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Cardialgia & Chest Pain — Comprehensive Medical Answer

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Question 83. Classification of Cardialgia by Origin

I. True Cardiogenic Pain (arising from the heart itself)

1. Ischemic (coronary)
   • Stable angina pectoris
   • Unstable angina pectoris
   • Prinzmetal (vasospastic) angina
   • Myocardial infarction (STEMI / NSTEMI)
   • Silent myocardial ischemia
2. Non-ischemic cardiac
   • Pericarditis
   • Myocarditis
   • Hypertrophic cardiomyopathy (HCM)
   • Aortic stenosis (left ventricular hypertrophy → relative ischemia)
   • Mitral valve prolapse
   • Aortic dissection (involves aortic root)

II. Non-Cardiogenic Chest Pain

1. Pulmonary — pneumothorax, PE, pneumonia/pleuritis, pulmonary hypertension
2. Gastrointestinal — GERD, peptic ulcer disease, esophageal spasm, cholecystitis, pancreatitis
3. Musculoskeletal — osteochondrosis, costochondritis (Tietze syndrome), intercostal neuralgia, rib fractures
4. Neurological — radiculopathy, herpes zoster (shingles), thoracic outlet syndrome
5. Psychogenic/functional — panic disorder, neurocirculatory dystonia (NCD), somatization

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Question 84. Differential Diagnosis of Cardiogenic vs. Non-Cardiogenic Chest Pain

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Question 85. Clinical Picture: Cardiogenic vs. Non-Cardiogenic Chest Pain

Cardiogenic Chest Pain

• Quality: Pressure, tightness, squeezing, heaviness, or "elephant on chest." Angina pectoris may not be described as "pain" but rather as discomfort.
• Location: Substernal or precordial; radiation to neck, jaw, shoulders, or either arm (classically ulnar aspect of left arm).
• Onset: With exertion, emotional stress, cold exposure; relieved by rest or nitroglycerin within minutes.
• Associated: Dyspnea, nausea/vomiting, diaphoresis, palpitations, syncope, sense of impending doom.
• Objective findings: ST changes on ECG, elevated troponin in MI, S3 or S4 gallop, signs of heart failure.

Non-Cardiogenic Chest Pain

• Quality: Sharp, stabbing, pleuritic (worse with breathing), burning (GERD), or dermatomal (nerve origin).
• Provocation: Deep inspiration, cough, trunk movement, palpation, meals/lying down (GERD), or specific postures.
• Location: Often localized, lateral chest, or epigastric; may be point-tenderness.
• ECG: Normal or non-specific.
• Biomarkers: Normal troponin.
• Examples:
  • Pleuritic: sharp, unilateral, worse with inspiration → pneumothorax, PE, pneumonia
  • Burning retrosternal: worse supine/postprandial → GERD
  • Dermatomal burning/tingling: vesicular rash → herpes zoster
  • Reproduced by palpation: Tietze syndrome, costochondritis

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Classification of Coronary Heart Disease (IHD) — WHO

1. Angina Pectoris
   • Stable (effort) angina
   • Unstable angina (progressive, rest angina, new-onset)
   • Prinzmetal (variant/vasospastic) angina
2. Acute Myocardial Infarction (AMI)
   • STEMI (ST-elevation MI)
   • NSTEMI (non-ST-elevation MI)
3. Post-Myocardial Infarction syndrome (Dressler's syndrome)
4. Heart Failure (ischemic cardiomyopathy)
5. Cardiac Arrhythmias (ischemic origin)
6. Sudden Coronary Death (sudden cardiac death from IHD)
7. Painless (Silent) Ischemia

• Chronic Coronary Syndromes (CCS) — stable angina, vasospasm, microvascular angina
• Acute Coronary Syndromes (ACS) — unstable angina, NSTEMI, STEMI

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Question 87. Characteristics of Pain Syndrome in Ischemic Heart Disease

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Question 88. Differential Diagnosis: Angina Pectoris vs. Myocardial Infarction

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Question 89. Main Symptoms of Cardiogenic Pain in Pericarditis

• Location: Retrosternal or left precordial; may radiate to the trapezius ridge (left shoulder/left trapezius — pathognomonic of pericarditis) and left arm
• Character: Sharp, stabbing, pleuritic
• Provocation: Worse with:
  • Deep inspiration (pleuritic component)
  • Lying flat (supine)
  • Swallowing (if pericardium involves posterior structures)
  • Movement / coughing
• Relief: Sitting forward (leaning forward reduces pressure on pericardium against diaphragm) — classic position
• Duration: Hours to days; persistent (unlike angina)
• Associated features:
  • Pericardial friction rub on auscultation (scratchy, to-and-fro sound)
  • Fever, malaise (often infectious etiology: viral most common)
  • Diffuse saddle-shaped ST elevation on ECG (widespread, concave upward, without reciprocal depression except aVR/V1); PR depression
  • Possible pericardial effusion → signs of tamponade in severe cases
  • May be preceded by viral illness (Coxsackievirus B, Echovirus, influenza)

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Question 90. Role of Hypertrophic Cardiomyopathy (HCM) in Cardialgia

Pathophysiology of Pain in HCM

1. Microvascular ischemia — The massively hypertrophied myocardium increases oxygen demand beyond the capacity of normal (or intramurally compressed) coronary vessels. Small intramural coronary arteries are structurally abnormal (medial hypertrophy, luminal narrowing).
2. Compression of septal perforators — Dynamic left ventricular outflow tract (LVOT) obstruction (systolic anterior motion of mitral valve, SAM) compresses septal branches.
3. Elevated LVEDP — Reduced diastolic compliance raises end-diastolic pressure, compressing subendocardial vessels (Gregg effect).
4. Increased O₂ demand — Massive hypertrophy dramatically increases myocardial O₂ consumption.

Clinical Features

• Chest pain similar to angina: exertional, substernal, squeezing
• Often occurs without significant epicardial CAD on coronary angiography (distinguishing feature)
• Accompanied by dyspnea on exertion, syncope, palpitations
• Family history of sudden cardiac death
• Systolic ejection murmur that increases with Valsalva maneuver and decreases with squatting
• ECG: LVH pattern, deep septal Q waves (II, III, aVF, V5–V6), T-wave inversions
• Echocardiography: asymmetric septal hypertrophy (septum/posterior wall ratio >1.3), SAM of mitral valve, LVOT gradient >30 mmHg

Management

• Beta-blockers (first-line) — reduce heart rate and LVOT gradient, decrease O₂ demand
• Non-dihydropyridine calcium channel blockers (verapamil)
• Avoid: nitrates, digoxin, diuretics (worsen obstruction)
• Surgical myectomy / alcohol septal ablation for refractory cases

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Question 91. Principles of Treatment of Cardiogenic Chest Pain in Acute Conditions

Immediate (Acute) Management — ACS Protocol

1. Position and monitoring
   • Seat patient upright (semi-recumbent); IV access, continuous ECG monitoring, pulse oximetry
2. Oxygen
   • Supplement O₂ if SpO₂ <90%; avoid hyperoxia in stable patients (may worsen outcomes)
3. Nitroglycerin (NTG)
   • Sublingual 0.3–0.4 mg q5 min × 3 doses for acute angina
   • IV NTG for ongoing ischemia, hypertension, or pulmonary edema
   • Contraindicated if SBP <90 mmHg, RV infarction, recent PDE-5 inhibitor use
4. Aspirin
   • 162–325 mg chewed immediately (antiplatelet, reduces thrombus propagation)
5. Morphine (or opioids)
   • 2–4 mg IV for pain not relieved by NTG; reduces anxiety and preload
   • Use cautiously (associated with delayed P2Y12 inhibitor absorption)
6. P2Y12 inhibitors (Clopidogrel / Ticagrelor / Prasugrel)
   • Dual antiplatelet therapy for ACS
7. Anticoagulation
   • Unfractionated heparin, enoxaparin, or bivalirudin
8. Beta-blockers
   • Reduce heart rate and myocardial O₂ demand
   • Avoid IV beta-blockers if cardiogenic shock, active HF, or significant bradycardia
9. Reperfusion (for STEMI)
   • Primary PCI (preferred within 90 minutes of first medical contact)
   • Fibrinolysis if PCI not available within 120 min (tPA, streptokinase, alteplase)
10. For Pericarditis:
    • NSAIDs (ibuprofen/aspirin) + Colchicine (reduces recurrence)
    • Avoid corticosteroids unless specific indication (autoimmune)
11. For HCM-related pain:
    • Beta-blockers; avoid vasodilators and inotropes

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Question 92. Classification of Non-Cardiogenic Chest Pain

1. Pulmonary / Pleural

• Pneumothorax
• Pulmonary embolism (PE)
• Pneumonia with pleuritis
• Pleuritis (primary)
• Pulmonary hypertension
• Lung cancer (pleural invasion)
• Hemothorax

2. Gastrointestinal

• Gastroesophageal reflux disease (GERD)
• Esophageal spasm (diffuse)
• Esophageal perforation (Boerhaave syndrome)
• Peptic ulcer disease
• Gastritis / esophagitis
• Cholecystitis / biliary colic
• Acute pancreatitis

3. Musculoskeletal

• Costochondritis / Tietze syndrome
• Rib fractures
• Intercostal muscle strain
• Fibromyalgia
• Thoracic osteochondrosis (vertebrogenic)

4. Neurological / Radicular

• Cervical / thoracic osteochondrosis with radiculopathy
• Intercostal neuralgia
• Herpes zoster (postherpetic neuralgia)
• Thoracic outlet syndrome (brachial plexus compression)

5. Vascular (aortic)

• Aortic dissection (Type A involves ascending aorta)
• Aortic aneurysm

6. Mediastinal

• Mediastinitis
• Mediastinal tumors

7. Functional / Psychogenic

• Neurocirculatory dystonia (NCD) / Da Costa syndrome
• Panic disorder / anxiety
• Somatization disorder
• Hyperventilation syndrome

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Question 93. Causes of Non-Cardiogenic Chest Pain Associated with Lung Diseases

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Question 94. Nature of Pain in Acute Gastrointestinal Diseases

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Question 95. Signs and Symptoms of Non-Cardiogenic Chest Pain in Neurological Pathologies

1. Intercostal Neuralgia / Radiculopathy

• Pain character: Sharp, burning, shooting; strictly unilateral, follows a dermatomal distribution (band-like)
• Provocation: Deep inspiration, coughing, trunk rotation, direct pressure on the paravertebral region
• Associated: Hyperesthesia or hypoesthesia along the dermatome
• Cause: Disc herniation (T4–T8), osteophytes compressing thoracic nerve roots

2. Herpes Zoster (Shingles)

• Pre-eruptive phase: burning, tingling pain along dermatomal distribution — may mimic angina/pleuritis before rash appears
• Post-eruptive: vesicular rash along 1–2 dermatomes, hyperesthesia
• Postherpetic neuralgia: persistent burning pain after resolution of rash

3. Thoracic Outlet Syndrome

• Compression of brachial plexus, subclavian artery/vein by cervical rib or structural abnormality
• Pain in shoulder, arm, neck; paresthesia in ulnar distribution
• Aggravated by arm elevation (Adson's test positive)

4. Panic Disorder / Anxiety

• Chest tightness, palpitations, dyspnea; associated with trembling, sweating, fear of dying
• Hyperventilation → respiratory alkalosis → chest tightness, perioral/fingertip paresthesia, tetany
• Normal ECG and biomarkers; pattern typically intermittent with identified triggers or spontaneous

5. Mediastinal Tumors / Mass Lesions

• Constant dull aching; may cause superior vena cava syndrome (facial plethora, arm swelling)

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Question 96. Role of Osteochondrosis in Non-Cardiogenic Chest Pain

Pathophysiology

• Narrowing of intervertebral foramina
• Compression of thoracic nerve roots (T1–T12) → intercostal neuralgia
• Irritation of the sympathetic chain → referred cardialgia mimicking angina
• Periarticular inflammation → facet joint pain

Clinical Features

• Character: Sharp, stabbing, burning, or dull aching; can be left-sided and precordial (mimics angina)
• Provocation:
  • Body movements (bending, turning, extension)
  • Deep inspiration
  • Coughing or sneezing
  • Prolonged static posture (sitting at desk)
  • Palpation of paravertebral points, spinous processes (positive "vertebral percussion sign")
• Relief: Rest in a comfortable position, analgesics (NSAIDs), heat
• Radiation: From thoracic spine → anterior chest, hypochondrium, arm (C7–T1 involvement)
• Duration: Hours to days (unlike angina which is <20 min)
• NTG test: No relief (important negative finding)

Distinguishing from Angina

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Question 97. Neurocirculatory Dystonia (NCD) — Laboratory & Instrumental Diagnostics

Clinical Presentation

• Cardialgia (often left-sided, precordial, stabbing or aching), not clearly related to exertion
• Palpitations, tachycardia
• Dyspnea, "inability to take a full breath" (air hunger)
• Fatigue, weakness, poor exercise tolerance
• Anxiety, emotional lability, sweating
• Lability of blood pressure and heart rate (orthostatic tachycardia)
• Symptoms exacerbated by emotional stress, fatigue, menstrual cycle, caffeine

Laboratory Diagnostics

• CBC: Normal
• Biochemistry (glucose, electrolytes, TSH, T3/T4): Important to exclude thyrotoxicosis, anemia, diabetes as secondary causes
• Troponin, CK-MB: Normal (essential to exclude ACS)
• Lipid profile: Normal or non-specific
• No inflammatory markers elevated

Instrumental Diagnostics

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Question 98. Treatment of Non-Cardiogenic Chest Pain in Gastroesophageal Reflux Disease (GERD)

Pathophysiology

Treatment Principles

• Elevate head of bed 30° (prevents nocturnal reflux)
• Avoid meals 2–3 hours before bedtime
• Avoid triggers: fatty foods, chocolate, coffee, alcohol, mint, NSAIDs, tobacco
• Weight reduction (obesity is a major risk factor)
• Small, frequent meals

• Aluminum/magnesium hydroxide, calcium carbonate — immediate relief
• Limited to mild/intermittent symptoms

• Famotidine, ranitidine — reduce acid secretion
• Useful for mild-moderate GERD

• Omeprazole 20–40 mg/day, pantoprazole, esomeprazole, lansoprazole
• Take 30 min before meals
• 4–8 week course; maintenance therapy in chronic GERD
• High efficacy (>90% symptom resolution in esophageal chest pain)

• Metoclopramide, domperidone — improve esophageal motility and LES tone
• Adjunct in patients with delayed gastric emptying

• Smooth muscle relaxants: nitrates (NTG, isosorbide dinitrate), calcium channel blockers (diltiazem)
• Tricyclic antidepressants (low dose amitriptyline 10–25 mg at bedtime) — visceral pain modulation

• Laparoscopic Nissen fundoplication for refractory GERD or large hiatal hernia

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Question 99. Diagnostic Methods for Cardiogenic and Non-Cardiogenic Chest Pain

Approach to Chest Pain Evaluation

• Pain character, location, radiation, duration, triggers, associated symptoms
• Vital signs, cardiovascular auscultation, chest wall palpation, lung auscultation

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Cardiogenic — Key Diagnostic Methods

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Non-Cardiogenic — Key Diagnostic Methods

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Integrated Diagnostic Algorithm

Chest Pain
    ↓
12-lead ECG immediately
    ↓
ST elevation → STEMI → Immediate reperfusion (PCI/fibrinolysis)
    ↓
No ST elevation → Serial troponin (0h / 3h / 6h)
    ↓
Troponin elevated → NSTEMI/UA → ACS management
    ↓
Troponin normal + low risk → Consider non-cardiogenic causes:
    → CXR, D-dimer (if PE suspected)
    → GI evaluation (GERD, endoscopy)
    → Musculoskeletal exam (palpation, spine imaging)
    → Neurological evaluation
    → Psychiatric/functional assessment

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• Rosen's Emergency Medicine: Concepts and Clinical Practice — Chapters 64 (ACS), 144 (Cocaine-Related Chest Pain)
• Murray & Nadel's Textbook of Respiratory Medicine — Chapter 38 (Differential Diagnosis of Chest Pain, Table 38.2)
• Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine — Chapters on IHD, PE, PAH
• The Washington Manual of Medical Therapeutics — Cardiovascular section
• Harrison's Principles of Internal Medicine, 22nd Edition — Cardiology sections