Associated symptoms
Associated symptoms may not reliably distinguish between a cardiac and gastro-intestinal origin of chest pain, which can coexist in up to 35 percent of patients.

• Belching, a bad taste in the mouth, and difficult or painful swallowing are suggestive of esophageal disease, although belching and indigestion also may be seen with myocardial ischemia.

• Vomiting may occur in the setting of myocardial ischemia (particularly transmural myocardial infarction), in addition to gastrointestinal problems such as peptic ulcer disease, cholecystitis, and pancreatitis.

• Diabetic ketoacidosis, which can be precipitated by acute myocardial infarction, is another cause of vomiting.

• Diaphoresis is more frequently associated with myocardial infarction than esophageal disease.

The presence of other associated symptoms may aid the diagnosis of chest pain:

Dyspnea – Exertional dyspnea is common when chest pain is due to myocardial ischemia and may predate the sensation of angina. Dyspnea that occurs concurrently with chest pain may be due to myocardial ischemia or a number of pulmonary disorders including

pathology of the airways, lung parenchyma, or pulmonary vasculature.

Cough – The differential diagnosis of chest pain and cough includes infection, as well as congestive heart failure, pulmonary embolus, and neoplasm. Cough, hoarseness, or wheezing may also be the result of gastroesophageal reflux disease.
Syncope – The patient with myocardial ischemia may describe presyncope. However, syncope associated with chest pain should raise a concern for aortic dissection, a hemodynamically significant pulmonary embolus, a ruptured abdominal aortic aneurysm, or critical aortic stenosis (particularly if the patient has a history of exertional dyspnea).

Palpitations – Patients with ischemia can feel palpitations resulting from ventricular ectopy, or may have an abnormal awareness of their sinus rhythm. While atrial fibrillation is associated with chronic CAD, new onset, isolated atrial fibrillation is uncommon in patients with acute myocardial infarction.

Psychiatric symptoms: Symptoms of panic disorder, generalized anxiety, depression, or somatization may occur in patients with chest pain. Panic disorder is present in 30 percent or more of patients with chest pain who have no or minimal CAD; it also may coexist with CAD.

Constitutional symptoms: The elderly in particular may describe profound fatigue as the presenting complaint of myocardial infarction. True chest wall pain is not usually associated with systemic symptoms. Exceptions include pain due to chest wall neoplasm, associated intrathoracic trauma, and the constitutional symptoms or rash of herpes zoster.

Risk factors – The clinical impression raised by the patient’s description of pain must be interpreted together with other aspects of the history, including risk factors for various etiologies of chest pain. Knowledge about such risk factors provides important information regarding disease likelihood, which may ultimately guide the type and extent of evaluation performed. (see chapter).

The presence of hyperlipidemia, left ventricular hypertrophy, cocaine use, or a family history of premature CAD increase the risk for myocardial ischemia. Hypertension is a risk factor for both CAD and aortic dissection.

Cigarette smoking is a nonspecific risk factor for serious pathology; it is associated with CAD, thromboembolism, aortic dissection, pneumothorax, and pneumonia. A recent infection, especially viral or tuberculous, may precede an episode of pericarditis. Other risk factors for pericarditis include a history of chest trauma, autoimmune disease, recent myocardial infarction or cardiac surgery, and the use of certain drugs such as procainamide, hydralazine, or isoniazid. Age is an important risk factor for CAD; among patients older than age 40, chest pain resulting from stable CAD or an acute coronary syndrome (unstable angina or myocardial infarction) becomes increasingly common. Men older than age 60 are most likely to suffer aortic dissection, while young men are at highest risk for primary spontaneous pneumothorax. Young adults of both sexes are diagnosed with viral pleurisy more often than are their elders.

A past history of CAD, symptomatic gastroesophageal reflux, peptic ulcer disease, gallstones, panic disorder, bronchospasm, or cancer is very helpful. It is important to establish if the present symptoms are similar to those which occurred when the diagnosis was previously established. A history of diabetes mellitus should heighten the concern for a nonclassic presentation of CAD. It is important to exclude recent blunt trauma to the chest which can result in pneumothorax, disruption of the aorta, tracheobronchial tree, and esophagus, myocardial or pulmonary contusion, or chest wall injury with associated musculoskeletal discomfort.