Chest pain

Douleurs thoraciques

A few figures help to understand the problem that occurs most often in an emergency context:

– Chest pain represents about 5% of the chief complaints in the emergency services;

– Allowed to leave their homes nearly 5% of patients with chest pain is related to acute coronary symptom;

– Pulmonary embolism is one of the most common causes of medical error.

Chest painSome rules should guide the diagnostic thinking:

– Rigor of the examination is an essential time of diagnosis, and we can help the checklist PQRST: P for provocative factors; Q for quality of pain; R to area of pain, not to mention its irradiation; S for severity (or intensity) of the pain; T evolution versus time (in particular duration of pain);

– A clinical examination must be complete, not to mention neurological examination not ignore chest pain with radicular or spinal origin;

– Some laboratory tests (troponin, D-dimers) came in recent years, provide valuable assistance (but not always decisive) the diagnosis;

– New imaging techniques (multi-slice spiral CT, magnetic resonance imaging) are also very useful, provided you have a very fast access;

– It is important to distinguish immediately, possibly with the aid of scores, chest pain requiring immediate diagnosis and treatment, and less urgent pain that leave time for reflection.


They are five in number. Both require anticoagulation and / or thrombolytic in the minutes following the patient examination: myocardial infarction or coronary syndromes and pulmonary embolism. Three are cons-indications to anticoagulation: aortic dissection, pericarditis, and esophageal rupture.

Acute coronary syndromes:

They represent over a quarter of consultations for chest pain in the emergency department (10% for myocardial), while the other causes of acute chest pain are less than 5% of emergency consultation patterns.

This means that the doctor should always have the fear of not letting leave home a consultant for prodromal patient with myocardial infarction.

Myocardial infarction:


It must be particularly suspected in patients who have already made a coronary problem and in those with vascular risk factors, primarily hypertension, dyslipidemia, diabetes (knowing that the pain can be alleviated or very atypical in this context), smoking and family history of coronary disease.

The pain could occur during exercise or at rest.

It is constrictive, described as a crushing ( “it’s rheumatism Heberden”). It is typically shown with the flat of the hand in the cardiac region and radiates to the left arm, jaw, but its headquarters and radiation can be very atypical (the back, the upper abdomen, right arm, etc.). It is typically (but not always) intense, incommensurate with the usual angina attacks, if the patient has already had one, and resistant to nitroglycerin. It lasts several minutes or several tens of minutes.

In most cases, ECG and troponin evoke a diagnosis of infarction.

The ECG-12 lead usually shows the lesion current (plus shift ST = wave Pardee) and repolarization disorders in the infarcted area a few hours before the onset of the Q wave, however, it may be normal for the first hours or difficult to interpret, especially if there is a left bundle branch block.

In these cases, increased troponin involves keeping the patient to do an echocardiogram in search of a disorder of the left ventricular wall motion, to assay the CPK and CPK-MB, and repeat the ECG a few hours later or even to coronary angiography.


Making the diagnosis of myocardial imposes several emergency actions:

– Pain relief needed by opioids;

– Institution of anticoagulant therapy with heparin and dual antiplatelet therapy (aspirin and clopidogrel);

– Institution of thrombolytic therapy (eg Actilyse® 100 mg intravenously over 1 hour), possibly in the ambulance SAMU who leads the patient to the emergency if the period is estimated to achieve long coronary angiography, or from the arrival cardiological intensive care with angioplasty, where necessary and possible under antiplatelet infusion (ReoPro).

Unstable angina:


When there is no ST elevation, it can be a challenge unstable angina or angina as a recent appearance or suddenly worsened, occurring for minimal effort or even at rest, with crises increasingly severe and prolonged. An unstable angina particular case is variant angina, or angina friendly, electively occurring late at night and especially accompanied by arrhythmias. Angina due to coronary spasm can occur on coronary “normal” to coronary angiography or with only a discrete atherosclerotic plaque.

In the absence of ST elevation on ECG done urgently, called TIMI score can identify patients at high risk of myocardial infarction and / or worsening.


Making the diagnosis of unstable angina should also lead to institute emergency treatment with heparin, antiplatelet agents and beta-blockers in the absence of indication-cons, and quickly perform coronary angiography.

Pulmonary embolism (PE):


Risk factors:

It is one of the most difficult diagnoses to make, particularly in elderly patients, heart failure or have had a bacterial pneumonia.

In an autopsy review of medical errors observed at the University of Kiel, Germany, for 40 years, pulmonary embolism was the most common cause of these errors. In the US, about two thirds of fatal pulmonary embolisms are undiagnosed until autopsy.

Some situations are particularly at risk: immobility, surgery or peri-partum neoplasia. We must add the less important risk factors: heart failure, venous catheters (Port-a-Cath in particular), hormonal treatments, travel long distances(economic class syndrome).

A biological thrombophilia, congenital or acquired is also an important risk factor especially the factor V Leiden, deficits in C or protein S, the presence of antiphospholipid antibodies. For example, the factor V Leiden mutation multiplied by 3-5 the risk of pulmonary embolism. Associated with COCs, it multiplies the risk by about 35.

Symptoms and Signs:

The diagnosis of pulmonary embolism should be considered in any patient dyspnea (75% to 84% of cases of pulmonary embolism) and / or having chest pain (66-74% of cases of pulmonary embolism). Almost all patients with pulmonary embolism has at least one of these two symptoms. The objective clinical examination tachypnea (≥ 16 breaths per minute) in over 90% of patients, tachycardia (greater than 100 / min) in 45% of patients, fever (sometimes misleading because moving towards pneumonia ) in 43% of patients. However, thrombophlebitis clinical signs are present in less than a third of patients from which

the need for venous Doppler ultrasound, knowing that it is at fault in 30% of patients.

Complementary exam:

When the diagnosis of pulmonary embolism is suspected, six additional tests may be helpful: blood gases (they show in principle hypoxemia and hypocapnia, due to the shunt effect, but they are normal in nearly 40% of patients youth), ECG, echocardiography, measurement of D-dimer, the chest CT or if the lung scan. All these tests are not the same diagnostic value. A rate of D-dimer <500 mg / mL with correct technique (or ELISA Immunoassay) is a large negative predictive value. It eliminates the diagnosis of pulmonary embolism unless the clinical suspicion is high. Similarly, a spiral CT, provided it is done quickly, eliminates the diagnosis of pulmonary embolism if there is no defect in the pulmonary arteries.

The negativity of the other tests does not eliminate the diagnosis of pulmonary embolism.


Different scores were used to assess the risk of pulmonary embolism: criteria Wells of Wicki, Charlotte, and most recently scoring Geneva. The most interesting seem to be those that use only criteria obtained by questioning and clinical examination.

These are the scores of Wells and Geneva.


Depending on the clinical suspicion (Wells score or Geneva) algorithms were developed to dictate the escalation of further tests and therapeutic attitude.

In the particular case of massive pulmonary embolism with hypotension, ECG and echocardiography bedside exams are very useful.


The treatment of hemodynamically stable pulmonary embolism based on the urgency of heparin: unfractionated heparin with a starting dose of 20 IU / h / kg, Calciparine®, low molecular weight heparin.

The patient’s home, the first-line treatment (in the absence of known allergy to heparin) is a low molecular weight heparin.

Eg enoxaparin (Lovenox®) 2 subcutaneous injections per day depending on the patient’s weight. The relay with a vitamin K antagonist (Coumadin®, Previscan, Sintrom®) can be taken at the 24th hour, in order to avoid a possible allergy to heparin (which occurs exceptionally before the 5th day). The duration of anticoagulant treatment after a pulmonary embolism must be at least six months because, in particular, during this period unmask any responsible cancers. This event is observed in 7-10% of patients (etiologies for thromboembolic disease, or phlebitis also paragraph in Chapter pain of a calf).

Aortic dissection:


It must be mentioned particularly in elderly men and hypertensive (3/4 patients), but also in Marfan syndrome and certain systemic diseases (GCA, polychondritis, etc.). Dissection itself may be preceded by a hematoma dissecting intraparietal. The diagnosis is easily raised if the pain is very intense from the outset, transfixing, and if one is examining an aortic regurgitation murmur (type A dissection of the Stanford classification) or abolition of a radial pulse or a pulse to the lower limbs. A sudden paraplegia, sometimes regressive, is also possible. However, there are also very misleading presentations, such as acute pericarditis tables.

The chest radiograph made emergency may reveal a widened mediastinum, loss of aortic contour pleural effusion.

The association pain immediately very intense type of tear-abolition of a pulse or blood pressure, widened mediastinum on the asymmetry chest radiograph to suspect more than 95% of aortic dissections.

In fact, the diagnosis is based on echocardiography (for dissection of the ascending aorta) and / or the CTA to make great urgency. The identification of a slough or bruising intraparietal confirms the diagnosis of dissecting hematoma or dissection of the aorta.


Once the diagnosis brought, it is urgent not to anticoagulant and hypertension control possible using vasodilator antihypertensives and discuss the indication of aortic replacement urgently. Despite these measures, the hospital mortality of aortic dissection is approximately 25 to 30% of cases.

Acute pericarditis:


Symptoms suggestive are in decreasing order of frequency: pain (over 50% of cases), dyspnea (25 to 40%) and fever (17%). The pain may radiate to the back, neck, shoulders (such as heart attack) but it is particular by its increase in inspiration and decrease in sitting and leaning forward. Pericardial friction is seen in three-quarters of patients. This is a friction three times heard best at the left edge of the sternum, the endapex. It is absent when the effusion is abundant.

We must seek to examine the signs of tamponade, especially hypotension, jugular distension, and a paradoxical pulse. The ECG shows a concave ST sub-offset upwardly and negative T waves. These abnormalities are diffuse and do not correspond to a coronary territory. At this early stage, there may be a sub-offset PQ, very evocative of pericarditis. If there is a microvoltage shall especially be feared tamponade.

In this case, the cardiac silhouette is usually significantly extended on the plate thorax face. Biology usually shows an inflammatory syndrome with very early increase in CRP. Deceptively, it can show elevated troponin.

The essential supplementary examination is when echocardiography shows a circumferential effusion. When the table is unique and discrete or absent ECG signs and no pericardial friction, it must be remembered minimal pericardial detachment may be physiological and not enough to assert pericarditis. If effusion, but mainly located in the posterior region, check that the sonographer is experienced and has not confused with pleural effusion pericardial effusion.

If the diagnosis of acute pericarditis is retained, it is usually viral, but do not ignore the one hand tuberculosis, on the other hand some systemic diseases (systemic lupus erythematosus and Still’s disease, essentially) . Dressler’s syndrome (acute pericarditis observed with the waning of a myocardial infarction) has become very rare. Finally, in patients who underwent mediastinal radiotherapy or breast, even 15 years ago, we must not ignore a postradique pericarditis.


Treatment is based, in most cases, anti-inflammatory drugs (aspirin 2 to 3 g / d) trying to avoid prednisone (unless it is a lupus or Still’s disease ). One can associate colchicine probably decreases the frequency of relapses. Anticoagulants should of course be avoided, as they may turn a clear liquid effusion in haemopericardium. In case of tamponade, pericardial drainage is indicated in emergency. It is pointless to do in this case pericardial biopsy usually does not light on the cause of pericarditis.

Esophageal rupture:


This is the famous Boerhaave syndrome described in more detail in another chapter, which usually occurs after severe vomiting efforts, mainly in elderly or alcoholic patients. It is a diagnosis particularly difficult, especially when vomiting is absent. The patient then usually complains of dyspnea, cough, fever, and upper abdominal pain. The presence of snow crackling in the precordial area or in the supraclavicular fossa moving towards the diagnosis.

Chest radiography confirms the diagnosis by showing a pneumo-mediastinum or pleural effusion or hydropneumothorax.

We can then make esophageal transit, endoscopy, or a CT scan.


Should perform surgical patient. A delay in the intervention increases the risk of sepsis and hospital mortality is about 50%.





The Heberden of rheumatism is constrictive retrosternal pain may radiate to the neck and upper extremity (ulnar) of usually short duration. It can occur during exercise (walking uphill in cool weather) and, in this case, quickly gives way to stop the effort. It can also occur at rest, and even at night (which should suggest a variant angina by coronary spasm).

Nitroglycerin should alleviate the crisis in less than two minutes.

You must obviously find the usual cardiovascular risk factors: dyslipidemia, hypertension, smoking, diabetes. In diabetes, chest pain may lack even the existence of repolarization disorders (silent ischemia).

Clinical examination search corneal arc, xanthelasma and oblique fold of the ear (see oblique fold of the ear). The necessary examinations are resting ECG, exercise ECG and coronary angiography. If resting angina, mainly in variant angina, ECG and exercise testing may be negative, which does not eliminate the diagnosis.

In some cases (not stress, diabetes, etc.), it may be useful to use myocardial scintigraphy.


Medical treatment of coronary artery disease has at least one antiplatelet (Kardégic® 75, 100 or 160 Aspégic®, Plavix® in case of against-indication for aspirin) and a statin to reduce total cholesterol below 2 g / L and LDL cholesterol above 1 g / L. Is a beta-blocker in patients with exertional angina. If angiography leads to angioplasty with stent, the current trend is to let the patient for at least one year under antiplatelet (Kardégic® 75 + Plavix®).

Aortic stenosis:

Aortic stenosis may be complicated by angina attacks or even sudden death. After calculating the transaortic gradient aortic surface echocardiography, it almost always makes a preoperative coronary angiography to achieve at the same time surgical valve replacement and bypass surgery or aortocoronaires if necessary.

Mitral valve prolapse:


The mitral valve prolapse (Barlow’s disease) can cause atypical precordial discomfort, often prolonged, sometimes accompanied by palpitations. This “ballooning” mitral, very common in young women, is usually mild, except in cases of rupture of rope. However, it faces the risk of endocarditis Osler.


Small surgery should be framed by taking antibiotics (in non allergic subject to penicillin, amoxicillin 3 g / day for 48 hours, beginning two hours before the procedure).

Pulmonary Hypertension:


Pulmonary arterial hypertension (PAH) can cause chest pain and even fainting for little effort.

Echocardiography is used to roughly assess systolic pulmonary artery pressure from the measurement of the speed of transtricuspidien flow during systole.

This should be confirmed by right catheterization, more reliable, and to measure mean pulmonary arterial pressure and cardiac output and pulmonary resistance.

We must seek scleroderma (CREST syndrome) in case of PAH.


It is important to track the PAH we now have effective and easy to administer treatment (oral bosentan 125 mg morning and evening, and / or sildenafil 20 mg / 2 to 3x / day).

Digestive origin:

They represent 40% of chest pain motivating consultation in an emergency department, once eliminated coronary causes.

In fact, it is not always easy to distinguish a coronary insufficiency esophageal pain, especially as gastroesophageal reflux disease (GERD) can cause myocardial ischemia in patients with coronary artery disease and overlying because nitroglycerin can relieve esophageal pain.

Esophageal pain:


Esophageal pain are the most frequent chest pain of digestive origin. GERD, easily suspected clinically, can be confirmed by manometry (decreased lower sphincter tone of the esophagus, especially in cases of scleroderma) and the 24-hour pH monitoring. The gastroesophageal gastroduodenal endoscopy also allows viewing its main complication, the Barrett’s esophagus.


Treatment is based on proton-pump inhibitor (eg, omeprazole 20 mg morning and evening) associated with antireflux physical agents (Gaviscon, etc.) and prokinetic (Motilium® 3 cp / d). If unsuccessful, antireflux plasty (hemi-Nissen) can be performed under laparoscopic surgery, including in SSc patients.

If there is no reflux, manometry can distinguish achalasia by loss of esophageal peristalsis, and instead the hyperpéristaltismes, particularly the esophagus cassenoisettes (enhanced by nitrates).

Gastric or duodenal ulcer:


Gastric ulcer, or duodenal same, can result in chest pain.

The diagnosis is confi rmed by the fi broscopie with biopsy looking for Helicobacter pylori.

Helicobacter infection can also be diagnosed without biopsy breath test (Heli-Kit ®).


The treatment is highly standardized omeprazole 40 mg / day for one month and then 20 mg nightly for a month, amoxicillin 2 g / day for two weeks, Zeclar® 1 g / day for a week to ten days.

Cholecystitis and cholangitis:


Some cholecystitis and / or cholangitis are revealed by low retrosternal pain rather than a subcostal pain.

This highly misleading presentation can be reduced to its cause through good hepatobiliary ultrasound if needed abdominal CT or ultrasonography by a duodenal route under general anesthesia.


Cholecystitis requiring cholecystectomy, laparoscopic surgery as in the vast majority of cases. The cholangitis must first be treated medically injectable antibiotics.

After apyrexia sphincterotomy can be performed endoscopically, with removal at the same time choledochal calculations; the patient will undergo a second time cholecystectomy laparoscopy.

Acute Pancreatitis:


It is often difficult to make the diagnosis of acute pancreatitis to a base of the thorax pain, especially when this is accompanied pancreatitis repolarization disorders ECG or pleural effusion. Pancreatitis should be suspected if there is a notion of alcoholism or known gallstones.

Biology is very useful when it shows an increase in amylase, lipase of, transaminases, possibly of CA 19-9.

We must not omit to assay triglycerides at the first examination because major hypertriglyceridemia (above 10 g / L) are a cause of acute pancreatitis and because triglycerides to normal very quickly (in less than 48 hours). The hepatobiliary ultrasound and abdominal CT scan can help confirm the diagnosis, but they can also be falsely reassuring.


Treatment of acute pancreatitis in the vast majority of medical cases and is mainly based on parenteral nutrition with stopping oral intake. If pancreatitis biliary will require a second time to practice the surgical treatment of this cholelithiasis.

Irritable bowel syndrome:


Irritable bowel syndrome can be taken for angina when the pain comes from the left angle of the colon.

The chest radiograph and abdomen without preparation can be suspected colonic origin if it shows a lot of air in the left corner.


See chapter Abdominal pain.

Pleuropulmonary pain:



Pneumonia is usually easy to diagnose in a febrile patient with a chest beside the point, a cough, mucopurulent sputum and when auscultation reveals crackles a home.

Radiography helps to distinguish the systematic pneumonia, usually pneumococcal and atypical pneumonia, which must practice at least three serology: mycoplasma, Chlamydia pneumoniae, Legionella.

However, diagnosis can be difficult because the pain is sometimes discreet and normal chest radiography in the early hours. It is also possible to overlook a poorly visible retrocardiac opacity. CT scan may be helpful in showing a condensation home with aeric bronchogram. In addition, pneumonia may mask a pulmonary embolism, especially in elderly and / or heart failure subject, and, if in doubt, ask a chest CT.


Therapeutically, simple pneumonia lobar pneumonia requires amoxicillin 3 g / d, effective at that dose even with decreased susceptibility to beta-lactams. Atypical pneumonias are instead treated with erythromycin, quinolone, such as levofloxacin (Tavanic®) 500 mg to 1 g / day in two divided doses or moxifloxacin (Izilox®) 400 mg / day in one take.The duration of treatment is usually ten days. In patients at risk (elderly, chronically bronchopathe, insufficient cardiac, diabetic …), it is prudent to give immediately, before any community-acquired pneumonia, amoxicillin in combination with erythromycin, quinolone.

Pneumothorax pain:


The pain of pneumothorax is a point of brutal side, with tearing sensation, sometimes radiating to the shoulder, which may be accompanied by cough and dyspnea. Some clinical signs (jugular turgor) can be misleading. The essential problem is not to disregard a small peripheral lung detachment on the plate simple chest.

It is known that certain diseases particularly exposed to pneumothorax: Marfan’s disease, histiocytosis in young smoking and chronic pulmonary disease in the older smoker.


The therapeutic approach depends on the clinical impact and the chest radiograph.

If detachment (minor and stable) in a non dyspneic patient, it may allow the return home after 6-8 hours. On the contrary, in case of respiratory distress and / or lung retraction in the hilar region, it is of course hospitalize the patient and develop a pleural drain.

Pleural effusions:


The point of unilateral thoracic side of pleural effusion similar course to that of the pneumothorax. The pain has a sudden onset, it is under armpit or under the breast, but may radiate into the shoulder (diaphragmatic pleurisy) or the loins or the anterior abdominal wall. It can be extremely intense, insomniante. It increases with deep breathing, coughing, sneezing. It is relieved by breathing pauses or immobilization of the affected side. Auscultation found pleural friction, highly localized, inspiratory and expiratory or inspiratory only, like the creak of new leather.

The pain and friction usually disappear when pleural effusion appears on the chest radiograph or increases in volume.The chest radiograph shows the classic line Damoiseau when effusion is moderate. CT scan often shows a more abundant effusion than might be supposed plain films. It also allows to study well the underlying parenchyma.

Once diagnosed with pleural effusion, two situations are possible:

– Satellite effusion is a known lung or abdominal pathology:

– Pleurisy rich in protein during pulmonary embolism or pneumonia

– Pleurisy satellite of acute pancreatitis, a subphrenic abscess or hepatic amoebiasis

– Pleural transudate (usually on the right) during a decompensation cirrhosis ascites;

– Effusion is significant in this case, thoracentesis help find the cause:

– Empyema, then it must again think of pulmonary embolism before concluding the isolated empyema,

– In general, pleurisy rich in protein (exudate) and lymphocytes. Pleural cytology can search metastatic cells and mesothelioma (in this case, can be assayed hyaluronic acid in pleural fluid). The context may suggest tuberculosis and whether BK research is negative,

you have to go to the pleural biopsy. connective Wanted principle (systemic lupus erythematosus, rheumatoid arthritis. A asbestosis pleurisy (which often precedes mesothelioma) is discussed based on the professional context (contact with asbestos, even very old) and if there is pleural plaques on plain films, or scanner. If the etiological investigation is negative, it is probably lymphocytic pleurisy viral.

Parietal and radicular pain:

They represent about 28% of unexplained chest pain but not heart addressed to emergency services.


Earlier chondrites:

This is a one-time pain, sometimes intense, often sitting in the precordial area where the anxiety of patients. Before concluding that this is a trivial Tietze syndrome amenable to an anti-inflammatory gel or infiltration of lignocaine, we must ensure that this chondrite is not integrated into a systemic disease (ankylosing spondylitis, Wegener’s disease, polychondritis). A variant of chondrite is slipping rib syndrome that affects the last rib and which is due to a subluxation of a floating rib on the upper side, hence the name of slipping rib.

The treatment is essentially based on the infiltration of Xylocaïne® 1%.

* Rib fracture:

Pain may also worry about the patient if it occurs without any trauma and if it is sitting in the precordial area. The rib cage clichés are often not contributing and that is the bone scan which shows the fracture. Immobilization by Elastoplast often helps relieve the patient. Rarely fracture coast reveals a neoplastic disease, evoked if there is a costal lysis.

* Breast pain:

They can be misleading when they are unilateral. It may be an abscess. We then find signs of inflammation in the clinical examination. It can also be a mastitis during systemic diseases (diseases Wegener, Horton). Most often, it is a benign tumor of the female breast (fibroadenoma, cyst) or benign gynecomastia in a young man. When in doubt, you have to mammography and ultrasound.

Mastitis complicating systemic disease are improved by corticosteroids (prednisone 0.7 to 1 mg / kg / day) may be associated with immunosuppression.

* Chest Myositis:

They fall mostly within the epidermal myalgia Bornholm, due to the coxsackie virus group. Pain, sudden onset, are moving from one examination to another, and there may be free interval between two painful episodes.

The dosage of CPK allows for the diagnosis.

* Phlebitis Mondor:

It carries an inflammatory cord browsing a part of the thorax, which may extend into the abdomen. This superficial phlebitis is often isolated and benign.

Treatment may include colchicine and low-dose aspirin (75 or Kardégic® Aspégic® 100)


It is essentially spinal pain (see Spine).

When they occur abruptly and with fever, they must first be investigated spondylitis or discitis.

This is the MRI says that diagnosis.

If the sedimentation rate is high while the inflammatory proteins (CRP, fibrin) are normal, think and ask myeloma electrophoresis and a protein immunofixation. Once again, the spine MRI confirms the diagnosis.

In doubtful cases the spinal biopsy provides certainty.

When back pain have an inflammatory time, and when we eliminated the two raised pathologies, it evokes a ankylosing spondylitis. The search for HLA B27, scan of the spine and sacroiliac joints can be useful for diagnosis.

More mundane pathologies may be responsible for back pain back: chondrocalcinose, rheumatism Forestier, osteoarthritis crisis.

Treatment depends on the cause (infectious, inflammatory or neoplastic).


Metameric pain with nocturnal recrudescence:

A metameric pain with typical nocturnal recrudescence of radicular origin must seek spondylitis if the patient is feverish, or a herniated disc. In the absence of spinal pain, we must think of a spinal tumor (usually benign neuroma or meningioma).

MRI is the modality of choice. It explores the spine going up several floors above the painful métamère because the seat of the pain can be misleading.

The treatment of benign spinal tumors (neuroma, meningioma) is exclusively surgical.

Metameric pain of insidious onset:

A metameric pain of insidious onset, with no specific schedule, such paresthesia, shingles should suggest to the pre-eruption phase (the rash may be off by several days).

We must begin treatment with valaciclovir (Zelitrex®) as soon as possible to prevent postherpetic pain at a dose of 2 tablets of 500 mg / 3x / day for one week. It is good practice to spine radiographs to verify that the level of the rash does not correspond to an underlying spinal injury.

Original pains neuropsychiatric:

Exceptionally generalized epilepsy can begin with chest pain will have.


Fibromyalgia can be proved by the predominant chest pain. The diagnosis can not be accepted if the review finds trigger areas in at least three painful sites (see Chapter chronic widespread pain).

Panic Attack:


The panic attack can start with chest pain crisis very distressing, causing a feeling of imminent death. The pain is usually accompanied by palpitations and tachycardia, tremors or thrills (without fever), dyspnea, paresthesia, nausea.

Several clinical arguments used to suggest the diagnosis:

– The crisis often occurs in specific circumstances (single patient home, or driving, etc.);

– There is no known CAD and no vascular risk factor;

– Pain is very atypical in its location and irradiation;

– There is a discrepancy between the high anxiety of the patient and the normality of the clinical examination and biology when seen by their physician or an emergency service.


The treatment of the crisis based on anxiolytics (bromazepam, lorazepam), but a basic treatment is essential. usually used inhibitors of serotonin reuptake (e.g., citalopram) for several weeks or months.