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C H A P T E R 8 Chest painThe first step in the evaluation of a patient with chest pain is to determine whether the pain is a lifethreatening condition. Acute coronary syndrome includes myocardial ischemia and myocardial infarction (MI), aortic dissection, pulmonary embolism (PE), or pneumothorax. These are lifethreatening causes of chest pain and must be assessed rapidly so emergent treatment can be initiated. A quick diagnosis of acute MI greatly increases the patient’s chances of survival. Aortic dissection is a rare but catastrophic cause of chest pain. PE is accompanied by the sudden onset of dyspnea. If acute ischemic heart disease is an unlikely cause, other causes of acute chest pain should be considered, such as pulmonary, gastrointestinal (GI), psychological, musculoskeletal, or other conditions (e.g., pericarditis). A significant proportion of patients whose presenting symptoms include acute chest pain have esophageal spasm or gastroesophageal reflux disease (GERD); however, harmless conditions can mimic more serious disease. Pericarditis and valvular diseases, such as aortic stenosis and mitral valve prolapse (MVP), are less emergent causes of cardiac pain. Pain in any organ or system can be the result of inflammation, obstruction or restriction, or distention or dilation. All pain arising from the GI, musculoskeletal, respiratory, cardiac, and pulmonary systems transmits to the same spinal cord segments—T1 through T5—and makes identification of the specific origin of discomfort difficult. Many causes of noncardiac chest pain relate to chest anatomy, specifically skin, muscles, ribs, cartilage, pleura, lungs, esophagus, mediastinum, and thoracic vertebrae. In an infant, sweat on the forehead can indicate congenital heart disease (CHD). A decrease in cardiac output causes a compensatory sympathetic overactivity, resulting in a cold sweat on the forehead. In children, chest pain is rarely associated with serious organic disease. The most common causes of chest pain in children are costochondritis, trauma, muscle strain to the chest wall, and respiratory conditions associated with cough. Chest pain from rheumatic heart disease or other cardiac disease is relatively rare in children. However, patients and families often associate chest pain with heart disease and can be anxious about the condition because of reports of sudden death in young athletes. Diagnostic reasoning: Focused history The identification of potentially acute, lifethreatening situations must be made immediately. After you have determined that there is no immediate risk of severe oxygen deprivation to vital organs (e.g., MI, aortic dissection, and PE), proceed with a focused history. First, is this a life-threatening condition? Key Questions • Can you describe the pain? What does it feel like? (Dull, sore, stabbing, burning, squeezing?) • Does the pain radiate?