Chest-wall pain

A number of disorders can cause discomfort that originates from the structures of the chest wall, including the skin as well as the ribs and their surrounding muscles. Herpes zoster can cause unilateral chest pain. In costochondritis (Tietze syndrome), inflammation of the rib-cage cartilage can lead to pain in the sternum or ribs on palpation. Thoracic outlet syndrome often results in complaints of burning supraclavicular pain along with paresthesias and pain in the distribution of the ulnar nerve. Trauma, weightlifting, or coughing can cause chest-muscle tenderness. Such movements as turning or twisting may aggravate this type of pain.

Appropriate diagnostic questions

As you can see, many maladies can lead to chest pain. Asking some simple questions is the first step in determining whether pain is cardiac or noncardiac in origin.


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Does the pain get better or worse with a change in body position? Typically, chest pain of cardiac origin should not be affected by such a change.

Does the pain get better or worse with respirations? Cardiac chest pain should not be intensified by respirations.

Is the pain intense, dull, or knifelike? For the most part, cardiac chest pain is usually described as a dull ache, heaviness, or pressure. It is rarely labeled sharp or stabbing.

Is the pain deep or close to the surface of the skin? Cardiac chest pain is usually described as deep.

Have you had a similar pain in the past? What did your health-care provider tell you was causing it?

Have you taken nitroglycerin or antacids for this pain in the past? Did it help? Did any other medications give relief? 

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When in doubt, proceed with cardiac workup

If the source of the chest pain is still undetermined, perform a proper cardiac workup. Normal or inconclusive results are an indication that the discomfort is noncardiac in origin. Appropriate tests include:

ECG. Be alert for ST elevation or depression, T wave inversion or flattening, or presence of Q waves. These findings will help determine whether the chest pain is attributable to angina or MI. Bear in mind that the ECG will be normal in approximately 25% of patients with angina.

Cardiac markers. As the heart tissue is deprived of oxygen and dies, creatine phosphokinase (CPK) and troponin are released into the bloodstream. Elevated CPK and troponin levels are a strong indication that an MI has occurred. Troponin usually peaks after about 12 hours, whereas the CPK and CPK muscle-band levels peak after 10 to 24 hours.

Echocardiography. This test should be done to evaluate for presence of valvular abnormalities and assess the overall pumping function of the heart.

Stress testing. If the chest pain is nonurgent, stress testing may be considered if the ECG and cardiac markers are normal. However, a stress test is not a perfect test. A “positive” test does not definitively show that a person has coronary artery disease (CAD). On the other hand, a “negative” test does not completely rule out CAD. Hence, stress testing only shows the probability of coronary atherosclerosis

Chest radiography. An x-ray should be performed to evaluate the lungs and size of the heart and rule out some causes of chest pain (i.e., pneumonia and pneumothorax).

Nuclear imaging. These studies are also beneficial in showing CAD. In this type of testing, a radioactive substance is injected into the bloodstream and accumulates in the healthy tissues of the heart. Pictures of the heart are obtained during rest and during stress to determine whether there is diminished blood flow to certain parts of the heart, thus contributing to chest pain.

Coronary angiography. Coronary angiography is used to reveal the presence of CAD. Dye is injected into the coronary arteries to show any partial or total arterial blockage.

CT. A chest scan should be done if an aortic dissection is suspected.

Summary

Distinguishing cardiac from noncardiac chest pain can be quite a challenge for the primary-care clinician. Recognizing the multiple causes of chest pain, asking appropriate diagnostic questions and, when in doubt, performing a comprehensive cardiac workup are the essential steps to providing appropriate treatment. n

Mr. Campbell is a nurse practitioner in the division of cardiovascular surgery at the University of Alabama at Birmingham Hospital.

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