In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency, unless the patient is a known angina pectoris sufferer and the symptoms are familiar (appearing at exertion and resolving at rest, known as "stable angina").
· Important cardiovascular and pulmonary causes of chest pain:
· Angina pectoris
· "Unstable" AP - this is an emergency and can resemble a heart attack
· "Stable" AP - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense
· Myocardial infarction ("heart attack")
· Aortic dissection
· Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
· Pulmonary embolism
· Pneumothorax and Tension pneumothorax
As in all medicine, a careful medical history and physical examination is essential is separating dangerous and trivial causes of disease, and the management of chest pain is often done on specialized units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection). Occasionally, visible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.
An emergency medicine doctor will also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking.
On the basis of the above, a number of tests may be ordered:
X-rays of the chest and/or abdomen (CT scanning may be better but is often not available)
An electrocardiogram (ECG)
V/Q scintigraphy (when a pulmonary embolism is suspected)
Full blood count
Electrolytes and renal function (creatinine)
Creatine kinase (and CK-MB fraction in many hospitals)
Troponin I or T (to indicate myocardial damage)
D-dimer (when suspicion for pulmonary embolism is present but low)
In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analyses are not sensitive enough (Chun & McGee 2004). The physician's typical approach is to rule-out the most dangerous causes of chest pain first (eg: heart attack, blood clot in the lung, aneurism). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient. If acute coronary syndrome ("unstable angina") is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (CK-MB or troponin). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.