Chest pain is common, but patients have different causes of chest pain, and it is crucial to have the correct differential diagnosis.
Chest pain is a common reason for outpatients to visit the clinic. Various inflammatory or physical factors stimulating the intercostal nerves, afferent fibers of the posterior roots of the spinal cord, sensory fibers innervating the heart and aorta, vagal sensory fibers innervating the trachea, bronchus and esophagus, and phrenic nerve can cause chest pain.
The most common type of chest pain is that caused by cardiac disease. Most non-cardiac chest pain originates from the pleura or chest wall because the lung tissue and dirty pleura lack nociceptive receptors, so chest pain may not occur even with severe lesions of the lung parenchyma.
Chest pain should not be taken lightly
A. Common types of clinical chest pain
1.Pleuritic chest pain
The degree of pleuritic chest pain varies greatly. Mild chest pain appears at the end of deep inspiration, while more severe chest pain appears at the time of shallow inspiration. Pleuritic chest pain becomes dull or disappears on expiration or breath-hold. Pressure on the painful area does not reduce the pain. With the exception of lesions affecting the diaphragm, pleural pain is often secondary to localized parenchymal lung disease.
Pleuritic chest pain is often caused by inflammation, malignancy, and pneumothorax. The speed of pleural chest pain and accompanying symptoms can provide clues to the diagnosis: sudden onset of chest pain often suggests pneumothorax, pulmonary embolism; faster onset of pain, accompanied by cough, fever often suggests pneumonia, bacterial pleurisy or pus; slow onset of chest pain accompanied by fatigue, weight loss should be considered tuberculosis and tumors.
2.Mediastinal chest pain
The nature of mediastinal chest pain varies greatly and can be caused by a variety of diseases. The organs in the mediastinum include trachea, esophagus, pericardium, thymus, aorta and numerous lymph nodes, and lesions in these parts may cause chest pain. The nature and degree of pain, the site of radiation, and the trigger of pain are all important in identifying the cause of pain.
(1) Mediastinal chest pain is often located in the retrosternal and precordial regions, and can also radiate to the neck, upper arm, or even the back. Most of them are caused by myocardial ischemia and are crushing in nature and may be accompanied by a feeling of suffocation.
In myocardial infarction, more severe and persistent chest pain can occur. Chest pain of a similar nature is also seen in massive pulmonary embolism.
Similar chest pain to angina is also seen in severe chronic pulmonary hypertension caused by mitral stenosis or multiple pulmonary embolisms.
(iv) Chest pain due to acute pericarditis is very similar in nature to chest pain due to cardiomyopathy, but chest pain due to pericarditis can be aggravated by breathing, swallowing, or bending.
⑤ The chest pain of aortic coarctation aneurysm is characterized by sudden onset of severe tearing chest pain that may radiate to the back, extend to the abdomen or even to the lower extremities.
(6) Limited aortic aneurysm can erode the sternum, ribs and thoracic vertebrae, causing “burning” pain behind the sternum or back pain.
(7) “Burning” pain from esophageal disease is often associated with eating. Reflux esophagitis may be worse in the prone position and relieved upon standing up.
(8) Another common outpatient pain behind the sternum may be caused by nerve endings distributed in the tracheal mucosa, mainly due to upper respiratory tract infections and severe dry cough.
⑨ Pericardiotomy syndrome often appears suddenly days or weeks after cardiac surgery and pericardiotomy. The pain is located behind the sternum and can radiate to the left side of the neck, and deep breathing can aggravate the chest pain.
3.chest wall pain
Chest wall pain caused by intercostal muscle injury may have a history of trauma, and even crying can cause injury to the chest wall muscles, but more commonly it is caused by a dry cough due to tracheobronchitis. Chest pain without these causes should be carefully searched for other causes, including intercostal neuritis, shingles, and rib lesions.
4.Bronchopulmonary diseases
Respiratory system inflammation, tumor, tuberculosis, pulmonary embolism and other diseases can also cause chest pain. Its performance is similar to pleurisy chest pain, but the diagnosis of chest pain caused by such diseases is often difficult to determine, such as lung abscess or tumor can cause deep indistinct chest pain; mostly accompanied by cough and sputum, or with hemoptysis; often with symptoms and signs of the primary disease.
Chest pain due to respiratory pathology has common clinical features.
① Pain persistent chest pain is often aggravated by coughing or deep breathing;
②There is no localized pressure pain in the chest wall, and the location is relatively limited, but it can be transmitted along the nerve distribution to the shoulder and back or upper abdomen;
③More often accompanied by cough, sputum, dyspnea and other symptoms;
④Symptoms and signs of the primary disease are often associated; ⑤Chest physical examination and X-ray examination can often detect the lesion.
Patients with pulmonary thromboembolism mostly have a history of lower limb venous thrombosis, fracture, trauma, surgery, malignancy, oral contraceptives, and long-distance travel. Symptoms: shortness of breath, chest pain, syncope, hemoptysis, cough, palpitations, irritability, near-death feeling, triad of signs. Signs: shortness of breath, cyanosis, dry and wet rales in the lungs, tachycardia, blood pressure changes, jugular venous filling, P2 hyperdissection, lower limb circumference inequality.
5.Digestive system diseases
Esophagitis, esophageal cancer, esophageal hiatal hernia, mediastinitis, etc. The pain is located behind the sternum, manifesting as persistent vague pain or drilling pain, and may radiate to other parts, often accompanied by dysphagia or increased pain when swallowing. Liver abscess, hepatocellular carcinoma and subdiaphragmatic abscess can also cause pain in the thorax and lower part of the sternum, and the pain can be radiated to the shoulder and neck when the central part of the diaphragm is stimulated.
6, clinically a common chest pain that occurs mostly in the left side of the chest, mainly located in the precordial region or the apical part of the heart, the degree is heavy, the nature is sharp pain, sometimes the location is variable. It occurs mostly at rest or during light activity, and can sometimes be triggered by mood swings, and lasts for about 30 seconds to 5 minutes. It often occurs during inspiration, and breathing has an effect on the chest pain, which gradually subsides as the patient maintains shallow breathing. It is a benign chest pain of unknown pathogenesis, which can be caused or aggravated by anxiety and is often associated with dyspnea and hyperventilation. It is significant because it needs to be differentiated from other severe chest pains, such as angina pectoris.
Common high-risk chest pain: acute coronary syndrome, aortic coarctation, pulmonary embolism, pericardial compression, tension pneumothorax, etc.
Low-risk chest pain: ① digestive system diseases: reflux esophagitis, esophageal spasm, peptic ulcers …… (treatment: acid suppressants may be effective); ② skeletal muscle diseases: costochondritis, muscle pain, intercostal neuralgia …… ③ herpes zoster; ④ mental factors. Fear, depression.