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Harrison’s Manual of Medicine



Potentially Serious Causes
Less Serious Causes
Other Causes

There is little correlation between the severity of chest pain and the seriousness of its cause.
The differential diagnosis of chest pain is shown in Fig. 2-1. It is useful to characterize the chest pain as (1) new, acute, and ongoing; (2) recurrent, episodic; and (3) persistent, sometimes for days (Table 2-1).

FIGURE 2-1. Differential diagnosis of recurrent chest pain. *If myocardial ischemia suspected, also consider aortic valve disease (Chap. 118) and hypertrophic obstructive cardiomyopathy (Chap. 119) if systolic murmur present.

Table 2-1 Some Causes of Chest Discomfort and the Types of Discomfort Associated with Them

MYOCARDIAL ISCHEMIA   Angina Pectoris (Chap. 122)   Substernal pressure, squeezing, constriction, with radiation typically to left arm; usually on exertion, especially after meals or with emotional arousal. Characteristically relieved by rest and nitroglycerin.
Acute Myocardial Infarction (Chap. 121)   Similar to angina but usually more severe, of longer duration (³30 min), and not immediately relieved by rest or nitroglycerin. S3 and S4 common.
PULMONARY EMBOLISM (Chap. 132)   May be substernal or lateral, pleuritic in nature, and associated with hemoptysis, tachycardia, and hypoxemia.
AORTIC DISSECTION (Chap. 125)   Very severe, in center of chest, a “ripping” quality, radiates to back, not affected by changes in position. May be associated with weak or absent peripheral pulses.
MEDIASTINAL EMPHYSEMA   Sharp, intense, localized to substernal region; often associated with audible crepitus.
ACUTE PERICARDITIS (Chap. 120)   Usually steady, crushing, substernal; often has pleuritic component aggravated by cough, deep inspiration, supine position, and relieved by sitting upright; one-, two-, or three-component pericardial friction rub often audible.
PLEURISY   Due to inflammation; less commonly tumor and pneumothorax. Usually unilateral, knifelike, superficial, aggravated by cough and respiration.
COSTOCHONDRAL PAIN   In anterior chest, usually sharply localized, may be brief and darting or a persistent dull ache. Can be reproduced by pressure on costochondral and/or chondrosternal junctions. In Tietze’s syndrome (costochondritis), joints are swollen, red, and tender.
CHEST WALL PAIN   Due to strain of muscles or ligaments from excessive exercise or rib fracture from trauma; accompanied by local tenderness.
ESOPHAGEAL PAIN   Deep thoracic discomfort; may be accompanied by dysphagia and regurgitation.
EMOTIONAL DISORDERS   Prolonged ache or dartlike, brief, flashing pain; associated with fatigue, emotional strain.
(1) Cervical disk; (2) osteoarthritis of cervical or thoracic spine; (3) abdominal disorders: peptic ulcer, hiatus hernia, pancreatitis, biliary colic; (4) tracheobronchitis, pneumonia; (5) diseases of the breast (inflammation, tumor); (6) intercostal neuritis (herpes zoster).

Approach to the Patient

A meticulous history of the behavior of pain, what precipitates it and what relieves it, aids diagnosis of recurrent chest pain. Figure 2-2 presents clues to diagnosis and workup of acute, life-threatening chest pain.

FIGURE 2-2. Differential diagnosis of acute chest pain.


For a more detailed discussion, see Lee TH: Chest Discomfort and Palpitations, Chap. 13, p. 60, in HPIM-15.


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