The Duke treadmill score is recommended to help predict long-term prognosis for patients undergoing stress ECG testing. Additional tests for diagnosis include: Substernal chest pain treatment will first rely on correctly identifying the underlying cause. Excessive exertion of untrained muscles in activities such as coughing, chopping wood or overhead painting and in sports with a lot of upper body exertion such as rowing. Rushton S, et al. The pain may shift to your shoulders, neck or arms. What are the benefits and risks of potential treatment options? Chest pain persisting longer than 12 hours and tenderness on palpation of the anterior chest wall are strong clinical indicators of a musculoskeletal cause of sternal pain. You may opt-out of email communications at any time by clicking on The signs and symptoms of a heart attack vary greatly from person to person. Available from: Adamich J, Howard A, Camp M. Do All Clavicle Fractures in Children Need To Be Managed by Orthopedic Surgeons? Click here for an email preview. Sternum pain is usually caused by problems with the muscles and bones near the sternum and not the sternum itself. Acta Anaesthesiol Scand. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Your thymus is an organ thats part of your immune system. Policy. The usual descriptions of peptic ulcer disease and GERD include epigastric discomfort and retrosternal burning, but often it is difficult to distinguish clearly between classic heart-burn and classic chest pressure. Although it often is thought that symptoms of anxiety can help distinguish pulmonary diseases from other causes of chest pain, this is not a consistent finding and should not be relied upon. https://vascular.org/patients/vascular-conditions/aortic-dissection. Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Accessed Feb. 15, 2022. We do not endorse non-Cleveland Clinic products or services. Some less common causes of noncardiac chest pain include: People with noncardiac chest pain commonly have other symptoms of GERD, including heartburn and acid reflux. Pain at medial border of scapula radiating anteriorly. National trends in chest pain visits in US emergency departments (20062016). 11th ed. Myocarditis: Caused by infectious agents (e.g. American Heart Association. National Institute of Diabetes and Digestive and Kidney Diseases. Certain key symptoms and clinical findings can help rule in or out specific diagnoses (Table 2).415, Determining whether pain is (1) substernal, (2) provoked by exertion, or (3) relieved by rest or nitroglycerin helps to clarify whether it is typical anginal pain (has all three characteristics), atypical anginal pain (has two characteristics), or nonanginal pain (has one characteristic). All . If you have persistent episodes of noncardiac chest pain, and your healthcare providers have ruled out cardiac causes, you may be diagnosed with noncardiac chest pain. Mediastinal tumors are growths that form in the area of your chest between your lungs. information is beneficial, we may combine your email and website usage information with Mayo Clinic does not endorse companies or products. 2017;10:663-668. Mayo Clinic. dizzy. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Theyre masses of cells that appear in the space between your lungs, called the mediastinum. 2017 Sep 18. doi: 10.1097/PEC.0000000000001269. Related: Chest pain update: Retrosternal chest pain, chest pain that comes and goes, anxiety chest pain. Brain natriuretic peptide level is particularly helpful for ruling in heart failure if it is more than 500 pg per mL (500 ng per L), and for ruling out heart failure if it is less than 100 pg per mL (100 ng per L).14,37, Chest wall pain usually can be diagnosed by history and physical examination if other etiologies have been excluded. This content does not have an Arabic version. Chest pain has many possible causes, all of which need medical care. health information, we will treat all of that information as protected health In most cases Physiopedia articles are a secondary source and so should not be used as references. To provide you with the most relevant and helpful information, and understand which Devon is keenly aware of trends and new developments in the area of health and wellness. Uncommon injury but when present, typically associated with swimming, javelin throwing, rowing and ice hockey. Only after we are satisfied with the products. Psychological stress can trigger gastrointestinal symptoms, and vice versa. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805811/), (https://www.merckmanuals.com/professional/pulmonary-disorders/mediastinal-and-pleural-disorders/mediastinal-masses), (https://www.merckmanuals.com/home/lung-and-airway-disorders/pleural-and-mediastinal-disorders/mediastinal-masses). McConaghy JR. Outpatient evaluation of the adult with chest pain. Rajan E (expert opinion). 9th ed. Patients at low risk usually do not need further testing unless there are other risk factors in their family or medical history that markedly increase their likelihood of CAD. Substernal chest pain might be abrupt or remain mild for several days before becoming severe. Atypical Chest Pain in Athletes. Substernal chest pain is commonly described as sharp, agonizing, compressing, and crushing in nature. If you are a Mayo Clinic patient, this could Pain felt just behind or below the sternum is called substernal pain and is sometimes caused by gastrointestinal problems[1]. Treatment of clavicle fractures: current concepts review. Asymmetry, swelling and bruising (either on the chest or into the axilla and arm) may be observed in the presence of severe muscle injuries such as a pectoralis major rupture and the patient may have felt a 'pop' at the moment of onset. What is a heart attack? This is especially true in acute coronary artery syndrome patients, where the blood vessels of the heart become significantly blocked, restricting blood flow. See permissionsforcopyrightquestions and/or permission requests. An algorithm illustrating the dicussed diagnostic strategy is provided in Figure 1.4, 5, 712, 1417, 2022, 25, 26, 28, 29, 3235 When a patient presents with new chest pain, a typical or an atypical anginal pattern, pain radiation or diaphoresis, cardiac risk factors, or ischemic ECG changes, serial measurement of troponins should be considered to determine whether hospitalization or outpatient evaluation with stress testing is warranted. Am Fam Physician. Gastrointestinal symptoms should prompt further evaluation. A patient with fever, cough, chest wall swelling or other respiratory findings on history or examination should also have a chest x-ray. Fever, egophony, or dullness to percussion should prompt evaluation for pneumonia with chest radiograph. The sternum is located near the heart, so many people experiencing sternum pain may confuse it with more general chest pain. As adjectives the difference between substernal and sternal is that substernal is (anatomy) situated under the sternum while sternal is of, relating to, or near the sternum. Broyles R. The location and purpose of the Xiphoid process [Internet]. Chest pain appears in many forms, ranging from a sharp stab to a dull ache. The most common types are thymomas, benign mediastinal cysts and lymphomas. Clin Nucl Med. Osteomyelitis of the sternum is rare and may stem from cardiac surgery, immunodeficiency, chest trauma (e.g. For some people, noncardiac chest pain is associated with psychological symptoms, such as stress, anxiety and depression. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. It may be bilateral and affecting multiple costochondral areas. Then youll be screened for heart attack or heart disease. Accessed Dec. 21, 2022. The next most common and effective treatment for noncardiac chest pain is a medicine that blocks the pain signals. the unsubscribe link in the e-mail. Sternum pain is pain or discomfort in the area of the chest that contains the sternum and the cartilage connecting it to the ribs. Last reviewed by a Cleveland Clinic medical professional on 04/04/2022. Heartburn is discomfort or actual pain caused by digestive acid moving into the tube that carries swallowed food to your stomach (esophagus). Accessed Dec. 21, 2022. It feels like a painful squeezing or tightness in your chest, or like pressure or heaviness, particularly behind your sternum. Trevor Minor. intercostals, serratus anterior, internal oblique, external oblique). Generally, children experience symptoms more commonly than adults. Nausea, indigestion, heartburn or abdominal pain. How to assess the chest pain? Your mediastinum contains your heart, aorta, esophagus, thymus, thyroid, trachea, lymph nodes and nerves. Pain that lasts more than a few minutes, gets worse with activity, goes away and comes back, or varies in intensity. 2005;13(1):59-68. Costovertebral subluxation can occur with rowing, gymnastics, dancing and butterfly swimming and typically results in posterior pain at the levels of the 6th and 7th ribs. Sternal fractures are often seen in association with deceleration injuries and/or direct blows to the chest, as in blunt chest trauma during motor vehicle accidents. Jan. 19, 2023. Hollander JE, et al. Muscle lengthening followed by sudden eccentric contraction. However, the common feature across all cases is mild to severe chest pain. information highlighted below and resubmit the form. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. The most common markers of myocardial damage are creatine kinase, the MB isoenzyme of creatine kinase (CK-MB), troponin T, and troponin I. Get useful, helpful and relevant health + wellness information. Eur J Pain. Accessed Feb. 15, 2022. A relative uncommon injury that mostly occurs in male athletes between 20 and 40 years of age. This content does not have an English version. There is a problem with Watson L, Dunn D, Fraser-Kirk G. Indolent Rib Osteomyelitis Following Breast Implant Reconstruction: An Unusual Case and Review of the Literature. Most form in the anterior (front) part of your mediastinum. Eur J Intern Med. Injury, infection or irritation to any of these tissues can be responsible for chest pain. Cold sweat. This bone may also be referred to as the breastbone. A CK-MB level greater than 6.0 ng per mL (6.0 mcg per L) within nine hours of presentation for emergency care modestly increases the likelihood of MI or death in the next 30 days.27 Elevated levels of either troponin T (i.e., higher than 2 ng per mL [2 mcg per L]) at least eight hours from presentation or troponin I (i.e., higher than 1 ng per mL [1 mcg per L]) at least six hours from presentation support the diagnosis of MI or acute coronary syndrome and increase the likelihood of death or recurrent MI within 30 days. Sometimes the pain radiates to your neck, left arm or back. Sudden arm or shoulder pain reported, possibly with a 'pop.'. Grant's Atlas of Anatomy. These tumors often begin in the nerves and arent cancerous. The differential diagnosis is broad and includes cardiac (e.g., acute coronary syndrome , pericarditis ), gastrointestinal (e.g., gastritis , peptic ulcer disease Active movements such as deep breathing (to expand the thorax) and elevation of the upper extremities may reinforce a musculoskeletal diagnosis. Probably, but there's a chance the chest pain is caused by reduced blood flow to your heart (angina) or an actual heart attack. Find the latest information from the globally recognized leader in digestive diagnosis, treatments and surgical innovations. https://www.medicalnewstoday.com/articles/320185, https://www.kenhub.com/en/library/anatomy/sternum, http://www.brighthub.com/science/medical/articles/57775.aspx, http://www.youtube.com/watch?v=PiLZ5cVP5bA, https://www.physio-pedia.com/index.php?title=Sternal_Pain_-_Different_Causes&oldid=328735. For example, osteoarthritis, rheumatoid arthritis and psoriatic arthritis of the sternoclavicular, sternomanubrial or shoulder joints. This content does not have an English version. It is also seen in the non-bowling arm of a cricket fast bowler. Troy: Bright Hub Inc; 2009 [updated 7 March 2017; cited 24 January 2018]. Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back. privacy practices. 2004;29(10):614-6. American Heart Association. By working to inform readers of the options available to them, he hopes to improve their health and quality of life. Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Devon has written extensively for Bel Marra Health. Home Pain Management Substernal chest pain: Causes, symptoms, diagnosis, and treatment. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Belching, intestinal gas, gas pains and bloating, A burning sensation in the chest that may also involve the upper abdomen, Usually occurs after eating or while lying down or bending over, May awaken you from sleep, especially if you have eaten within two hours of going to bed, May be accompanied by a sour taste in your mouth especially when you're lying down, May be accompanied by a small amount of stomach contents rising up into the back of your throat (regurgitation), Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back, Nausea, indigestion, heartburn or abdominal pain. Titles were reviewed to identify literature relevant to the outpatient diagnosis of chest pain. Suffering from substernal chest pain can be quite painful. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. Heart tests. Heart attack. Sternocostal slipping rib syndrome. AskMayoExpert. Cardiopulmonary scan - observation (e.g. Pain that lasts more than a few minutes, gets worse with activity, goes away and comes back, or varies in intensity. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Management of heart attack cases will utilize a combination of treatment measures including blood thinners, thrombolytics, nitroglycerine, and aspirin. Inside your chest cavity (thorax), your esophagus actually runs right alongside the heart. information is beneficial, we may combine your email and website usage information with Your lymph system, or lymphatic system, is also part of your immune system and helps protect your body. J Am Acad Orthop Surg. Cleveland Clinic Cancer Center provides world-class care to patients with cancer and is at the forefront of new and emerging clinical, translational and basic cancer research. Gastrointestinal disease can cause chest pain, but the history and physical examination are relatively inaccurate for ruling in or ruling out serious gastrointestinal pathology,24 and it is important first to rule out immediately life-threatening cardiovascular and pulmonary causes of chest pain. Accessed Dec. 21, 2022. 2012;21(3):423-9. Kalso E, Mennander S, Tasmuth T, Nilsson E. Chronic post-sternotomy pain. viral) and non-infectious (e.g. What is midsternal chest pain? Approximately 60% of anterior mediastinal masses are cancerous. The chest pain of aortic dissection is a ripping, tearing, or knife-like pain that begins suddenly at peak intensity, along with neurological or pulse abnormalities. It will help provide any additional clues that can be used as evidence before proceeding to additional testing. Meyerson J, Thelin S, Gordh T, Karlsten R. The incidence of chronic post-sternotomy pain after cardiac surgery--a prospective study. 1-3% of annual visits to a primary care provider in the United States is related to chest pain, Manubrium (uppermost part, see image at R). What is a heart attack? Typically these strains occur acutely in response to trauma, overuse or when returning to activity after a period of rest. 2017 Dec 6. doi: 10.1007/s00383-017-4221-1. Nuclear scintigraphy (organ scanning) may be positive with costochondritis but the test is not specific to that condition. Trupiano JK, Rice TW, Herzog K, Barr FG, et al. This type of fracture represents 0.5% of all sternal fractures and is thought to be caused by repetitive contractions of muscles attaching to that bone. https://www.nhlbi.nih.gov/health-topics/angina. (https://pubmed.ncbi.nlm.nih.gov/11845884/), video-assisted thorascopic surgery (VATS), Heart, Vascular & Thoracic Institute (Miller Family). Symptoms of a mediastinal tumor may include: Mediastinal tumors form for different reasons, including: When a mediastinal mass, or tumor, appears on a chest X-ray, healthcare providers often perform additional tests, like imaging or bloodwork, to learn more about it. Findings that suggest pneumonia include fever, egophony, and dullness to percussion, but their absence does not rule out the diagnosis.10 Although chest pain in patients with chronic obstructive pulmonary disease and at least four previous acute exacerbations of chronic bronchitis is more likely to be caused by a recurrent exacerbation of bronchitis or pneumonia,23 these patients are also at greater risk for CAD or acute coronary syndrome. Accessed Dec. 21, 2022. But noncardiac chest pain (NCCP) is diagnosed as a chronic condition. privacy practices. In settings where an ECG is unavailable, clinicians should refer these patients to the ED to undergo testing. Usually, if the pain is in the actual sternum, you'll have sharp pain when you push in the middle of your chest. PPIs are about 90% effective in treating GERD and its side effects. The epidemiology of chest pain differs markedly between outpatient and emergency settings. National Heart, Lung, and Blood Institute. However, some patients experience angina in the absence of physical exertion or emotional stress, and not all chest pain that begins after exertion is angina. Results should be compared with previous tracings. Bonasso PC, Petrus SN, Smith SD, Jackson RJ. The most common symptom of heart attack for both men and women is chest pain or discomfort. Local muscle groups may also be tender to palpation. Retrosternal chest pain can be a symptom of a condition causing a benign (noncancerous) or malignant (cancerous) tumor in the area behind the sternum. On arrival, you'll receive a complete physical exam that measures all of your vital signs, including blood pressure and heart rate. Palpation of tender area reproduces chest pain, Yes on at least one item of Autonomic Nervous System Questionnaire, Pain radiating to arm, shoulder, neck, or jaw, Troponin T > 2 ng per mL (2 mcg per L) at least eight hours from presentation, Troponin I > 1 ng per mL (1 mcg per L) at least six hours from presentation, Abnormal BNP level (cutoff 80 pg per mL [1 ng per L]). Heartburn, right? Once this has been achieved, proper treatment can ensue. Pectoralis major muscle injuries: evaluation and management. A study of emergency room visits found that less than 6% of people arriving with chest pain had a life-threatening heart issue. 2017 Jul;11(7):PD08-PD09. Cardiac chest pain is caused by myocardial ischemia. Patients at intermediate risk for CAD who can exercise and have no left bundle branch block, preexcitation, or significant resting ST depression on their ECG can be evaluated with an exercise stress ECG. Malignant tumors cause symptoms more often than benign tumors. Chest pain may also be a manifestation of stress or anxiety. Gastroesophageal reflux disease. Elsevier; 2021. https://www.clinicalkey.com. If life-threatening causes of chest pain are ruled out, then a history of spontaneous anxiety, palpitations, faintness, or dyspnea suggests panic disorder. Grant JCB. If you can't get an ambulance or emergency vehicle to come to you, have a neighbor or a friend drive you to the nearest hospital. An inflammatory condition affecting costochondral junctions or chondrosternal joints. Tumors (also called neoplasms) are masses of cells. Explore lung, breathing and allergy disorders, treatments, tests and prevention services provided by the Cleveland Clinic Respiratory Institute. Treatment usually begins with a high dosage to control your symptoms, then continues with a low dosage for two to four months. McKean SC, et al. 2020 Nov 1;37(11):696-9. The most life-threatening causes involve the heart or lungs. Finding the cause of your chest pain might take some investigation, but its worthwhile. Determining whether chest pain is anginal, atypical anginal, or nonanginal is recommended to help determine a patients cardiac risk. With the help of a medical professional, you can find the reasons behind your particular case of substernal pain, helping you address potential harmful medical conditions as soon as possible. What type of mediastinal tumor do I have? [ 1, 4] aortic dissection. Springer JS, Karlsson P, Madsen CS, Johnsen B, Finnerup NB, Jensen TS, Nikolajsen L. Functional and structural assessment of patients with and without persistent pain after thoracotomy. McGraw Hill; 2017. https://accessmedicine.mhmedical.com. These fractures account for 8-15% of all paediatric skeletal injuries and 2-5% of all fractures in adults. There are several symptoms of a broken sternum, including: Chest pain. It feels like a painful squeezing or tightness in your chest, or like pressure or heaviness, particularly behind your sternum. When they are complex, there is a lot to be learned about how your body responds to foods, stress and thoughts that can put you on the path to long-term recovery. The AHA/ACC guideline recommends the use of an electrocardiogram (ECG) in the office setting in patients with stable chest pain, unless there is an evident noncardiac cause of the chest pain. Two simple questions14 are a highly sensitive screen for panic disorder: In the past six months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy?, In the past six months, did you ever have a spell or an attack when for no reason your heart suddenly began to race, you felt faint, or you couldnt catch your breath?14, A yes on either item is a positive screen, and a no on both items makes panic disorder unlikely. Potential substernal chest pain causes include myocardial infarction (heart attack), pulmonary embolism, aortic stenosis, stable angina pectoris, acute coronary syndrome, atrial fibrillation, pneumonia, and severe anxiety and panic attacks, just to name a few. You may feel it on the right side or the left side or in the middle. The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts. He has a Bachelor of Forensic Science from the University of Windsor, and went on to complete a Juris Doctor from the University of Pittsburgh. 2005;16(6):432-6. Click here for an email preview. Dizziness, lightheadedness or weakness. Other conditions can cause short-term, acute chest pain, including lung problems and musculoskeletal injuries. https://www.nhlbi.nih.gov/health/heart-attack. Pain on palpation of lower four costal cartilages. Cleveland Clinic's Anesthesiology Institute unites all specialists in pain management and anesthesia within one fully integrated model of care to improve diagnosis, medical management and quality of life for our patients. van der Meijden OA, Gaskill TR, Millett PJ. do they get our quality seal of approval. In children, most tumors form in the posterior (back) mediastinum. Selective serotonin reuptake inhibitors (SSRI) have shown some promise in treating NCCP, although they are less well-established than TCAs. Mediastinal tumors are growths that form in the area of your chest between your lungs. Proton-pump inhibitors (PPI) are the most commonly used medicine to treat GERD. Many possible causes but most concerning is cardiac pain. McConaghy JR. Outpatient evaluation of the adult with chest pain. Angina. Psychotherapy can help you to work through these problems to reduce the occurrence of chest pain. Almost all patients with heart failure have exertional dyspnea, so the absence of exertional dyspnea is helpful in ruling out this diagnosis.13. Crushing or searing pain that spreads to the back, neck, jaw, shoulders, and one or both arms. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Once a cardiologist or your primary care provider has ruled out cardiac causes, youll likely be referred to a gastroenterologist next. Assign code 530.81, gastroesophageal reflux, The pain may get worse when you take a . Occasionally, pain can be referred from another area (such as the abdomen). numb in the left arm or shoulder. Cardiovascular conditions such as myocardial infarction (MI), angina, pulmonary embolism (PE), and heart failure are found in more than 50 percent of patients presenting to the emergency department with chest pain,3 but the most common causes of chest pain seen in outpatient primary care are musculoskeletal conditions, gastrointestinal disease, stable coronary artery disease (CAD), panic disorder or other psychiatric conditions, and pulmonary disease (Table 1).3,4 Unstable CAD rarely is the cause of chest pain in primary care, and around 15 percent of chest pain episodes never reach a definitive diagnosis.3,4 Despite these figures, when evaluating chest pain in primary care it is important to consider serious conditions such as stable or unstable CAD, PE, and pneumonia, in addition to more common (but less serious) conditions such as chest wall pain, peptic ulcer disease, gastroesophageal reflux disease (GERD), and panic disorder. Chest pain. You may feel it on the right side or the left side or in the middle. If we combine this information with your protected Thoracic spine including thoracic disc herniation (which is rare given the relative immobility of this region), A patient who is older than 35 years of age, has a history or risk of coronary artery disease or presents with cardiovascular symptoms should have electrocardiography and possibly a. Patients presenting with chest pain should have an ECG evaluation for ST segment elevation, Q waves, and conduction defects. Ask your healthcare provider about likely outcomes based on the type of tumor you have. Simpson JK, Hawken E. Xiphodynia: A diagnostic conundrum. All our products are backed by a 100% satisfaction guarantee. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. They also report a higher incidence of other gastrointestinal (GI) complaints, including sore throat, regurgitation and difficulty swallowing. Muscle or bone problems in the chest, chest wall, or spine (back). Ask your healthcare provider about likely treatment outcomes. National Heart, Lung, and Blood Institute. Ans - R07.82 (intercostal chest pain), G89.11 (acute pain due to trauma) If it goes away after a few minutes, it may not be an emergency, but you should still see your healthcare provider as soon as possible to determine the cause. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition, Mayo Clinic Minute: When chest discomfort becomes something to worry about. https://www.uptodate.com/contents/search. Chest pain. This content is owned by the AAFP. Anginal chest pain has a high risk for CAD in all age groups; atypical anginal chest pain carries intermediate risk for CAD in women older than 50 years and in all men; and nonanginal chest pain carries intermediate risk for CAD in women older than 60 years and men older than 40 years.16, The likelihood of MI is higher if there is pain radiating to both arms,5 hypotension,6 an S3 gallop on physical examination,7 or diaphoresis.8,9 Other factors predicting MI include age greater than 60 years, male sex, and prior MI.17 MI is less likely if pain is sharp or pleuritic.7 If the pain is reproducible by palpation of a specific tender area, the likelihood of MI decreases8 but the likelihood of chest wall pain increases.15 A history of rheumatoid arthritis or osteoarthritis also increases the likelihood of chest wall pain.18 The Rouan decision rule reliably predicts which patients with chest pain and a normal or nonspecific electrocardiogram (ECG) are at higher risk for MI (Table 3).17 However, because up to 3 percent of patients initially diagnosed with a noncardiac cause of chest pain suffer death or MI within 30 days of presentation, patients with cardiac risk factors such as male sex, greater age, diabetes, hyperlipidemia, prior CAD, or heart failure warrant close follow-up.19.