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Harrison's Principles of Internal Medicine, 18e > Chapter 12. Chest Discomfort

Table 12-1 Diagnoses among Chest Pain Patients Without Myocardial Infarction
Diagnosis
Percent
a
42
Gastroesophageal disease
Gastroesophageal reflux
Esophageal motility disorders
Peptic ulcer
Gallstones
Ischemic heart disease
Chest wall syndromes
Pericarditis
Pleuritis/pneumonia
Pulmonary embolism
Lung cancer
Aortic aneurysm
Aortic stenosis
Herpes zoster

31
28
4
2
2
1.5
1
1
1

aIn order of frequency.

Source: P Fruergaard et al: Eur Heart J 17:1028, 1996.
Copyright 2014 The McGraw-Hill Companies. All rights reserved.

Table 12-2 Typical Clinical Features of Major Causes of Acute Chest Discomfort
Condition
Duration
Quality
Location
Associated Features
Angina

Unstable
angina
Acute
myocardial
infarction

Aortic
stenosis

More than 2 Pressure,

and less
tightness,
than 10 min squeezing,
heaviness,
burning

Similar to
angina
but often
more
severe
Variable;
Similar to
often more angina
than 30 min but often
more
severe
1020 min

Recurrent
episodes
as
described
for
angina

As
described
for
angina

Retrosternal,
often with
radiation to or
isolated
discomfort in
neck, jaw,
shoulders, or
arms
frequently on
left
Similar to angina

Precipitated by exertion,
exposure to cold, psychologic
stress
S4 gallop or mitral
regurgitationmurmur during
pain
Similar to angina, but occurs
with low levels of exertion or
even at rest

Similar to angina Unrelieved by nitroglycerin

As described for
angina

May be associated with

evidence of heart failure or
arrhythmia
Late-peaking systolic
murmurradiating to carotid
arteries

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Pericarditis

Hours to
days; may
be episodic

Sharp

Retrosternal or
toward cardiac
apex; may
radiate to left
shoulder

Aortic
dissection

Abrupt
onset of
unrelenting
pain

Tearing
or
rippingse
nsation;
knifelike

Anterior
chest, often
radiating to
back,
between
shoulder
blades

May be relieved by
sitting up andleaning
forward
Pericardial friction rub
Associated with hypertension
and/or underlying connective
tissue disorder, e.g., Marfan
syndrome
Murmur of aortic insufficiency,
pericardial rub, pericardial
tamponade, or loss of
peripheral pulses

Pulmonary
embolism

Abrupt
Pleuritic
onset;
several
minutes to
a few hours

Often lateral, on
the side of the
embolism

Dyspnea, tachypnea,
tachycardia, and hypotension

Pulmon
ary
hypert
ension

Variable

Pressure

Substernal

Dyspnea, signs of increased

venous pressure including
edema and jugular venous
distention

Pneumo
nia or
pleuritis
Spontan
eous
pneumo
thorax
Esophageal
reflux

Variable

Pleuritic

Dyspnea, cough, fever, rales,

occasional rub

Sudden
onset;
several
hours
1060 min

Pleuritic

Unilateral, often
localized
Lateral to side of
pneumothorax
Substernal,
epigastric

Worsened by postprandial
recumbency

Burning

Dyspnea, decreased breath

sounds on side of
pneumothorax

Relieved by antacids
Pressure,
tightness,
burning

Retrosternal

Can closely mimic angina

Peptic ulcer Prolonged

Burning

Relieved with food or antacids

Gallbladder
disease

Prolonged

Burning,
pressure

Epigastric,
substernal
Epigastric, right
upper quadrant,
substernal

Musculos
keletal
disease

Variable

Aching

Variable

Aggravated by movement

Esophageal
spasm

230 min

Herpes zoster Variable

Sharp or
burning

Emotional
Variable;
and
may be
psychiatricco fleeting
nditions

Variable

May follow meal

May be reproduced by
localized pressure on
examination
Dermatomal
Vesicular rash in area of
distribution
discomfort
factors may
Variable; may be Situational
precipitate symptoms
retrosternal
Anxiety or depression often
detectable with careful history

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