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Non- Cardiac Chest pain Prof.Dr Yaşar Küçükardalı İç Hastalıkları ve Yoğun Bakım Uzmanı NCCP has a population prevalence of around 25–30% in the UK, USA, and mainland Europe and 14% in one study from Hong Kong . It accounts for 2– 5% of all emergency department admissions in Australia and Hong Kong . Acute aortic syndrome is the modern term that includes aortic dissection, intramural hematoma (IMH), and symptomatic aortic ulcer. In Münchausen syndrome, the affected person exaggerates or creates symptoms of illnesses in themselves to gain investigation, treatment, attention, sympathy, and comfort from medical personnel. Tietze syndrome is an inflammatory condition characterized by chest pain and swelling of the cartilage that joins the upper ribs to the breastbone (costochondral junction). On physical examination, a patient with sternalis syndrome exhibits myofascial trigger points at the midline over the sternum . Pain is reproduced with palpation of these trigger points, rather than movement of the chest wall and shoulders. SAPHO syndrome synovitis, acne, pustulosis, hyperostosis, osteitis Skin and sensory nerves Chest pain may be the presenting symptom of herpes zoster (shingles) it may precede the characteristic rash and, rarely, zoster may occur without a rash Dysesthesia is usually present in the affected dermatome. Postherpetic and postradiation neuralgia are other unusual causes of chest pain. Stress-induced cardiomyopathy — Emotional stress can precipitate severe, reversible left ventricular dysfunction in patients without coronary heart disease, related to exaggerated sympathetic stimulation. Patients most commonly present with acute substernal chest pain typically triggered by an acute medical illness or by intense emotional or physical stress, Postulated pathogenic mechanisms include •catecholamine excess, •multivessel coronary artery spasm, •microvascular dysfunction. Gastroesophageal reflux disease *GERD, can mimic angina pectoris and may be described as squeezing or burning, located substernally and radiating to the back, neck, jaw or arms, lasting anywhere from minutes to hours, and resolving either spontaneously or with antacids. It may occur after meals, awaken patients from sleep, and be exacerbated by emotional stress. Diagnosis is usually made via endoscopic biopsy after treatment with protonpump inhibitors fail to improve symptoms, or esophageal pH monitoring excludes GERD as the diagnosis Esophageal hypersensitivity There are considerable experimental data to indicate that some patients with chest pain have a lower threshold for esophageal pain than normal subjects. Studies utilizing intraesophageal balloon distension have shown that many patients with unexplained chest pain experience their pain at a lower volume of balloon inflation than that found in appropriate control subjects Abnormal motility patterns and achalasia The relatively uncommon diagnosis of a motility disorder or esophageal spasm chest pain is associated with dysphagia, barium swallow study does not reveal an anatomic abnormality of the esophagus Esophageal rupture, perforation, and foreign bodies * Spontaneous perforation of the esophagus most commonly results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting (effort rupture of the esophagus or Boerhaave's syndrome) . Odynophagia, tachypnea, dyspnea, cyanosis, fever, and shock develop rapidly thereafter . Other causes of perforation include caustic ingestion, pill esophagitis, Barrett's ulcer , infectious ulcers in patients with AIDS, and iatrogenic injury . A patient with a foreign body impacted in the esophagus may present with chest pain. Other causes of esophagitis The types of medication causing direct esophageal injury can be roughly divided into antibiotics (most commonly tetracyclines and clindamycin), antiinflammatory agents (especially aspirin), bisphosphonates potassium chloride, quinidine preparations, and iron compounds Esophagitis may also be due to infectious causes, including esophageal candidiasis or CMV esophagitis, particularly in immunocompromised hosts due to AIDS or stem-cell transplant patients. Radiation injury may also induce esophagitis. Other gastrointestinal causes of chest pain hiatus hernia, paraesophageal hiatus hernia can lead to symptoms due to life-threatening gastric volvulus. The possibility of radiating or referred visceral pain due to cholecystitis or biliary colic , peptic ulcer disease, pancreatitis, kidney stones, and even appendicitis should be considered in any patient with unexplained chest pain. Acute pulmonary embolism It should be considered in any patient who presents with chest pain Individual symptoms and signs are not helpful diagnostically The most common symptoms of pulmonary embolism were dyspnea (73 percent), pleuritic chest pain (66 percent), cough (37 percent), and hemoptysis (13 percent) . 90 percent had dyspnea, tachypnea, or signs of deep venous thrombosis; 84 percent had a chest x-ray abnormality; 50 percent had nonspecific electrocardiographic abnormalities. Pulmonary hypertension (PH) and cor pulmonale Patients with secondary PH often have symptoms that reflect the underlying etiology (eg, chronic obstructive pulmonary disease, pulmonary embolic disease, collagen vascular disease). There are, however, symptoms directly attributable to secondary PH including dyspnea on exertion, fatigue, lethargy, chest pain, and syncope with exertion. Idiopathic PH is a rare disease. Most patients present with exertional dyspnea, which is indicative of an inability to increase cardiac output with exercise. Exertional chest pain, syncope, and edema are indications of more severe PH and impaired right heart function Pneumonia The patient with community acquired pneumonia (CAP) caused by pyogenic organisms classically presents with the sudden onset of rigors followed by fever, pleuritic chest pain, and cough productive of purulent sputum. Chest pain occurs in 30 percent of cases, chills in 40 to 50 percent, and rigors in 15 percent. Because of the rapid onset of symptoms, most individuals seek medical care within six days Cancer Isolated chest pain is a relatively rare presentation of lung cancer . The chest pain experienced by 25 to 50 percent of lung cancer patients is usually in association with cough, dyspnea, weight loss, or hemoptysis. Some patients have a dull, intermittent pain on the side of the tumor; severe or persistent pain often indicates chest wall or mediastinal invasion. Sarcoidosis Chest pain is a common manifestation of pulmonary sarcoidosis, most commonly it is accompanied by cough and dyspnea. Granulomatous involvement of the ventricular septum and conduction system of the heart can lead to a variety of arrhythmias (including heart block) and sudden death; such involvement may be heralded by chest pain, palpitations, syncope, or dizziness. Asthma and COPD Diseases of the bronchial airways such as asthma and COPD may present with chest pain. both characterized by airway inflammation and bronchospasm. Chest pain is common in asthma exacerbations, 76 percent asthma and COPD exacerbations often have triggers (such as pneumonia or pulmonary embolism) that may actually be the cause of chest pain. Pleura and pleural space Pleuritic chest pain is caused by irritation of nerve endings of pain fibers in the costal pleura. It often worsens with inspiration. Pain referred from the pleura may be felt in the thoracic wall in the areas of skin innervated by the intercostal nerves . Clinicians should note that other etiologies of chest pain may worsen with deep breathing, such as pericarditis or musculoskeletal chest pain syndromes Pneumothorax A spontaneous pneumothorax should be considered in any patient who complains of the sudden onset of pleuritic chest pain and respiratory distress . A secondary spontaneous pneumothorax occurs as a complication of underlying lung disease such as chronic obstructive pulmonary disease, pneumocystic pneumonia, or as an iatrogenic complication of certain procedures. A tension pneumothorax is rare, but potentially life-threatening unless treated emergently. It occurs when a tissue flap from the injured lung creates a one-way valve, progressively trapping air in the intrapleural space during inspiration. Respiratory failure occurs as the healthy lung is compressed. Physical findings include unilateral loss of breath sounds with hypertympany, shift of the trachea away from the injured side, and jugular venous distension. Pleuritis Pleuritis is an inflammation of the parietal and serous pleura of the lung. Viral pleurisy is a common cause of pleuritic chest pain in young adults . Other causes include autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, and drugs that can cause a lupus-like syndrome including procainamide, hydralazin isoniazid, PSYCHOGENIC/PSYCHOSOMATIC CAUSES OF CHEST PAIN Chest pain may be a presenting symptom of panic disorder, depression, and hypochondriasis, as well as cardiac, cancer, or other phobias Reviews of the literature have estimated that approximately one-third of patients presenting to the emergency department for chest pain have a psychiatric disorder, while approximately one-half of patients with noncardiac chest pain have various psychiatric diagnoses . Among patients with chest pain due to coronary artery disease (CAD), 20 to 30 percent also have a coexisting psychiatric disorder. Hyperventilation, which is associated with panic attacks, can also result in nonanginal chest pain and occasionally electrocardiographic changes, particularly nonspecific ST and T wave abnormalities . Panic disorder Panic disorder is a particularly common cause of chest pain. chest pain found that 20 percent had panic disorder as the etiology. Vigilance is necessary since patients with psychiatric disorders may develop organic disease In addition, ischemia may occur during a panic attack in a patient with CAD . Thus organic disease must be reasonably excluded before ascribing chest pain to a nonorganic origin. Munchausen syndrome In one literature review, 58 patients with cardiac Munchausen syndrome were identified . Of these, 54 (95 percent) were male; the mean age was 44 years (range, 23 to 71). The most common presenting symptom was retrosternal chest pain (50 patients); other presenting complaints were syncope, dyspnea, and back pain. Patients typically gave a history of prior cardiac disease and often reported having "white collar" jobs; Acute myocardial infarction was the most common admitting diagnosis. All subjects had had numerous admissions and extensive cardiac testing, which were negative for cardiac disease but which the patients reported were positive. When confronted, most patients changed their history, became uncooperative, and refused psychiatric examination.