Chest pain

A good way to come up with a list of causes is to visualize the anatomy of the affected area and think of what could go wrong. Thus, in chest pain, there may be pathology of the heart, aorta, lungs, pulmonary vessels, oesophagus, stomach, thoracic nerves, thoracic muscles, or ribs. The main causes of acute chest pain in an individual aged over 60 include are listed in Figure 9.1. A younger patient is less likely to be suffering from diseases of old age, such as: • Acute coronary syndrome • Stable angina • Myopericarditis (usually post-infarction) • Thoracic aortic dissection • Thoracic aortic aneurysm A younger female patient on the combined oral contraceptive pill is more likely to be suffering from: • PE (the combined oral contraceptive pill is thrombogenic) • Pneumothorax (especially if tall and thin) • Cocaine-induced coronary spasm (still rare, but particularly unusual in older people). The following diagnoses require immediate management and should be kept in mind: • Acute coronary syndrome (unstable angina, or myocardial infarction (MI)) • Aortic dissection • Pneumothorax • PE • Boerhaave’s perforation The key features of each are listed below. 1 Features of acute coronary syndrome ■ History of sudden-onset, central, crushing chest pain radiating to either/both arms, neck or jaw, usually lasting a few minutes to half an hour (longer if there is ongoing infarction). Have a higher index of suspicion in those with a previous history of angina on exertion or MI and/or cardiovascular risk factors (smoking, hypertension, hypercholesterolaemia, diabetes mellitus, family history). ■ Signs of hypercholesterolaemia: cholesterol deposits in small skin lumps on the back of the hand or bony prominences like elbows (xanthomata), in creamy spots around the eyelids (xanthelasma), or a creamy ring around the cornea (arcus). Note that arcus is a normal finding in older people. ■ Signs of peripheral (atherosclerotic) vascular disease: weak pulses, peripheral cyanosis, cool peripheries, atrophic skin, ulcers, bruits on auscultation of carotids. ■ Signs of brady- or tachyarrhythmia. An arrhythmia is relevant for two reasons.