Chest pain is one of the symptoms that most worries patients, and rightly so. Although many cases are not related to a heart attack or another life-threatening disease, chest pain should never be taken lightly. It is especially important to assess whether the cause is cardiac, pulmonary, vascular, musculoskeletal, or gastrointestinal.
Which dangerous causes of chest pain must be ruled out first?
In practice, we always first consider urgent and potentially life-threatening conditions. Among them, myocardial infarction is the most common serious cause that must be ruled out. In patients who present to the emergency department with chest pain, acute coronary syndrome is confirmed in approximately 5% of cases, while in outpatient practice this percentage is lower (2–4%).
Pulmonary thromboembolism is less common, but clinically extremely significant. Its incidence in the general population is approximately 60–120 per 100,000 inhabitants per year, and it represents an important cause of acute chest pain accompanied by dyspnea.
Aortic dissection is rare, but one of the most dangerous diagnoses. Its incidence is around 4–7 per 100,000 inhabitants per year and requires urgent recognition and treatment.
What are other, more common causes of chest pain?
Much more often, the cause of chest pain is not dangerous. This includes pain originating from the chest wall (muscles, ribs), costochondritis, gastroesophageal reflux, esophageal spasms, anxiety, lung infections, and spine-related problems. In primary care, these causes account for the majority of cases.
When does chest pain require an urgent examination?
You should seek medical attention urgently if the pain is severe, tight or squeezing in character, lasts longer than a few minutes, occurs at rest or with minimal exertion, spreads to the arms, neck, or jaw, or is accompanied by shortness of breath, sweating, nausea, or fainting. Sudden difficulty breathing, a drop in blood pressure, or a “tearing” pain radiating toward the back are particularly alarming symptoms.
When do we perform laboratory tests?
Laboratory testing is performed when serious conditions are suspected. Troponin is crucial for diagnosing myocardial infarction, while D-dimer helps in the assessment of pulmonary embolism. NT-proBNP is used when heart failure is suspected. In addition, complete blood count, electrolytes, and kidney function are assessed.
When do we perform cardiac ultrasound?
Echocardiography enables assessment of heart function, heart valves, and possible complications. It is performed when heart failure, valvular disease, cardiomyopathy, or complications after myocardial infarction are suspected.
When do we indicate exercise stress testing?
Exercise stress testing is used in patients with suspected stable coronary artery disease, especially when symptoms occur during physical exertion. It helps assess ischemia and functional capacity.
When do we indicate dobutamine stress echocardiography?
Dobutamine stress echocardiography is used when the patient cannot perform a physical exercise stress test or when a more detailed assessment of myocardial ischemia and viability is needed.
Conclusion
Chest pain requires careful assessment because it can have a wide spectrum of causes. Timely diagnostics, including ECG, laboratory testing, and echocardiography, enable rapid differentiation between dangerous and benign conditions.
If you have concerning symptoms, you can immediately book an urgent examination at Dr Mačkić Clinic, where a complete cardiological evaluation can be performed quickly.
References
- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation. 2021.
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021.
- Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for chronic coronary syndromes. Eur Heart J. 2020.
- Nishimura RA, Otto CM, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.
- Ponikowski P, Voors AA, Anker SD, et al. ESC Guidelines for Heart Failure. Eur Heart J.
- Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for pulmonary embolism. Eur Heart J. 2020.
- Erbel R, Aboyans V, Boileau C, et al. ESC Guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J.
- Pellikka PA, Nagueh SF, Elhendy AA, et al. ASE Recommendations for Stress Echocardiography. J Am Soc Echocardiogr.