A 47-year-old woman presents at night to the Emergency Department with chest pain. She states that the pain started that evening and has progressively been getting worse. She is concerned that she is having a heart attack. The pain is described as a burning sensation associated with a sour taste in her mouth, and it started shortly after she ate dinner; it has occurred on previous occasions, but never as bad as it is now. Previously, she used calcium carbonate tablets that were effective for the pain. She has no history of heart disease or other medical problems, and she takes no regular medications. She does not smoke cigarettes or use cocaine. Her vitals are normal, and her physical examination is unremarkable. Initial laboratory tests and an ECG are normal.
Which of the following is the most likely cause of this patient’s chest pain?
A. Unstable angina: Gastroesophageal reflux disease. In a patient with a chief complaint of chest pain, it is important to consider life-threatening causes (e.g., myocardial infarction) as well as noncardiac causes of chest pain, which include disorders of the respiratory, GI, and musculoskeletal systems. This patient’s history of recurrent burning chest pain after meals that is associated with a sour taste in her mouth makes GERD the most likely diagnosis. Not all patients with ACS present with a classic history of retrosternal chest pain/pressure radiating to the jaw and left arm, so it is important to have a low index of suspicion for ACS in any patient (especially women and those with risk factors). Other cardiovascular causes of chest pain include any cause of angina (including Prinzmetal angina), pericarditis/myocarditis, and aortic dissection. Pulmonary causes include pneumonia, pulmonary embolism, pleuritis, and pneumothorax. Gastrointestinal causes include GERD, diffuse esophageal spasm, and peptic ulcer disease. Musculoskeletal causes include costochondritis, rib fracture, and muscle strain. Beyond these systems, psychiatric conditions (anxiety, panic disorder) and herpes zoster can both present as chest pain.
(A) Unstable angina is a type of ACS that presents without elevated cardiac enzymes and ± ECG findings of ischemia. The history itself is not suggestive of a cardiac etiology. (B) Myocarditis is an inflammatory process of the heart muscle that is commonly the result of a viral process (e.g., Coxsackie). It presents as pleuritic chest pain with elevations in cardiac enzymes; it can lead to heart failure from poor ventricular function. (C) Pulmonary embolism will cause pleuritic chest pain, especially if it causes pulmonary infarcts. Look for this in a patient with risk factors (Virchow triad: blood stasis, endothelial injury, and a hypercoagulable state) and with tachycardia and tachypnea. (E) Costochondritis is caused by inflammation of the costal cartilage that connects the ribs to the sternum. The typical history is chest pain that is reproduced with palpation.