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Chest pain 

Chest pain
Chest pain

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

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date: 26 October 2021

Introduction to chest pain

The majority of patients with chest pain referred for a respiratory opinion have either acute pleuritic pain or persistent, well-localized pain. Cardiac pain rarely presents in this manner, although it should be considered in exertional pain or in the presence of risk factors for ischaemic heart disease. Within the respiratory system, pain may arise from the parietal pleura, major airways, chest wall, diaphragm, and mediastinum; the lung parenchyma and visceral pleura are insensitive to pain. Processes involving the upper parietal pleura cause a pain localized to that part of the chest. The lower parietal pleura and outer region of the diaphragmatic pleura are innervated by the lower six intercostal nerves, and pain here may be referred to the abdomen. The central region of the diaphragm is supplied by the phrenic nerve (C3, 4, and 5), and pain may be referred to the ipsilateral shoulder tip. Tracheobronchitis tends to be associated with retrosternal pain.

Acute pleuritic chest pain

  • Pleuritic pain is sharp, well localized, worse on coughing and inspiration, and the subsequent limitation of inspiration often leads to a degree of breathlessness

  • Causes of acute pleuritic chest pain include:

    • Pulmonary infarction (following embolism)

    • Pneumonia

    • Pneumothorax

    • Pericarditis

    • Pleural infection (empyema, tuberculous)

    • Autoimmune disease (e.g. systemic lupus erythematosus (SLE), rheumatoid arthritis (RA))

    • Musculoskeletal

    • Fractured rib

  • In addition, consider atypical presentations of serious conditions such as MI, aortic dissection, oesophageal rupture, and pancreatitis. Consider angioinvasive fungi, such as Aspergillus, as a cause of pleuritic chest pain in the immunocompromised

  • Diagnosis is typically based on ‘pattern recognition’ of clinical features, followed by selected investigations. Initial investigations typically include CXR, ECG, ABGs, serum inflammatory markers, and D-dimers. Further investigations may include V/Q scanning or CTPA, pleural aspiration, and measurement of serum autoantibodies

  • PE (see Chest pain pp. [link][link]) commonly presents with pleuritic pain, and exclusion of this diagnosis is the usual reason for referral. Assess risk factors for thromboembolic disease. Normal O2 saturations and PaO2 in the ‘normal’ range do not exclude the diagnosis; calculate the A–a gradient (see Chest pain p. [link]). The presence of a pleural rub is a non-specific sign that occurs with pleural inflammation of any cause

  • In young adults, pneumococcal pneumonia may present with acute-onset pleuritic chest pain, although systemic symptoms, such as fever, usually predate the pain by hours

  • The pain from pericarditis is pleuritic, but central, and relieved on leaning forward; there may also be a pericardial rub, characteristic ECG features, and a small pericardial effusion on echo

  • Musculoskeletal pain may occur as a result of cervical disc disease, arthritis of the shoulder or spine, a fractured rib, or costochondritis (Tietze’s syndrome), which often follows a viral infection

  • The presence of chest wall tenderness does not invariably indicate a benign musculoskeletal cause; tenderness may be seen in malignant chest wall infiltration and sometimes following pulmonary infarction

  • Other features besides pleurisy that may suggest a diagnosis of SLE include rash, photosensitivity, oral ulcers, arthritis, pericarditis, renal or neurological disease, cytopenia, positive ANA, and dsDNA.

Chronic chest pain

  • Persistent chest pain that is well localized is typically caused by chest wall or pleural disease. Causes include:

    • Malignant pleural disease or chest wall infiltration

    • Benign musculoskeletal pain

    • Pleural infection (empyema, tuberculous)

    • Benign asbestos-related pleural disease

    • Autoimmune disease (e.g. SLE, RA)

    • Recurrent pulmonary infarction (emboli, vasculitis)

  • Pain from malignant chest wall infiltration is often ‘boring’ in character and may disturb sleep; it is frequently not related to respiration. Causes include 1° lung cancer, 2° pleural malignancy, mesothelioma, and rib or sternal involvement from malignancy (including myeloma and leukaemia)

  • Chronic thromboembolic disease tends to present with breathlessness; when chest pain occurs, it is usually episodic, rather than persistent

  • As with acute pleuritic pain, investigations are directed by initial clinical suspicion. Consider CT chest, bone scan, serum autoantibodies, FBC and film, serum electrophoresis. CXR may appear normal in malignant chest wall disease.