When Is Chest Pain Dangerous?

Introduction

Chest pain is an extremely common presenting complain in virtually all healthcare settings and can be caused by a wide range of conditions which range from musculoskeletal disorders to potentially life-threatening issues like ischemic heart disease. Chest pain comprises approximately 5-10% of all emergency department visits. In this article, we will be reviewing the plethora of causes of chest pain and delineate the “red-flags” which should prompt urgent medical attention.

Epidemiology of Chest Pain

In emergency departments, chest pain is the 2nd most common complaint. The approximate percentage occurrence of chest pain in patients who present to the emergency department is outlined below:

  • Acute Coronary Syndrome (30%)
  • Gastrointestinal Reflux Disease (30%)
  • Musculoskeletal Causes (28%)
  • Pneumonia (2%)
  • Pulmonary Embolism (2%)
  • Pericardial Tamponade/Pericarditis (4%)
  • Aortic Dissection (1%)
  • Pneumothorax (Unreported)
  • Oesophageal Perforation (Unreported)
  • Herpes Zoster (Unreported)

As delineated above, the causes of chest pain are extremely varied. The thoracic cavity (chest) contains a multitude of organs spanning various systems, and chest pain can be a manifestation of dysfunction in any one of them.

Cardiovascular Chest Pain

The cardiovascular system comprises of mainly the heart, its surrounding pericardium which can be thought of as a pouch containing the heart, as well as the great vessels such as the aorta and the superior vena cava. Stresses to the heart which reduce the oxygenation of the heart muscle (myocardium) can often result in what is known as “Acute Coronary Syndrome”. This is an umbrella term used to denote stable angina, unstable angina and myocardial infarction (heart attack). Patients with Acute Coronary Syndrome usually present with a crushing central chest pain, accompanied by nausea, vomiting, sweating, giddiness and even loss of consciousness. The character of the pain has been likened to an “elephant sitting on one’s chest” and has been reported to radiate to the left neck and/or left shoulder. Typically, patients will also have a history of co-morbidities such as hypertension (high blood pressure), hyperlipidaemia (high cholesterol) and/or diabetes mellitus. Other than the heart itself, the great vessels can also be a source of chest pain. Aortic dissection is an extremely serious but uncommon condition in which the wall of the aorta has sheared off and a “false passage” has been created. This pain is characteristically severe and has been described to be “tearing” in nature. The pain has also been reported to radiate to the back. It may sometimes precipitate a heart attack due to its severity and proximity to the heart. In summary, the red flags for cardiovascular chest pain are:

  • Severe, crushing chest pain that is not well-localised
  • Prolonged duration
  • Radiation to the neck/shoulder/back
  • Giddiness/loss of consciousness
  • Shortness of breath
  • Profound sweating
  • Nausea/Vomiting

Respiratory Chest Pain

The respiratory system can be divided into the upper and lower respiratory systems. Chest pain is often caused by the lower respiratory system which comprises of the lungs and their surrounding pleura, which can be thought of as a thin film coating the lungs. Infections of the lung, such as pneumonia are characterised by shortness of breath, fever, productive cough and a pleuritic chest pain. A pleuritic chest pain differs from cardiac chest pain, in that it is often well-localised, and has a sharp character which coincides with inhalation. Pneumothorax, a condition in which a lung has collapsed due to a leakage of air into the space between the lung and chest wall is characterised by a sharp pain that is also well-localised and is accompanied by a greater degree of shortness of breath. Rarely, pulmonary embolisms occur in the respiratory system. These are blood clots in the pulmonary arteries and/or veins which occur in hypercoagulable (prone to clotting) states. Often, they travel to the lungs from the deep veins in the lower limbs. Again, they are characterised by a greater degree of shortness of breath with pleuritic chest pain. At time, they may not be accompanied by chest pain at all. In summary, the red flags for respiratory chest pain are:

  • Sudden onset pleuritic chest pain
  • Severe shortness of breath
  • Swollen calf
  • Fever

Gastrointestinal Chest Pain

Even though the gastrointestinal tract resides largely in the abdominal cavity, some components of it reside in the thorax (chest). Perforations of the oesophagus (feeding tube) and stomach can lead to severe, sudden-onset chest pain. Peptic ulcers and functional dyspepsia may be accompanied by a “burning” chest pain which is exacerbated after meals, or in a recumbent position. Reflux disease, also known as heartburn, may also share these symptoms. The red flags for gastrointestinal chest pain are:

  • Sudden onset severe chest pain
  • Sudden pain after prolonged bouts of vomiting/retching
  • Rectal bleeding
  • Blood in vomitus

Musculoskeletal Chest Pain

Musculoskeletal chest pain occurs very frequently, due to sprains and strains in the musculature of the chest wall. This pain is extremely well-localised and is often exacerbated on movement, unlike chest pain which originates from the other systems. Skin lesions such as herpetic vesicles can also cause chest pain, especially if they run along the course of a nerve (e.g. Intercostal nerve). Most cases of musculoskeletal chest pain can be managed conservatively in the primary care (e.g. GP) setting. Red flags for musculoskeletal chest pain are:

  • Fracture
  • Dislocation
  • Severe bruising
  • Blunt trauma

CH1ER Management

If patients have chest pain, and any one of the above red-flags, they are strongly advised to seek immediate medical attention. The Community Health 1st ER has a state-of-the-art on-site laboratory and radiology and imaging services to rapidly diagnose or exclude life-threatening causes of chest pain. Most life-threatening causes of chest pain such as acute coronary syndrome, pneumothorax and pneumonia can be rapidly diagnosed with an EKG and an X-Ray. Our trained expert physicians and ancillary healthcare staff are well-prepared to address your chest pain efficiently and effectively!