Discussion

This local inflammatory process is probably related to minor trauma and would not be brought to medical attention so often if it did not occur in the chest, thereby invoking fear of a heart attack. Carefully reassuring the patient and her family is, therefore, most important. This disorder is self-limited, but there may be remissions and exacerbations. The pain usually resolves in weeks to months.

Tietze syndrome is a rare variant that is generally less diffuse and is associated with local swelling. Tumors of the anterior chest wall can also cause these symptoms; if the complaints persist or any swelling progresses, CT or MRI scans should be obtained.

Precordial catch syndrome, or Texidor twinge, is described as a sharp, needle-like pain that is well localized. The pain usually occurs at rest and has a split-second onset, taking the patient by surprise. Typically, the pain lasts only seconds to minutes, with deep breathing making the pain worse. Patients may sit straight up to help relieve the pain. Physical examination is normal, without reproducible pain. These patients are usually young, of light or medium build, and apparently healthy. It can occur once or twice in some people or several times a day for a number of weeks in others. Patients with these symptoms require only reassurance.

Slipping rib syndrome may cause lower chest and upper abdominal pain because of hypermobility at the anterior ends of lower costal cartilages. The diagnosis is made by eliciting tenderness over the costal margin, as well as by performing the “hooking maneuver.” This is done by curving your fingers under the costal margin and pulling the ribs forward, thereby eliciting a click that reproduces the patient’s pain. Treat with rest and physical therapy.

Chest pain in the pediatric population is most commonly benign, but a careful history and physical examination are critical. If there are any concerning elements in the history (e.g., syncope, dyspnea or pain with exertion, shortness of breath, family history of sudden death), or abnormalities on examination, a workup is indicated. When the history and physical examination reveal a healthy child, routine testing has not been shown to be helpful. An ECG may be useful for providing reassurance, which is the mainstay of therapy in this situation.

In adults, a recent study showed that almost 3% of patients thought to have noncardiac chest pain had an adverse cardiac event (myocardial infarction, coronary artery bypass graft, death) within 30 days. It is always the medical practitioner’s primary responsibility to rule out the worst case scenario. Even when your first impression is that of noncardiac chest pain, if your patient has known coronary artery disease or a history of congestive heart failure, coronary risk factors, weakness, diaphoresis, or chest pain similar to what he may have experienced in a previous acute coronary syndrome event, it may be prudent to pursue a more extensive workup.

Do not let yourself be led down an incorrect “noncardiac” path by a patient who is downplaying his or her symptoms, acting in a histrionic manner, or has the reputation of being a frequent flyer with similar symptoms. When there are underlying risk factors and symptoms or signs that are not inconsistent with a serious medical disorder of any cause, always play it safe, investigate, consult, and, when necessary, admit.