The following symptoms and complaints may occur along with Chest pain (chest pain):
Leading symptoms
- Constricting the chest
- Impeding breathing; dyspnea (shortness of breath).
- Stinging/burning/tearing
- Radiation to other parts of the body (e.g., arm, hand, neck, etc.).
- Occurrence after stress, after a meal, etc.
Associated symptoms
- Nausea (nausea)
- Vomiting
An immediate decision should be made in any patient with acute chest pain:
- cardiac – non-cardiac
- acute (unstable) – chronic (stable)
- potentially life-threatening – benign (benign)
See also below under warning signs (red flags). The “Marburg Heart Score” supports the differential diagnostic clarification of chest pain in a family practice* .
Marburg Heart Score
| Feature | Score |
| Gender and age(men ≥ 55 years; women ≥ 65 years). | 1 |
| Known vascular disease | 1 |
| Complaints load-dependent | 1 |
| Pain is not reproducible by palpation. | 1 |
| Patient suspects heart disease as the cause. | 1 |
| Points | Probability CHD | |
| 0-1 | < 1 % | very low |
| 2 | 5 % | Low |
| 3 | 25 % | Medium |
| 4-5 | 65 % | high |
If 0 – 2 points: assume noncardiac causes!Further notes.
- Constricting retrosternal pressure pain (“behind the sternum“) with radiation to shoulder, arms, or back → think of: Myocardial infarction (heart attack)Note: Radiation to the right or both arms has a higher specificity than radiation to the left shoulder/arm (about 50% of cases).
- Pleuritic pain (sharp) and intensification with cough and deep inspiration (inhalation) → think of: pulmonary (lung-related) or extracardiac (“outside the heart“) genesis (pulmonary embolism, pneumothorax (lung collapse further complicated by a valve mechanism), pneumonia (pneumonia), pleurisy (pleurisy), pericarditis (pericarditis)).
- Note: criteria of a vital threat to the patient (see below “Physical examination“).
Warning signs (red flags)
- Anamnestic information:
- Chest pain between midnight and 9 am → acute coronary syndrome* (ACS) (12%); ST-elevation myocardial infarction (STEMI) (25%), non-ST-elevation myocardial infarction (NSTEMI) (approximately 50%); effect of time of day in men was more pronounced: Early callers were 2.3 times as likely to have an ACS as callers after 9 AM; in women, an ACS before 9 AM was only 1.3 times as common.
- Profuse vomiting/blood vomiting (hematemesis) → think of: Esophageal rupture (esophageal rupture; was an endoscopic procedure? )/Boerhaave’s syndrome* (rupture of distal, mostly thoracic esophagus after violent vomiting?).
- Hypertension (high blood pressure) → think of: Aortic dissection* (acute splitting (dissection) of the wall layers of the aorta (main artery)), myocardial infarction (heart attack).
- Long immobilization, condition n. surgery; known thrombophilia → think of: Pulmonary embolism*
- Pain:
- Angina pectoris (“chest tightness”; sudden pain in the heart area) → think of: Acute coronary syndrome (AKS or ACS, acute coronary syndrome; spectrum of cardiovascular disease ranging from unstable angina (iAP; UA) to the two main forms of myocardial infarction (heart attack), non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI)), coronary artery disease (CAD).
- Vomiting of blood/coffee grounds (hematemesis), skin emphysema (free air under the skin) → think of: Esophageal perforation
- Radiation of pain (neck, jaw, shoulder, arm(s), upper abdomen) → think of: ACS, CHD
- Trauma → think of: Tension pneumothorax* (life-threatening form of pneumothorax in which increased pressure in the pleural space causes problems with blood flow to the heart, as well as restricted unfolding of the opposing lung).
- Clinical signs:
- Respiration
- Resting dyspnea (shortness of breath under resting conditions).
- In combination with respiratory synchronous pain → think of: Pulmonary embolism
- Tachypnea (> 20 breaths/min) + moist rales (RGs) → think of: Left heart failure (heart failure), pneumonia (pneumonia).
- Tachypnea (> 20 breaths/min) + unilateral absent breath sound → think of: Pneumothorax (lung collapse further complicated by a valve mechanism), pleural effusion (abnormal accumulation of fluid in the pleural cavity), atelectasis (lack of ventilation of lung segments).
- Breath-dependent pain → think of: Pleurisy (pleurisy).
- Resting dyspnea (shortness of breath under resting conditions).
- Cardial (cardiovascular)
- Heart rate (< 40 or > 100) → think of: see under differential diagnoses “cardiovascular system”
- Skin
- Central nervous system (CNS)
- Respiration
* The “big five.” Note: Patients with unclear chest pain (chest pain) showed a significantly higher rate of cardiovascular events over the five years of follow-up than the group with an identified noncoronary cause.
