Chest Pain
Common Presentations
MSK: Chest wall tenderness, worse with movement, ± injury
Bornholm’s syndrome: Unilateral chest/abdo pain, rhinitis, Coxsackie virus infection
Shingles: Intense, unilateral chest pain; rash after 3d
Oesophageal spasm: Central chest pain ± acid reflux ± burning pain
Aortic dissection: Sudden, tearing, radiating to back, unequal BP in arms
Pericarditis: Sharp sternal pain, better leaning forwards, worse lying on left
Pneumothorax: Sudden pleuritic pain, SOB, trachea deviated
Pleurisy: Chest infection, pain worse with deep breathing/coughing
PE: Sudden SOB, tachycardia, hypoxia, ± haemoptysis
Cardiac ischaemia/infarct: Central pressure radiating to neck/arms/jaw ± autonomic symptoms
Causes
Think anatomically
Skin — shingles. Pain can start 2–3d before rash. Cellulitis.
Muscles — spasm, tendon damage
Bones — costochondritis, fractures, tumour
Lungs — infection, embolus, pneumothorax
GI (most common cause) — reflux, ulcers. Remember abdo pain could also be cardiac though
Tubes — aortic dissection, oesophageal spasm/oesophagitis
Other — Bornholm’s syndrome (unilateral chest and/or abdo pain with rhinitis, Coxsackie virus, simple analgesia)
Heart = muscle = crushing, pressure-like central pain with radiation to neck/jaw/arms
S- Central chest
O — Gradual
C — Crushing discomfort
R — Radiates to neck/jaw/arms
A — Associated with symptoms of autonomic dysfunction
T — Lasts >15m
E — Better with GTN spray
S — Severity varies but can be very mild to very severe
Shortness of breath has the worst prognosis in the setting of chest pain
Management in primary care
Pain now — GTN, aspirin 300mg, transfer to hospital
Pain 12–72h ago — Same-day assessment
Pain >72h ago — ECG, trops, then decide
