Chest pain, breathlessness, and fatigue

J. Dwight

in Oxford Textbook of Medicine

Fifth edition

Published on behalf of Oxford University Press

Published in print May 2010 | ISBN: 9780199204854
Published online May 2011 | e-ISBN: 9780199570973 | DOI:

Series: Oxford Textbooks

Chest pain, breathlessness, and fatigue

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Chest pain, breathlessness, and fatigue are common diagnostic challenges. They have a broad differential diagnosis that includes a number of life-threatening pathologies.

Chest pain

The most reliable discriminating feature for angina, as opposed to other causes of chest pain, is its constricting nature, a fixed and predictable relationship to exertion, and that is relieved, within a few minutes, by rest or glyceryl trinitrate.

The ECG is used to triage patients with chest pain on admission to the Emergency Department, with treatment by thrombolysis or angioplasty after a brief confirmatory history in patients with significant ST elevation. However, these represent only a small fraction of those presenting with chest pain, and patients without ST elevation present the greater diagnostic challenge. A detailed history is needed to establish whether the pain is cardiac, and to inform the risk-stratification process that determines the nature and time course of subsequent therapy and investigation.

The character of pain in acute coronary syndromes is similar to exertional angina, but usually more severe. It usually reaches maximal intensity over the course of a few minutes: pain reaching its maximum intensity instantaneously suggests an alternative cause.

Aortic dissection is a rare but important cause of chest pain: its pain is very sudden in onset, usually described as tearing or ripping, and the patient may report that it migrates from the front to the back of the chest. Pain with this description, loss of peripheral pulses, blood pressure difference between the two arms (>20 mmHg), and mediastinal widening on the chest radiograph are the most helpful diagnostic indicators.

Pericarditis occurs most commonly following myocardial infarction or viral infection. The pain is usually sharp and precordial, its onset is often sudden, and it is characteristically worse on inspiration, but is relieved by sitting up and leaning forward. A pericardial friction rub heard over the sternum may be positional and can appear and disappear within hours.

Breathlessness and fatigue

Most patients find it impossible to distinguish between cardiac and pulmonary causes of dyspnoea. The New York Heart Association classification is used to classify the extent of disability.

In the diagnosis of left ventricular failure, the most helpful features in the history are exertional breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, or a history of myocardial infarction. Tachycardia, cyanosis, and an elevated jugular venous pressure are features of heart failure, but they are also features of the major differential diagnoses. A displaced apex on palpation is helpful and relatively specific. A third heart sound has a high specificity (90–97%) but low sensitivity (31–51%) for detecting left ventricular dysfunction. Basal inspiratory crackles are suggestive of pulmonary oedema but have a sensitivity and specificity as low as 13 and 35%, respectively.

Other considerations

The cardiovascular history routinely includes assessment of risk factors and those aspects of the patient’s past medical history that make cardiovascular disease more likely. The presence of numerous risk factors may, on occasion, prompt the physician to proceed to further investigation even in the face of a relatively unconvincing history.

Most diagnoses are made on the basis of the history, and the physician is always compelled to return to the initial history and examination to put the findings of any investigations into context and to plan therapy appropriate for the individual patient.

Chapter.  6525 words.  Illustrated.

Subjects: Cardiovascular Medicine

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