In daily practice, there are various dogmas regarding chest pain, not scientifically proven. For example, the belief that chest pain radiating to the left arm is cardiac chest pain. Only 15% of chest pain cases treated in emergency departments (ERs) are acute coronary syndrome (ACS). Meanwhile, 85% of chest pain cases in the ER are non-cardiac chest pain (NCCP). A publication in Germany in 2018 reported that 30% of coronary catheterization procedures excluded coronary heart disease or found <50% coronary stenosis.

4 Dogmas regarding Chest Pain
Chest pain


No. 1: Severity of chest pain associated with acute myocardial infarction and its prognosis

Many doctors think that the more severe chest pain manifestations, the prognosis is bad or myocardial infarction is getting worse.

A prospective cohort study was conducted to examine whether there was a correlation between chest pain severity in patients with suspected acute coronary syndrome (ACS) and acute myocardial infarction or cardiovascular complications after 30 days. The statistical analysis showed no significant relationship between chest pain severity and acute myocardial infarction and cardiovascular complications after 30 days. The research found that The myocardial infarction risk was 3% on the 1-8 pain scale and 3.9% on the 9-10 pain scale.


No 2: Specific Typical Chest Pain is Definite Myocardial Infarction

Body et al. Evaluated various clinical symptoms to predict which symptoms increase or decrease the likelihood of diagnosing myocardial infarction or adverse cardiac events. In this study, they found that pain radiating to the right hand or both hands, the presence of vomiting, middle chest pain, and diaphoresis are symptoms that increase the likelihood of acute myocardial infarction. Meanwhile, pain in the left anterior chest, chest pain at rest, and chest pain radiating to the left hand are the symptoms of negative predictors of myocardial infarction.

The study suggested that many atypical symptoms, such as chest pain radiating to both shoulders, actually increase the likelihood of myocardial infarction more than the traditional typical symptoms so far believed.

Another study by Mokhtari et al. supports the findings of Body et al. Mokhtari et al. calculated the diagnostic value for ACS from risk factors obtained through history taking, general clinical assessment for possible ACS, chest pain characteristics, ECG, and troponin T values. The risk factors explored included age, gender, history of peripheral arterial disease / PAD, stroke, diabetes, coronary heart disease, and heart failure.

Mokhtari et al. found that increasing age only slightly increased the possibility of ACS. However, the history of other diseases (PAD, stroke, diabetes, coronary heart disease, and heart failure) did not affect ACS's likelihood.

The clinician's general assessment of "very clear SKA" or "high probability of SKA" significantly increased the likelihood of SKA (29 times and 4.8 times, respectively). Meanwhile, "non-ACS" can exclude the diagnosis of ACS.

Typical chest pain (substernal, such as pressure,> 15 minutes, with or without radiating to the shoulder or arm) accompanied by ECG ischemic changes and elevated troponin increases ACS's probability by 4.9 times. Meanwhile, chest pain alone, without ECG and troponin levels changes, only have a small impact on ACS's possibility.

ECG and elevated troponin levels increased the likelihood of ACS by 7.6 and 24.9 times, respectively.
Basically, the heart, blood vessels, esophagus, and visceral pleura are located close together in the thoracic cavity and get their nerve supply from visceral nerve fibers. Visceral nerve fibers enter the spine at several levels via dorsal nerve fibers. This causes pain that is difficult to localize and difficult to describe (such as discomfort, heaviness, dullness, or aching pain). Also, dorsal nerve fibers can overlap 3 levels below or above, so the thoracic cavity's organs can produce pain anywhere from the jaw area to the epigastrium.


No. 3: Chest Pain Relieved by Giving Nitrates is Cardiac Chest Pain

Many clinicians believe that chest pain that gets better with nitrate administration indicates that chest pain stems from coronary heart disease. However, a cohort study in 2006 involving 270 patients with one month of follow-up stated different results. The study reported that relief of chest pain with nitrates did not increase cardiac chest pain possibility.

In patients with chest pain that subsides after nitrate administration, the real likelihood of coronary heart disease (positive likelihood ratio) is only 1.1. This is because nitrates relax smooth muscle, both coronary and gastrointestinal vessels, so that the relief of chest pain with nitrate administration does not necessarily mean that chest pain is caused by cardiac causation. Even in patients with gastroesophageal reflux disease (GERD) who are given nitrates, heartburn symptoms may disappear.


No.4: Aortic Dissection Has Characteristics Of Ripping Pain That Radiates To The Back

Aortic dissection was previously believed to often present as 'tearing' chest pain and penetrating the back. However, many kinds of literature report that patients with aortic dissection do not have typical chest pain. Aortic dissection was found without chest pain in 43% of patients. Patients with aortic dissection may present with abdominal pain (36%) or back pain (44%). In the case report, a patient with aortic dissection presented with a gait disturbance or neurological symptoms without prior chest pain.


Conclusion
There are many dogmas in the medical world, and as doctors, we must always refer to scientific evidence. In the case of a patient with chest pain, the main thing to do is rule out the possibility of acute coronary syndrome and aortic dissection.


References
  1. Frieling T. Non-Cardiac Chest Pain. Visceral Medicine. 2018;34(2):92-6. https://www.karger.com/DOI/10.1159/000486440
  2. Body R, Carley S, Wibberley C, McDowell G, Ferguson J, Mackway-Jones K. The value of symptoms and signs in acute coronary syndromes' emergent diagnosis. Resuscitation. 2010;81(3):281-6. https://www.ncbi.nlm.nih.gov/pubmed/20036454
  3.  Irzyk A. Cardiac differential diagnosis. MCEMS. 2015. https://www.heart.org/idc/groups/heart-public/@wcm/@mwa/documents/downloadable/ucm_474939.pdf.
  4.  Mattu A. Painless aortic dissection in the emergency department. Medscape. 2017 Sep 15 [cited on 2018 Nov 15]. https://www.medscape.com/viewarticle/885676
  5. Colak N, Nazli Y, Alpay MF, Akkaya IO, Cakir O. Tex Heart Inst J. 2012; 39(2): 273-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384028/.
  6. Edwards M, Chang AM, Matsuura AC, Green M, Robey JM, Hollander JE. Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes. Annals of emergency medicine. 2011;58(6):501-7. https://www.ncbi.nlm.nih.gov/pubmed/?term=21802776
  7. Estreicher M, Portale J, Lopez B. Aortic dissection presenting as gait disturbance. Am J Em Med. 2013;31(1):269. https://www.ajemjournal.com/article/S0735-6757(12)00194-5/abstract
  8. Mokhtari A, Dryver E, Soderholm M, Ekelund U. Diagnostic values of chest pain history, ECG, troponin, and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department. SpringerPlus. 2015;4:219. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431985/
  9. Steele R, McNaughton T, McConahy M, Lam J. Chest pain in emergency department patients: if the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? CJEM. 2006; 8(3): 164-9. https://www.ncbi.nlm.nih.gov/pubmed/17320010.