Chest pain is one of the most common complaints in internal medicine.
In terms of ambulatory practice most common cause is musculoskeletal pain, while in terms of emergency assistance in 50% of cases are acute coronary syndrome (myocardial infarction or unstable angina pectoris). The differential diagnosis of chest pain includes cardiac, pulmonary, gastrointestinal, musculoskeletal and mental reasons.
Acute coronary syndrome is an important cause of chest pain. Ischemic chest pain presents classic as increased substernal pressure, pressure or oppression by irradiation to the lower jaw, shoulder, back or left hand. The pain aggravate most of fisicheski or mental effort, though it can occur unexpectedly at complete peace of patient and calm down or not by taking natroglitserin. It can be accompanied by the emergence and vegetative symptoms such as nausea, vomiting and diarrhea. The unexpected appearance of central anginal pain or intensify the symptoms of stable angina pectoris available without elevation of cardiac markers (creatine phosphokinase MB fraction and troponin) is part of the clinical picture of unstable angina pectoris. Patients suffering it diabetes, women and older patients may present with atypical symptoms such as dyspnea or hiccup free of chest pain t.nar.stenokardni equivalents. Ischemic chest pain lasting less than 20 minutes, chest pain lasting more than 20 Miguel spoke in favor of acute coronary syndrome or an alternative diagnosis. Most power clinical features associated with chest pain who speak in favor of acute coronary syndrome include: (1) irradiation of pain in both hands; (2) presence of a third heart sound, and (3) hypotension. In contrast, chest pain with normal ECG, chest pain that changes its intensity depending on the position of the patient’s body or enhanced by palpation makes ischemic etiology less likely.
Coronary artery vasospasm (Prinzmetal angina) is represented by tsentarlno stinarodna pain occurring at rest similar to anginal and elevation of the ST segment of the electrocardiogram. Serial ECG minute show, however, reverse the amendments as opposed to progressive changes in acute coronary syndrome. Taking cocaine can cause such ST segment changes due to development of coronary vasospasm or ischemia without evidence of myocardial damage diraktna.
Acute pericarditis (bacterial or viral) can be preceded by inflammation of the upper respiratory tract and fever.Pericarditis is characterized by acute substurnalna chest pain that radiates to the trapezoid muscle; Pain often vlashava inhalation and transition from standing to lying down and calm down while bending forward. Pericardial friction noise is present in 85-100% of cases of pericarditis sotar. Klasichiskiya pericardial noise consists of 3 components: atrilana systole, diastole and ventricular sieve. ECG changes include difzni ST wave elevations (no konstilatsiite typical for selective occlusion available with acute coronary sinrom), the PR -depresiya and findings are not specific. Echocardiogram is a boon for the establishment of pericardial effusion or tamponade.
Patients with desekatsiya of the thoracic aorta present clinically with acute onset of searing described as chest pain radiate to the back or abdomen. Aortic dikesatsiya may be associated with syncope due to reduced cardiac output, stroke or heart attack caused by karotivna or coronary occlusion arterilana / dissection, cardiac tamponade or sudden cardiac death due to massive dissection. Hypertension is present in 50% of patients and does not constitute diagnositchna value. The difference in heart rate established carotid, radial or femoral artery is of great importance diagnositchno. In 50% of cases Auscultation noise diastolic aortic inzifitsientsiya, especially in dissection type A, but his presence or absence should not enter into the assessment of whether or not there aortic dissection. In a small proportion of patients may have focal deficits in neurological examination. Extensions mediastinum found in the overview Earl of lung and heart, is the most common initial findings (available in 90% of cases of aortic dissection). When suspected aortic dissection is shown visualization of the aorta through: (1) CT; (2) Nuclear Magnetic Resonance; (3) transezofagialna echocardiography or (4) aortic angiography.
Aortic stenosis is a common cause of onset of chest pain, which may be accompanied by dyspnea, syncope or heart failure. Physical examination establishes sistulochine noise with irradiation to the carotid heard best in the second right intercostal space. Transezofagialnata echocardiography is the diagnostic test of choice for suspected aortic stenosis.
Cardiac syndrome X (microvascular angina) causes anginal pain most often in women and diabetics. It can be part of the microvascular complications of diabetes, and rarely to be one of his first occur by chance. It are characterized by anginal symptoms, the ST segment depression established in velergometriya and normal coronary arteries on angiography. If there is no diabetes should be sought psychiatric podlezhai reasons.
Pulmonary embolism may present clinically with acute pleuritic chest pain, dyspnea, cough and hemoptysis. The presence of risk for the occurrence of embolism factors such as positive history for the presence of deep vein thrombosis, recent surgery, immobilization or malignancy may suggest the diagnosis. Physical examination can identify non-specific findings as tachycardia, tachypnea and wheezing. Additionally could establish evidence of pulmonary hypertension.
Pleuritic chest pain may be also mafinestatsiya of pneumonia and then often associated with fever, sweats, cough, expectoration, and dyspnea pathological. Physical examination can establish evidence of pulmonary consolidation as dull perkutoren tone egofoniya and bronhofoniya.
Pneumothorax should be suspected in any patient presented with sudden appeared chest pain and dyspnea.Physical examination establishes the absence or weakened breath sounds on the side of pneumothorax, hypotension and trahialna deviation to the opposite side of pneumothorax.
Pulmonary hypertension is common, but unfortunately untimely diagnosed pathology. Most often it manifests with recurrent syncope, dyspepsia, and chest pain. Physical examination can establish accent (even split) P2 best Auscultation in the second left intercostal space.
Pulmonary cause of chest pain establish best with an overview graphy lung. In patients with dyspnea, pulsavata oksemetriya and KGA are also shown. In visokosugestivnite conditions for the presence of pulmonary embolism is recommended to perform a helical scan with or without a Doppler of the lower extremities. The absence of increased levels of D-dimer helps to exclude the diagnosis of pulmonary embolism.
Gastrointestinal diseases may appear clinically through imitation of ischemic chest pain. Important distinctions are: easing the pain of taking antiaditsi (in terms of speshnato it is difficult prilozhmo because emergency cabinet even bigger hospital will antacid so rarely needs differential diagnosis use intravenous administration of spazmoanalgetitsi that soothe disfagichnata chest pain), its deterioration in the transition to the supine position (NB:! DD with pericarditis), strengthening its after eating or waking the patient from sleep due to the onset of severe pain (with ischemic chest pain cardiovascular accidents occur usually after normal waking the patient from sleep , casuistry is primarily in aortic dissection patient to be awakened from sleep due to the onset of pain).Other symptoms speaking in favor of the gastrointestinal causes of chest pain is nalichietno of heartburn, unexpectedly fill the mouth with saliva (which is a normal physiological mechanism which is intended to neutralize the increased acidity content of the stomach), chronic cough, dry throat and presence of hoarseness.Upon physical examination of patients can identify wheezing in lung auscultation, bad breath (halitosis), dental erosions and farigealna erythema.
In a normal ECG urgency, lack of elevation of cardiac markups and ilpsata of physical findings speaking in favor of cardiovascular diagnostic crash nasochnva thought to extracardiac causes of chest pain.
Musculo skeletal causes are more common in women than in men; the most common cases include osteochondritis, arthritis and fibromyalgia. Musculoskeletal pain is sudden onset and lasts for hours and days. It is an acute and localized in a specific area of the chest, but may be the wrong localized. The pain made worse by deep dvishvane, bending the body in one direction or movement of arms. The pain is aggravated by palpation (NB:! Deterioration characteristic of the pain by palpation not reject ischemic character) and cardiovascular examination is often normal. The availability of a sensitive area at the top of the chest often speaks in favor of fibroialgiyata. For musculoskeletal pain, physical examination and careful medical history are key to postanyave correct diagnosis, performing an overview Earl of lung and heart, as well as some other tests may be indicated depending on the circumstances.
Chest pain may be a manifestation of severe anxiety or panic attack.
Patients may complain of abdominal distress and changes in sensations, as well as nausea and vomiting.Upon physical examination can be established tachycardia and tachypnea, and nothing abnormal.
Psychosomatic chest pain is a clinical diagnosis of exclusion, which should be placed after the rejection of the other reasons for its occurrence.