging with gallium-67-labeled or indium-111-labeled antimyosin antibodies and cardiac MRI. 18,21 These methods may assist in differentiating between acute coronary syndrome and myocarditis if the diagnosis is uncertain. These studies generally are time intensive and are performed on admission after the diagnosis is suspected.

The mainstay of treatment in idiopathic or viral myocarditis consists of conservative management, including hemodynamic support. In severe cases, immunosuppressive therapy with prednisone or azathioprine may be beneficial but generally is not started in the ED.18 If diagnosed early, antiviral therapy with ribavirin or pleconaril may be initiated in cases of viral myocarditis.19 If patients become unstable and are unresponsive to traditional support therapies such as vasopressors and inotropes, more aggressive care may be warranted. This includes left ventricular assist device (LVAD), extracorporeal membrane oxygenation (ECMO), or lastly cardiac transplantation.19

Mitral Valve Prolapse

Mitral valve prolapse (MVP) is a frequently unrecognized cause of chest pain, primarily in young females. Because of its subtle presentation and physical exam findings, it often is forgotten in the differential diagnosis of chest pain in the ED. It is the most common valvular disorder in industrialized countries, affecting approximately 2.4% of the population.22

Generally speaking, MVP is recognized as a benign condition. In rare instances, complications may develop and treatment may be necessary. If left undiagnosed, dysrhythmias, congestive heart failure, endocarditis, stroke, and sudden cardiac death may occur.23

MVP occurs when there is bulging of the valve leaflets into the left atrium during left ventricular contraction. The underlying cause involves abnormalities in connective tissue proteins, and it usually is inherited.22

Patients with MVP usually are asymptomatic, but may complain of atypical chest pain, palpitations, generalized fatigue, anxiety, and shortness of breath.22 Increases in morbidity have been associated with symptoms during exercise. 24 On physical exam, the provider should pay close attention to auscultation of heart sounds. Classically, a mid-systolic click is heard at the apex.22

Diagnostic studies and treatment are not indicated in ED patients suspected to have MVP, but the provider should assess the patient carefully for its complications, depending on symptomatology.22 Patients may be referred to outpatient cardiology for an echocardiogram to confirm the diagnosis and to assess other mitral valve dysfunction and complications. Patients sometimes are prescribed beta-blocker therapy if they are symptomatic with palpitations, but this is not performed routinely by the ED provider.22

Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is an inherited autosomal dominant disease that is characterized by ventricular hypertrophy, mostly affecting the interventricular septum. It has been shown to have a prevalence in the general population of approximately one in 500 people. 25 It can occur in any race or gender and is seen in any age, but it is diagnosed most commonly among people 30-40 years of age.26 It is caused by mutations in sarcomere genes, which encode sections of the contractile proteins in the heart muscle.26 The most common mutation occurs on the beta-myosin heavy chain.25 Over time, this translates into development of asymmetrical left ventricular hypertrophy. The reduction in compliance of the hypertrophied left ventricle leads to poor diastolic function and restricted ventricular filling.25

Dyspnea on exertion is the most frequent initial complaint seen in the ED.22 Chest pain, palpitations, syncope, and sudden cardiac death are other associated symptoms. In athletes, hypertrophic cardiomyopathy is the most common cause of sudden cardiac death.27 It is important to ask the patient about family history of sudden cardiac death, as this can be an indicator of familial inheritance of the disease. The chest pain experienced is due to a mismatch between the oxygen demand of the hypertrophied muscle and the available rate of perfusion in the myocardium.25

On physical exam, a systolic ejection murmur may be auscultated, which is best heard at the apex of the heart. This murmur may be enhanced if the patient is asked to stand from the seated position or if a Valsalva maneuver is performed. In turn, this causes alterations in preload and afterload that accentuate the murmur.

Patients who present with chest pain and suspected hypertrophic cardiomyopathy should have an ECG and chest X-ray performed in the ED. Although not completely diagnostic, changes on either test may lead the provider to further suspect the disease. About 75-95% of ECGs in these patients will be abnormal and can show signs of left ventricular hypertrophy and left atrial enlargement.26,27 Specifically, anterior, lateral, and inferior Q waves, known as “septal Q waves,” with associated upright T waves may be present. 25 The chest X-ray may appear normal, but can show enlargement of the left ventricle or the left atrium.

If the diagnosis is suspected, disposition should be made in conjunction with a cardiologist, and arrangements made for an echocardiogram. The echocardiogram can be performed on an outpatient basis if the patient is stable and has reliable follow-up, unless the patient experienced a syncopal event prior to ED arrival. This can be an indicator of deadly dysrhythmia, for which patients need to be admitted to a monitored bed. This subset of patients requires a more extensive workup in addition to an echocardiogram, including a possible stress test, tilt testing, and Holter monitor placement.

Once performed, the echocardiogram can show disproportionate septal hypertrophy, reduced septal motion, or left ventricular outflow tract narrowing.26 In the instance in which the echocardiogram is inconclusive, cardiac MRI is recommended.25,26,27 Genetic screening may be helpful to identify other family members who may carry the disease.

Beta-blockers are the first-line therapy in patients with hypertrophic cardiomyopathy who have episodic chest pain. Medicated patients have improved left ventricular filling, due to prolonged diastolic filling time. In addition, the negative inotropic effect of beta-antagonism reduces outflow tract obstruction.26,29 Second-line therapy includes calcium channel blockers if the patient has no reduction in symptoms with beta-blockers.29

If the patient is unresponsive to medical management, septal myomectomy may be a last resort in patients with severe symptomatic disease.27 Newer therapies also include percutaneous septal ablation, in which ethanol is injected into one of the septal branches, which causes a chemical necrosis of the tissue and thinning of the hypertrophied ventricle over time.27 Nitroglycerin should be avoided in these patients, as it decreases preload, which the patient requires to maintain adequate cardiac output. 26,27

Patients with increased risk for sudden cardiac death need to be evaluated for implantable cardioverter defibrillator placement. Risk factors for sudden death include a family history of sudden cardiac death in someone younger than 45 years of age, evidence of non-sustained ventricular tachycardia on Holter monitor, more than two incidences of syncope, abnormal blood pressure response during exercise, or LVH with wall thickness greater than 30 mm seen on echocardiogram. If the patient has two or more risk factors, implantable cardioverter defibrillator implantation is recommended.27

If the patient is discharged from the ED, close outpatient follow-up is critical. The provider must have the patient refrain from any strenuous activity until he or she is evaluated by a cardiologist.


Costochondritis is defined as inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.30 Although it is harmless, the condition’s symptomatology can cause concern for patients who fear their pain is cardiac in nature. It is a common cause of chest pain seen in the ED and was responsible for 30% of ED visits in one prospective study.31 It sometimes can be mistaken for Tietze syndrome, in which there is swelling of a single costal cartilage, usually of the second rib.30 Costochondritis, on the other hand, usually involves multiple rib spaces and lacks the swelling seen in Tietze syndrome.

Patients with costochondritis can complain of chest pain of varying nature, although typically the pain is described as pressure-like, sharp, or achy. Pain can be worsened by movement, breathing, and exertion. Inciting factors include prior respiratory illness with forceful cough, recent strenuous exercise, and pulling, pushing, or reaching with the upper extremity. Ribs 3 and 4 are affected most often, and the pain is more frequently unilateral.30 On physical exam, patients will have tenderness to palpation of the affected sites.

A diagnosis of costochondritis should be made only after other serious, life-threatening causes of chest pain have been ruled out, as cardiac-related chest pain also can be reproducible. A study published in 1994 showed that 6% of patients presenting to the ED with reproducible chest pain ultimately were diagnosed with myocardial infarction (MI).31

In young adults with symptoms and signs consistent with costochondritis, the only ancillary test needed is an ECG. In patients older than 35 years of age, those with risk factors for acute coronary syndrome, or those who have other cardiopulmonary symptoms, an ECG and chest X-ray should be performed.30 Further imaging with CT should be reserved for patients in whom there is suspicion for costal mass or neoplastic process.30

The mainstay of treatment for costochondritis is pain relief with non-opiate analgesics. Acetaminophen and ibuprofen are appropriate treatment modalities, and the patient should be instructed to refrain from strenuous activity that reproduces symptoms. Heating pads applied to the area also may be helpful. Severe cases may be treated with intercostal lidocaine/corticosteroid combinations or other local anesthetics. 30

Patients should be informed that the pain can resolve within weeks to months, but may last up to one year.30,31 Nonetheless, costochondritis is a self-limiting condition in which symptomatic improvement is the mainstay of treatment.


A pneumothorax occurs when free air enters the intrapleural space. It is a potential life-threatening cause of chest pain encountered in the ED. It can be due to trauma or can occur spontaneously with or without underlying lung disease. A pneumothorax that occurs in the absence of pulmonary pathology is termed a primary pneumothorax. This usually occur in males, smokers, those with a history of Marfan syndrome or mitral valve prolapse, and changes in ambient pressure.32 In addition, familial patterns indicate an inherited association.32,33

Spontaneous pneumothorax occurs in approximately 15 patients per 100,000 population per year in males and five patients per 100,000 population per year in females. 34,35 It develops when there is rupture of a subpleural bleb, forming a passage for free air into the pleural space.32 This usually involves the apex of the lung.32,34

Patients will present with sudden-onset unilateral pleuritic chest pain and dyspnea. Sinus tachycardia is the most common physical finding. Many primary pneumothoraces often are small in size and may not be evident on physical exam. While breath sounds classically are absent or significantly diminished with a large pneumothorax, in cases of small primary pneumothoraces, bilateral breath sounds can be present. Tracheal deviation generally is not seen, as the occurrence of a spontaneous tension pneumothorax is rare.36

Diagnosis is made with an upright posteroanterior chest X-ray. It is recommended to obtain a lateral view as well, as one study showed this view led to the diagnosis of an additional 14% of cases that were not identified initially.32,37 Findings on X-ray include loss of lung markings in the periphery and a pleural line that runs parallel to the chest wall. 32

The management and disposition is dependent on the size of the pneumothorax, as well as the patient’s clinical picture. Measurement of the pneumothorax can be done using a variety of different techniques; for ED management purposes, the important distinction is small vs. not small. A small primary pneumothorax can be determined if the distance from the lung apex to the cupula is 3 cm or less on an upright chest radiograph.35 If a chest X-ray is inconclusive but suspicion remains high, a chest CT without contrast can be obtained.

For a small pneumothorax (classified as less than 20%) occurring in an otherwise healthy young adult, observation with oxygen therapy is recommended.32,35,38 The addition of 100% oxygen has been shown to increase the absorption rate four-fold per day compared to observation alone.32,35 This treatment works by decreasing the partial pressure of nitrogen, which in turn increases the rate that air diffuses across the pleural-alveolar barrier. 35

Patients may be observed in the ED or a traditional observation unit for four to six hours in the case of a small, minimally symptomatic pneumothorax. A repeat chest X-ray should be obtained prior to discharge to ensure that there is no increase in size.

Patients should be advised to avoid air travel and underwater diving until complete resolution of the deficit. Other options include aspiration of air with a small catheter or small chest tube placement.32 (See Table 3.)

Small pneumothorax (< 20%) in otherwise healthy young adult:

  • Observe and administer oxygen therapy.
  • Observe in ED or observation unit for 4-6 hours for small, minimally symptomatic pneumothorax.
  • Obtain repeat chest X-ray prior to discharge to ensure there is no increase in size.
  • Advise patient to avoid air travel and underwater diving until complete resolution.

Anxiety Reaction

ED providers are seeing an increasing number of patients with complaints of chest pain who have no risk factors for coronary artery disease and a non-diagnostic or normal evaluation. Many of these patients are found to have similar features, including life stressors, restlessness, fatigue, insomnia, and poor eating habits.39 This symptomatology, known as a stress reaction or panic disorder, can be responsible for causing chest pain and should be included in the differential diagnosis.39,40

Panic disorder affects more than 6 million Americans and usually develops in young adulthood.39 A significant percentage of young adults evaluated in the ED for chest pain are found to have panic disorder.39-42 When symptoms noted above are present, the provider should attempt to avoid unnecessary and costly workups.39

Patients who typically experience a stress reaction or panic disorder may make multiple visits to the ED for fear they are experiencing a serious cardiac event. This is because the underlying anxiety can cause symptoms that resemble those found in acute coronary syndrome, including tingling, palpitations, and disordered breathing in addition to chest pain.39 It is crucial to obtain a thorough history in these patients, as this is what likely will lead the provider to the diagnosis of anxiety. In a young patient without significant medical history, no workup is required. If the patient has risk factors for acute coronary syndrome, further testing with an ECG, chest X-ray, and laboratory studies is necessary.

Treatment varies, but the majority of studies support the use of conservative management with outpatient cognitive therapy. Because the spectrum of psychological therapy can be time-consuming and progressive, its use is not practical for imitation in the ED. With multiple sessions, cognitive therapy discussions may help the patient understand the triggers behind the attacks and how to prevent them. It is important for the ED physician to validate the patient’s concern and reassure the patient that the symptoms are treatable.

If calming the patient in the ED fails, medical therapy may be required. Small doses of oral benzodiazepines, such as lorazepam, diazepam, or alprazolam, can be used to alleviate anxiety.39 If the patient receives medication in the ED and the chest pain remains unchanged, further workup is recommended. On discharge, patients should be referred to professional mental health personnel for long-term care and treatment.

Cocaine-associated Chest Pain

Cocaine abuse is a common problem in the United States, with more than 14% of the population 12 years of age and older having used it once in their lifetime.6 Acute MI occurs in approximately 6% of patients presenting to the ED with chest pain after using cocaine.6,43 One study found most patients with cocaine-induced MI were young, nonwhite tobacco smokers who had used cocaine within the past 24 hours prior to arrival.6,44 Chest pain is the most common complaint in patients presenting to the ED after cocaine use. Cocaine users are at increased risk of myocardial ischemia because of its effects on coronary vasoconstriction, platelet aggregation, and myocardial oxygen demand.6,45

The nature of the chest pain may vary, and no specific historical factor is more highly associated with cocaine-induced MI than an alternative diagnosis. Vital signs may be normal, but an acute rise in blood pressure commonly is seen.6 Chest pain may be accompanied by tachycardia, diaphoresis, and tremulousness.

All patients who are evaluated for cocaine-related chest pain should have a full cardiac workup because of the increased risk of myocardial ischemia and aortic dissection.6 This includes ECG, chest radiography, and cardiac biomarkers.

Treatment of chest pain related to cocaine use is similar to treatment for chest pain due to atherosclerosis, with the addition of benzodiazepines such as lorazepam. The patient should be placed on cardiopulmonary monitoring, and aspirin should be given. The combination of a benzodiazepine with sublingual nitroglycerin is effective by counteracting the sympathomimetic effects of cocaine, and also may be beneficial for those with significant elevations in blood pressure.46 Honderick et al found that the combination of the two drugs was more effective in relieving chest pain caused by cocaine use than either drug alone.47 If the patient is unresponsive to this therapy, calcium channel blockers are a second option.46

It has been stated that providers should refrain from administering beta-blockers in cocaine-related chest pain, but this conventional wisdom is controversial. Theoretically, beta-blockade can worsen myocardial tissue damage by allowing unopposed alpha-receptor stimulation. A randomized study published in 2010 in which beta-blockers and calcium channel blockers were given to patients with cocaine-related chest pain found that there were no significant adverse outcomes.46,48

In patients with cocaine-related chest pain who have evidence of ischemia on ECG and who do not show improvement on repeat ECG after medical therapy, percutaneous coronary intervention is warranted and is considered superior to fibrinolytic therapy. 46 Fibrinolytic therapy may be necessary if timely transport for percutaneous coronary intervention is not an option.

Several novel approaches have emerged in the literature for additional approaches when treating cocaine-related chest pain. Phentolamine administration has been shown to decrease pain and coronary vasoconstriction, but further studies are needed to validate its effectiveness.46 Dexmedetomidine is a sympatholytic drug that may be effective in decreasing cocaine-associated hypertension because of its ability to counteract cocaine’s effect on central sympathetic upregulation.46 In this specific study, a low dose of 0.4 μg/kg was used, which proved to be non-sedating.46,49 Lastly, apocynin has the ability to decrease cardiac oxidative stress, although its NADPH oxidase inhibition and may be useful in decreasing poor outcomes.46

Pulmonary Embolism

Pulmonary embolism (PE) occurs when a thrombus occludes a specific site in the pulmonary vasculature. Most pulmonary emboli stem from a deep venous thrombosis of the extremities or inferior vena cava.50 About 200,000 new cases of PE are diagnosed in the United States each year.50 PE is the second leading cause of non-traumatic death in outpatients.50 In otherwise healthy patients younger than 50 years of age who are hemodynamically stable, the fatality rate is 1%.50,51

Pulmonary emboli occur when a venous clot in the periphery dislodges and travels through the right side of the heart into the pulmonary circulation. Patients who are predisposed to developing venous thromboembolisms include women taking oral contraceptives containing estrogen because of their procoagulant effect. Patients with prolonged immobility, such as those who recently have undergone surgery or extended travel, are at an increased risk. Other risk factors include pregnancy, malignancy, trauma, and obesity.50,52 Acquired risk factors include systemic lupus erythematosus, factor V Leiden, and antiphospholipid antibody syndrome. 50

The most common symptom in patients with PE is shortness of breath, followed by chest pain (often pleuritic in character) and cough (sometimes with hemoptysis).50 The patient also may complain of extremity pain, redness, or swelling, which could indicate underlying deep venous thrombosis as the source of the PE. Pulmonary embolism can present similarly to pleurisy, in which the patient experiences pain with deep inspiration. This may occur after an upper respiratory infection that causes inflammation of the parietal pleura.

Although uncommon, patients may present with the initial complaint of syncope, as this was seen in 3-4% of patients ultimately diagnosed with PE.51 Patients may be tachycardic, tachypneic, hypoxic, and febrile with a low-grade fever.50

Providers must be aware that vital signs may be completely normal in young, healthy patients who present with shortness of breath and a history concerning for PE.50 The diagnosis of PE should be considered in a patient with dyspnea or hypoxemia and clear lung sounds on physical exam. 50 Routine labs, ECG, and chest X-ray should be ordered if the diagnosis is suspected. No specific abnormality may be seen, but the ECG can demonstrate sinus tachycardia or nonspecific ST- and T-wave changes.50

The evaluation of a patient for PE has undergone extensive study in the past 20 years with the development of risk stratification and diagnostic decision-making tools. The first step is to risk-stratify the patient using one of several tools. The most studied tools are the Wells and Geneva scores. (See Tables 4 and 5.) If the patient is considered to be of low risk for pulmonary embolism by either tool or by clinical gestalt, then the two approaches are of equal efficacy. The first approach is to apply the PERC criteria to determine if the potential of PE is so low as to render further testing unnecessary. (See Table 6.) The second approach is to measure the D-dimer, and if the D-dimer is not elevated above a validated threshold, then no further testing is necessary. Either approach reduces the potential for a missed pulmonary embolism to less than 1 in 100 to 200, with an even lower risk for subsequent sudden death.



Clinically suspected deep vein thrombosis


Alternate diagnosis is less likely than pulmonary embolism


Tachycardia (heart rate > 100 bpm)


Immobilization (≥ 3 days) or surgery in previous four weeks


History of deep vein thrombosis or pulmonary embolism




Malignancy (with treatment within 6 months) or palliative


Traditional interpretation:

Score > 6. 0 – High (probability 59%)

Score 2.0-6.0 – Moderate (probability 29%)

Score < 2 – Low (probability <4%)

Adapted from: Reda LV, Choi A. Pulmonary embolism. Emerg Med Rep 2015;36:54.



Age > 65 years


Previous DVT or PE


Surgery or fracture within 1 month


Active malignancy


Unilateral lower limb pain




Pain on deep vein palpation of lower limb and unilateral edema


Heart rate 75-94 bpm


Heart rate > 94 bpm


Score ≤ 2 unlikely to have a current PE (probability 3% with negative D-dimer)

Adapted from: Reda LV, Choi A. Pulmonary embolism. Emerg Med Rep 2015;36:53.

  • Age ≥ 50 years?
  • Heart rate ≥ 100 bpm?
  • O2 saturation on room air < 95%?
  • Prior history of DVT/PE?
  • Recent trauma or surgery?
  • Hemoptysis?
  • Exogenous estrogen?
  • Unilateral leg swelling?

If no to all criteria and with clinician’s pre-test probability < 15%, PERC Rule criteria are satisfied and no further workup needed.

Adapted from: Reda LV, Choi A. Pulmonary embolism. Emerg Med Rep 2015;36:55.

Patients judged to be of moderate-risk also can be assessed using the D-dimer, but the risk of missing a pulmonary embolism if the D-dimer is not elevated is greater because of the heightened pre-test probability. Some experts deem this risk of missing a pulmonary embolus acceptable when balanced against the complications of prolonged oral anticoagulation. An alternative approach is to image all moderate-risk patients without D-dimer testing, similar to the recommendation for all high-risk patients.

If the patient fails to satisfy all PERC criteria, has an elevated D-dimer, or is considered at high-risk for PE, imaging is needed in the form of either a CT angiography of the chest or, less commonly, a V/Q scan. In patients who present with hemodynamic instability, a bedside echocardiogram performed by the ED provider may quickly assess for right ventricular strain, further supporting the diagnosis of PE.

Once the diagnosis is confirmed, the mainstay of therapy includes anticoagulation to prevent further clot formation.50,52 Both low molecular-weight heparin (LMWH) and unfractionated heparin traditionally are used, and studies have shown that LMWH may have fewer side effects, which include bleeding and death.50 Direct-acting oral anticoagulants (DOACs), such as rivaroxaban, apixaban, and dabigatran, also may be considered. 50

If patients with diagnosed or suspected PE become hemodynamically unstable at any point, a massive clot burden must be considered. In these instances, patients may benefit from fibrinolytic therapy, especially in the situation of cardiopulmonary arrest.55 In young patients who are found to have a large proximal PE with associated hypotension, surgical embolectomy may be performed.50 New studies are emerging which show that low-risk patient populations with hemodynamically stable PEs may be discharged safely with close follow-up on a DOAC.56

Acute Aortic Dissection

Acute aortic dissection (AAD) is a rare cause of acute chest pain in patients presenting to the ED; it is about 100 to 1,000 times less common than acute MI. Most patients with AAD are middle-aged and have a history of hypertension.57 This disorder is rare in young adults and most often is associated with predisposing conditions such as a connective tissue disorder (Marfan and Ehlers-Danlos syndromes), family history of aortic disease, known aortic valve disease, recent aortic manipulation, or known thoracic aortic aneurysm.

The most sensitive clinical feature is the patient’s report of an abrupt onset of pain that is maximal at symptom onset.58 The most useful ancillary test is a chest radiograph looking for a widened mediastinum or obscured aortic knob. Other clinical features, such as the description of the pain as tearing or ripping, a pulse deficit in one wrist, hypotension, or the auscultation of a new murmur (assumed to be caused by acute aortic regurgitation/insufficiency) generally have low sensitivity (< 25%) but high specificity (97-99%).

The Aortic Dissection Detection Risk Score (ADD risk score) has been developed to assist in the evaluation of patients with acute chest pain.59 (See Table 7.) The value of the ADD risk score in clinically excluding AAD in ED patients is unsettled because this tool was derived from a population with a much higher prevalence of AAD than the typical ED population; even with a score of zero, the incidence of AAD was 4. 3%.59




High-risk conditions

Marfan syndrome

Family history of aortic disease

Known aortic valve disease

Recent aortic manipulation

Known thoracic aortic aneurysm


High-risk pain features

Chest, back, or abdominal pain described as any of the following:

  • Abrupt onset
  • Severe intensity
  • Tearing or ripping


High-risk physical examination features

Evidence of perfusion deficit: pulse deficit, systolic BP differential, focal neurologic deficit

Murmur of aortic insufficiency

Hypotension or shock


Total Score



0 = low risk

1 = moderate risk

2-3 = high risk

Because clotting is part of the dissecting hematoma in AAD, the D-dimer has been studied to see if it is a sensitive test for AAD, and a non-elevated value can be used to exclude dissection. 60 The overall sensitivity is excellent (98%), but even at that high value, the D-dimer alone has not been considered adequate to exclude a disorder such as AAD because of the high potential for a catastrophic outcome if not promptly detected and treated. The combination of a low-risk clinical assessment (prevalence of 6% or less) and a non-elevated D-dimer has the potential to exclude AAD to a rate of less than 1 in 300 (0.3%).60,61 Although not zero, it seems a reasonable approach to exclude AAD in young adults.


The ED provider must be aware of the many causes of chest pain. It is important that the life-threatening causes are ruled out and patients are managed and dispositioned properly. The differential for chest pain is broad and not limited to only cardiac causes, especially in the younger population.


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Non-Cardiac Chest Pain | Digestive & Liver Disease Specialists

What is non-cardiac chest pain?
Non-cardiac chest pain is chest discomfort that does not arise from a cardiovascular (heart-related) source. A thorough cardiac evaluation by a cardiologist should be performed to be sure that the pain is not heart related. Chest discomfort can be described in a number of ways including pressure or fullness, burning, aching or pain, squeezing, sharp, or dull. Symptoms may be associated with physical movement, exertion, swallowing, or breathing and be of variable duration and severity depending on the cause.

What causes non-cardiac chest pain?
Causes of non-cardiac chest pain can include esophageal motility (movement) disorders, gastroesophageal reflux disease (GERD), anxiety, pulmonary (lung-related) or musculoskeletal (chest wall) systems. Esophageal chest pain may result from acid or alkaline (bile) reflux into the esophagus, esophageal dysmotility (abnormal esophagus or upper and lower esophageal sphincter movements) or esophageal hypersensitivity (discomfort experienced with normal esophageal processes due to an increased awareness or heightened nerve sensitivities).

How is non-cardiac chest pain diagnosed?
Diagnosis is based on the results of a number of tests that evaluate for esophageal motility disorders, gastroesophageal reflux disease (GERD), or other sources of pain such as from the lungs or musculoskeletal (chest wall) systems. Tests also aid in planning the best treatment options.

  • Chest x-ray or chest CT scan to evaluate for lung and some musculoskeletal related issues.
  • Barium swallow studies (thick barium contrast solution is swallowed to see esophagus structures and movements by x-ray).
  • Upper endoscopy (EGD is a camera scope placed in the esophagus for direct visualization of the upper GI tract).
  • Esophageal manometry and pH (measures esophageal pressures, swallowing ability, and acid levels).

What are examples of treatments for non-cardiac chest pain?
Depending on the cause, diet modification and changes in eating habits can be helpful for some sources of esophageal chest pain. Recommended changes include eating low acid foods (no citrus or tomato-based foods), avoidance of extreme temperatures with foods and beverages, limiting alcohol, caffeine and carbonated beverages, smaller meals, and eating slowly.

  • Medications to reduce acid or bile levels can be helpful for GERD associated symptoms.
  • Esophageal dysmotility and hypersensitivity can be responsive to changes in eating habits and diet along with medications to relax muscle contractions or reduce nerve sensitivities.
  • Chest wall pain can be relieved by the use of anti-inflammatory medications, direct heat or nerve blocking medications.
  •  Stress avoidance or measures to reduce stress levels may be helpful for anxiety-related pain along with anti-anxiety medications.

When to seek medical advice for non-cardiac chest pain?
If chest pain should change location, duration, character (type of pain) or becomes more severe, seek medical advice as soon as possible as this could indicate a new or more serious problem.


Part 3. Injuries of the chest.

Let’s continue talking about injuries. Today, we will talk about chest trauma. In isolation, this type of injury is rare in children, but it leads to high mortality. the chest contains such important organs as the heart and lungs. Most often, a chest injury occurs in an accident, but it can also occur when falling from a height, when the chest is squeezed between solid objects (during a collapse).

The most common are closed chest injuries: bruises and bone fractures.
With bruises of the soft tissues of the chest, the child complains of pain, and upon examination, swelling and bruising (bruising) are visible at the site of the injury. Soft tissue injuries are subject to outpatient treatment.

Chest fractures are rare in children and adolescents due to the high elasticity and flexibility of the chest. However, because of this feature, the risk of damage to the internal organs of the breast increases.

When a rib is fractured, the victim experiences severe chest pain, which is aggravated by breathing, coughing, movement, so the child tries to spare the chest, his breathing is short and shallow. He feels better sitting up than lying down.

As mentioned earlier, children are more likely to develop damage to the internal organs of the chest.

With bruised lungs, the victims complain of severe chest pain, shortness of breath, and a painful cough. Hemoptysis, shortness of breath, cyanosis (blue) of the skin may occur.

In case of heart contusion, complaints of pain in the region of the heart, palpitations, rhythm disturbances.

With bruises of the lungs, there can be the development of pneumothorax – air accumulation in the pleural cavity, hemothorax – blood accumulation in the pleural cavity, leading to lung collapse, clinically manifested by frequent shallow breathing, skin cyanosis, heart palpitations, anxiety, aggravation.

We will not analyze the traumatic asphyxia of the lungs during compression, chest injuries with the development of such life-threatening conditions as injuries to the heart, lungs, large vessels, tracheal esophagus, since they are always accompanied by an obvious extremely serious condition of the victim, which requires immediate hospitalization of the patient.

Let’s highlight again the MAIN SYMPTOMS of for chest trauma:
External signs of trauma: hemorrhage, swelling of soft tissues, injuries. Chest pain, aggravated by breathing, straining, coughing.
Shortness of breath, rapid, labored, shallow breathing.
Cyanosis of the skin and mucous membranes.
Rapid heartbeat, rhythm disturbances.
Anxiety, poor health.
Often forced position (the child chooses a position in which it becomes easier for him, tries to move less, because it hurts him).
Chest deformity.

FIRST AID for chest trauma
Calling the ambulance brigade.
Put the child in a half-sitting position.
Prevent your child from talking loudly and breathing deeply.
Free from tight clothing, provide free access to fresh air.
If the child is conscious, give pain reliever (analgin).
Warm the child, cover him with a blanket or warm clothes.
If there is a foreign object in the wound, do not pull it out. When vomiting and coughing up blood, make sure that the child does not choke, if he is unconscious, turn his head to one side.
Before the arrival of an ambulance, watch your breathing, pulse, consciousness.

Take care of yourself and your family!

“Non-cardiac” cardialgia – Medical practice “Healthy Back”

Some patients with diseases of the spine complain of “ pain in the heart “, cardialgia. This is vertebrocardiac syndrome , which requires additional examination.The main task of the doctor is to determine if it is heart pain or “non-cardiac” pain. We use an algorithm for the differentiation of chest pain, we conduct examination and treatment accordingly, and determine the risk factors for cardiovascular diseases. A cardiologist of our center for pains in the heart area makes an ECG, conducts a clinical examination of the patient, and examines complaints in detail. Most of these patients had no organic changes in the heart and vertebrogenic thoracocardialgia (chest pain in the region of the heart) was added to the main diagnosis.

Patients with vertebrocardiac syndrome complained of pain in the region of the heart and behind the breastbone, lasting minutes or several hours or even days. They were dull, aching, bursting pains. In addition to pain in the heart, pains in the back, interscapular region were observed, sometimes the pain radiated to the region of the shoulder girdle on the left and left arm. Sometimes the pain syndrome was accompanied by a feeling of heaviness and stiffness throughout the chest.

Pain in the heart is of varying severity, long-term or short-term.It is important to distinguish cardialgia from angina pectoris, which requires urgent treatment, therefore, in case of pain in the heart, you should consult a doctor or call an ambulance. Angina often depends on physical or emotional stress. May occur while walking fast. Retrosternal pressing pains radiate to the left, to the shoulder, scapula, to the jaw. Cores usually carry nitroglycerin or an Isoket-type spray with them. Each doctor is obliged to teach such a patient to properly help himself.

If pain is accompanied by high blood pressure in a hypertensive person, you should take drugs of rapid hypotensive action (dissolve under the tongue).

If the pain in the heart appeared for the first time, it has an indefinite localization, as a rule, the patient points the point of pain with his finger or puts his hand, the pain may be accompanied by a feeling of lack of air, anxiety, it is necessary to stop, take validol, corvalment under the tongue. You can take a few short breaths with your nose, hold your breath a little and exhale slowly. If you are unsure of the exact cause of your pain, see your doctor immediately or call an ambulance.

Patients with back pain come to our “Healthy Spina” center and very often complain of pain in the heart area, now arising, now passing. Particularly disturbing are night pains in the region of the heart, numbness of the hands during sleep; interruptions, sometimes tachycardia.

The cause of noncardiac cardialgia can be:

  1. Various disorders of the spine, neurological diseases. Osteochondrosis in the cervicothoracic spine, intercostal neuralgia, inflammation of the pectoral muscles, musculo-fascial syndrome, injuries of the ribs and sternum, shoulder pain , periarthrosis of the shoulder scapula.The pain begins with physical exertion, or in the morning after waking up, with a deep breath, coughing, sneezing. Often the pain syndrome is associated with hypothermia, a sharp increase in severity, after physical training, a long uncomfortable position of the body.
  2. Hormonal changes during menopause in women.
  3. Diseases of the gastrointestinal tract. These are hernia of the esophageal opening of the diaphragm, cholecystitis, inflammatory diseases and ulcers of the esophagus. High standing of the diaphragm due to bloating, obesity, provokes pain after eating, especially if the patient lies down.
  4. Diseases of the lungs, pneumonia. Pleurisy, especially on the left.
  5. Psychogenic cardialgia, requires a special approach, examination of complaints, mandatory examination. Such a patient also requires attention, conversation. Very often, a sincere conversation about the situation that has happened is a great relief for the patient.

Treatment depends on the active participation of the person himself and a reasonable attitude towards his health. Pain in the heart, pain in the chest, any pain is a signal for action.Pain, regardless of the cause, indicates some kind of abnormality in the body. Pain makes a person seek help and seek ways to prevent illness.

We wish you health and are always ready to help!

Chest pain – what causes the pain syndrome?

Answer to the question “What causes chest pain?” cannot be unambiguous, since there are many reasons for such clinical manifestations. First of all, with a sudden appearance of chest pain, especially if it is localized to the left or behind the sternum, it is necessary to exclude cardiac pathology.Pain can be a sign of serious heart disease, such as acute myocardial infarction, angina attack, myocarditis, etc. If you first have pain in the left side of the chest or behind the sternum, urgently consult a cardiologist. Chest pain can also be caused by diseases of the lungs, esophagus, stomach and duodenum.

However, most often chest pain is associated with damage to the musculoskeletal system. Pain syndrome, the causes of which are diseases of the spine, is denoted by the term “vertebral thoracalgia”.

If you have chest pain, do not self-medicate. Seek professional medical help at the CELT Pain Clinic, where you will certainly be helped to establish the cause of the pain and quickly eliminate pain.

At CELT you can get advice from a specialist algologist.

  • Initial consultation – 4,000
  • Initial consultation of the head of the Pain Clinic – 4,500

Make an appointment

Diseases causing chest pain

Intercostal neuralgia

This is one of the most common causes of chest pain. It occurs due to irritation of the intercostal nerves due to various reasons: muscle spasm due to intense physical or emotional stress, hypothermia; injuries to the ribs, spine; degenerative changes in the spine. In some cases, the appearance of intercostal neuralgia precedes herpes infection. In the treatment of intercostal neuralgia, diagnostic and treatment blocks are used, an individual course of conservative treatment is selected.


  • Fractured ribs
    Occur with a strong blow to the chest area or after a fall.In this case, severe pain occurs, which increases with inhalation or with active twisting movements of the trunk. If the pain in the front of the chest was preceded by an injury, see a traumatologist immediately.
  • Compression fractures of the thoracic spine
    Most often occurring in the elderly, occur on the background of osteoporosis. The onset of pain may be preceded by a fall, a sharp lifting of heavy objects, but compression fractures can occur without a visible provoking factor. Compression fractures are detected on radiography, computed tomography, or MRI of the thoracic spine. Once a compression fracture is diagnosed, there are a number of procedures that can help relieve pain quickly: see epidural block, radiofrequency nerve ablation, peripheral block.

Myositis and myotonic syndrome

One of the most common causes of back pain is damage to the muscles of the thoracic spine and chest.The cause of pain is microtrauma or muscle spasm. Often “muscle” pain occurs after physical exertion, sports, hypothermia. As a rule, pain in such cases depends on the position of the body and increases either with active movements, or vice versa at rest, at night. This type of chest pain is more common in young people and middle-aged people. see peripheral blockade, exercise therapy


As a rule, the diagnosis of herpes zoster or herpes zoster does not cause difficulties in diagnosis: this disease is characterized by a blistering rash along the intercostal spaces. However, pain along the ribs may precede the appearance of a rash or persist for a considerable time after the blisters have healed. In the latter case, there is a complication such as postherpetic neuralgia. see postherpetic neuralgia


The concept of “dorsopathy” combines a number of degenerative degenerative-dystrophic changes in the spine

  • Herniated disc
    Herniated disc in the thoracic spine is relatively rare and usually manifests itself as shooting pain along the intercostal spaces, and the intensity of the pain depends on the position of the body.Epidural block, radiofrequency ablation
  • have a good analgesic effect for a hernia in the thoracic spine

  • Facet syndrome or spondyloarthrosis
    The disease is caused by arthrosis of the facet (facet, intervertebral) joints. It is manifested by local pain in the thoracic spine, especially aggravated by extension, prolonged standing and by changing the position of the body from horizontal to vertical. The pain arising from the facet syndrome lasts for months and years, and its intensity increases over time.Radiofrequency ablation of the facet joints will help to get rid of this excruciating pain for a long time.

Tietze Syndrome

If the pain is localized in the anterior part of the chest, at the point of attachment of the ribs to the sternum, it may be caused by osteochondritis, an inflammation of the cartilage tissue, also called Tietze’s syndrome. With this disease, the intensity of pain increases with movement or at the height of a deep breath. Properly selected conservative therapy and peripheral blockade can help with this disease

Diagnosis of chest pain

Diagnosis of pain in the left side of the chest should begin with the exclusion of heart disease.It is necessary to perform an ECG, visit a cardiologist. Additionally, the doctor may prescribe EchoCG, Holter ECG monitoring. For chest pain associated with degenerative changes in the spine, the most informative diagnostic method is MRI of the thoracic spine, for traumatic injuries – X-ray and CT.

Since chest pain can be caused by diseases of internal organs, in order to determine the nature of the disease that led to the appearance of pain syndrome, a specialist consultation is required before the examination: the doctor collects an anamnesis (history) of the disease.Finds out the patient’s complaints and the circumstances of the onset of pain. Then the specialist conducts a physical examination: palpates the abdomen, listens to heart sounds and breathing, checks the mobility of the joints, determines the localization of pain points, and assesses the neurological status.

Chest pain treatment

As already mentioned, in the case of thoracalgia syndrome, the specialists of our Pain Clinic direct all efforts to eliminate the original cause of the disease.

All procedures are carried out by certified doctors with extensive experience.We will improve the quality of your life by eliminating pain from it!



Cardialgia pain in the region of the heart, differing in its characteristics from angina pectoris.

Etiology and pathogenesis

Any pain in the left side of the chest can be regarded as cardialgia until the diagnosis is clarified. Cardialgia occurs in a number of clinical syndromes and pathological conditions.As a rule, cardialgias do not stop after taking nitrates. The presence of cardialgia does not exclude the existence in some patients of atherosclerosis of the coronary arteries of the heart and can sometimes be interspersed or combined with true attacks of angina pectoris.

Clinical picture

Cardialgia with lesions of the peripheral nervous system. Cervical osteochondrosis and herniated discs can cause compression of the nerve roots; cardialgic syndrome can also be a consequence of irritation of the sympathetic plexus of the vertebral artery.In the first and second cases, the appearance of pain in the left half of the chest is associated with certain positions and movements of the arm, head, but not with physical stress; pains may intensify or occur at night, when the cervicothoracic roots are pulled (abducting the hand behind the back, stretching it to the side). In the third case, when the sympathetic plexus of the vertebral artery is compressed, edema of the hand sometimes joins the described symptoms, which is associated with a violation of sympathetic innervation; when bending the head turned towards the lesion, pain occurs.

Cardialgia can be a consequence of cervicobrachial syndrome resulting from compression of the subclavian arteries, veins and brachial plexus with an additional cervical rib or pathological hypertrophy (“syndrome”) of the anterior scalene muscle. The peculiarities of the pain syndrome in these cases include the appearance of pain when carrying small weights in the hand, when working with raised arms.

Cardialgia can occur with left-sided intercostal neuralgia, shingles, neuroma of the roots (in the latter case, the pain can be very intense).

Cardialgia can be observed with a high standing of the diaphragm, caused by bloating of the stomach or intestines, obesity, etc. Pain occurs often after eating, if the patient lies, but disappear when moving to an upright position, when walking; sometimes they are combined with real angina pectoris.

Cardialgia can be caused by diaphragmatic hernia, which occurs more often in old age when the esophageal opening of the diaphragm is stretched, as well as traumatic rupture of the dome of the diaphragm.Aching pains, retrosternal or other localization, arise as a result of displacement of the mediastinal organs or entrapment of the stomach, or with the formation of an ulcer in the prolapsing part of the stomach. Pain appears immediately after eating or in a horizontal position, sometimes at night (with late meals). The pain disappears when walking, after belching, when moving to an upright position. When a hernia is infringed, a severe chest pain may appear soon after eating, which does not stop from the use of conventional analgesics, nitrates, but disappears suddenly when the position of the body changes (usually in an upright position).

Peptic ulcer of the esophagus, cardiospasm, esophagitis may be accompanied by cardialgia, a distinctive feature of which is a clear connection with the passage of food through the esophagus. When the transverse colon is located over the liver, there may be either severe pain to the right of the sternum (with infringement of the intestine), or aching chest pain (with bloating).

Cardiac syndrome can be observed in primary pulmonary hypertension, pulmonary infarction (it may be accompanied by an attack of angina pectoris), parapneumonic pleurisy.Aching and stabbing pains in the heart area can occur with myocarditis (one of the signs of rheumatic heart disease), pericarditis. Dyshormonal cardiopathy is observed in the treatment of adenoma or prostate cancer with sex hormones.

Cardialgia , ventricular premature beats occur during puberty (pubertal heart). With this syndrome, both vegetative and behavioral features of the dyshormonap state are observed, although they are significantly less pronounced than with menopause. All the features of climacteric cardiopathy can be observed before the onset and in the first days of menstruation – premenstrual syndrome.


ECG. Magnetic resonance imaging of the spine (with suspicion of osteochondrosis of the spine, herniated discs). Consultation with a neurologist. Esophagogastroduodenoscopy (EGDS), X-ray of the stomach with suspected diaphragmatic hernia, esophageal ulcer. Consultation with a gastroenterologist.


Cardialgia with lesions of the peripheral nervous system, with left-sided intercostal neuralgia, herpes zoster, neuroma of the roots.Treatment of the underlying disease is necessary.

With an additional cervical rib in the case of severe pain syndrome and compression of the subclavian vessels, removal of this rib is indicated; in the syndrome of the anterior scalene muscle in mild cases, pain relievers, NSAIDs are prescribed, with severe lesions, drugs are injected into the hypertrophied anterior scalene muscle.