Clinical approach to “Central” Chest Pain

Differential diagnosis

• Esophageal pain
  • Esophageal spasm
  • Esophageal reflux
• Musculoskeletal pain
• Anginal pain

History taking

• Active process.
• Direct questioning to check details and to confirm common understanding of the words.
• Co-existing fundamentally different pain is also possible.

Characteristics of Angina “like” central chest pain

Site

• Constant and characteristic for each patient (different for different patients).
• Location is diffuse.
• Not “inframammary”.

Character

• Gripping/tight.
• Not stabbing/sharp.

Severity

• Unrelated to severity/duration of ischemia.
• Silent ischemia: 50% of times.

Onset

• Not abrupt.
• Pain is either present or absent. It is not a background pain.

Duration and relief

• Ischemia: 3-10 mins. Decreases with relaxation/rest/nitrates (Onset of action: 2-3 mins).
• Infarction: pain > 30 mins. Any pain more than 30 mins without any subsequent evidence of myocardial infarction (Clinical, ECG, cardiac enzymes) - CARDIAC INVOLVEMENT UNLIKELY.

Initiation factor

• Stable effort angina:

  • Atherosclerotic plaque (leading to fixed coronary artery narrowing)
    • At rest and upto certain limit of effort: normal blood supply distally.
    • After certain limit: blood supply to distal region impaired, “angina” develops.
  • Precipitated by: physical exertion, emotional stress, excessive meals, cold weather.
  • Stereotype events: Rest (asymptomatic) –> Exertion (asymptomatic) –> more exertion (angina) –> Rest (asymptomatic)

• Unstable angina/acute myocardial infarction:

  • Plaque fissure
    • Thrombus –> intraluminal extension (Fixed component)
    • Chemical mediators –> VAsospasm (Dynamic component)
  • Stereotype is lost
    • Angina: unexpected occurence, increased frequency and duration.
  • Different cases have different proportion of:
    • THROMBUS ——— VASOSPASM (100% is called prinzmetal angina)

• Symdrome X (Microvascular syndrome):

  • Indistinguishable from Stable Effort Angina.

Confirmation of diagnosis

• Stress Angina:
  • Stress Testing: proves that chest pain is due to cardiac cause.
  • Angiography: diagnosis of cause as coronary block.
• Unstable Angina:
  • Stress Testing: Potentially dangerous.
  • Continuous ECG monitoring.
• Syndrome X:
  • Stress Testing: positive.
  • Angiography: negative.

Cardiac vs esophageal pain

• Chest pain > 30 min and ECG normal: Unlikely to be cardiac.
• Chest pain decreasing with antacids: Esophageal.
• Chest pain increased with deglutition of saliva: Esophageal.
• Chest pain associated with dysphagia: Esophageal.

May be indistinguishable

Cardiac vs muscular pain

• Chest pain induced by movement of part: Muscular pain.