Approach to the Patient with Chest Pain

Chest pain from esophageal causes commonly is described as squeezing or burning, is substernal in location, and may last from minutes to hours. Physical examination occasionally helps to delineate the cause of chest pain. Coronary artery spasm in response to ergonovine is reported in some individuals with chest pain. Chest pain from musculoskeletal sources is characterized by localized chest wall tenderness and definable trigger points and may be reported at rest, with movement, or during sleep. Esophageal disorders, the most common causes of noncardiac chest pain, account for 20–60% of cases. Treatment of esophageal chest pain may be unsatisfactory because of diagnostic uncertainties, the intermittent nature of symptoms, the side-effect profiles of available pharmaceutical agents, and the awareness that many of these conditions improve spontaneously without treatment. The major risk in evaluating a patient with unexplained chest pain is the premature exclusion of coronary ischemia, which may have life-threatening consequences.