Tip
- Based strictly on location, it is clinically impossible to differentiate epigastric pain from chest pain.
- Visceral afferent fibers for the heart, esophagus, and stomach share common pathways (T5–T9 spinal segments), leading to significant referred pain overlap.
Etiology
- Coronary Artery Disease (CAD)
- Quality: Substernal pressure/heaviness. c
- Triggers: Precipitated by physical exertion or emotional stress.
- Relieving Factors: Relieved by rest or Nitroglycerin (NTG).
- High-Yield Note: Stable angina is predictable; Unstable Angina (UA)/NSTEMI/STEMI involves pain at rest or increasing frequency/intensity.
- Pulmonary & Pleuritic (Pleurisy, Pneumonia, Pericarditis, PE)
- Quality: Sharp, stabbing pain. c
- Triggers: Worse with inspiration (pleuritic) or coughing.
- Pericarditis Specific: Positional pain; worse when lying flat, improved by leaning forward.
- PE Specific: Often associated with sudden-onset SOB, tachycardia, and hypoxia.
- Aortic (Dissection, Intramural Hematoma)
- Quality: Abrupt, “tearing” or “ripping” pain; maximal intensity at onset.
- Radiation: Often radiates to the back (interscapular area).
- Risk Factors: Uncontrolled HTN, Bicuspid Aortic Valve, Marfan Syndrome, or Ehlers-Danlos.
- Key Finding: Possible asymmetric BPs/pulses between arms.
- Esophageal (GERD, Esophagitis, Diffuse Esophageal Spasm)
- Quality: Substernal pain; may refer to the neck or back.
- Triggers: Provoked by recumbent position (lying down) or post-prandial state.
- Associated Symptoms: Bitter taste (regurgitation), dysphagia, or dyspepsia.
- Relieving Factors: Nonexertional; relieved by antacids or H2 blockers/PPIs.
- Note: Nitroglycerin can occasionally relieve Esophageal Spasm, often confusing it with CAD.
- Chest Wall / Musculoskeletal (MSK)
- Quality: Persistent, localized pain.
- Triggers: Worse with movement, certain positions, or palpation (e.g., Costochondritis).
- History: Often follows repetitive activity or heavy lifting.
- Key Finding: Reproducible pain on palpation of the chest wall.
Diagnosis
- Initial/Screening (The Universal “Next Best Step”):
- 12-lead ECG (Must be done within 10 mins of arrival!). c
- CXR (Evaluate for pneumothorax, widened mediastinum, pneumonia).
- Key Labs: Cardiac biomarkers (High-sensitivity Troponin I/T).
- Confirmatory/Gold Standard (Tailored to suspicion):
- High probability PE: CT Pulmonary Angiography (CTPA).
- Aortic Dissection: CT Angiography (CTA) of Chest/Abdomen/Pelvis (or TEE if hemodynamically unstable/renal failure).
- ACS (STEMI): Coronary angiography.