The patient should be asked about factors that provoke or make the pain worse:
Postprandial chest pain may be due to gastrointestinal or cardiac disease; inthe latter case it can be a marker of severe myocardial ischemia (eg, left main or three-vessel CAD.
Chest discomfort provoked by exertion is a classic symptom of angina,
Other factors that may provoke ischemic pain include cold, emotional stress, meals, or sexual intercourse.
Pain made worse by swallowing is likely of esophageal origin.
Body position or movement, as well as deep breathing, may exacerbate chest pain of musculoskeletal origin.
Truly pleuritic chest pain is worsened by respiration and may be exacerbated when lying down.
Causes of pleuritic chest pain include pulmonary embolism, pneumothorax, viral or idiopathic pleurisy, pneumonia, and a pleuropericarditis
Factors that make the pain better should be established:
Pain that is reliably and repeatedly palliated by antacids or food is likely of gastro-esophageal origin.
Pain that responds to sublingual nitroglycerin may be of either esophageal or cardiac etiology.
Relief of pain following the administration of a "GI cocktail" (eg, viscous lidocaine and antacid) does not reliably distinguish gastrointestinal from ischemic chest pain. On the other hand, pain that abates with cessation of activity strongly suggests an ischemic origin.
The pain of pericarditis typically improves with sitting up and leaning forward.
The severity of pain is not a useful predictor of CAD. As many as one-third of myocardial infarctions may go unnoticed by the patient.
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