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Print | Close Window Note: Large images and tables on this page may necessitate printing in landscape mode. | Tintinallis Emergency Medicine Section 7: Cardiovascular Disease Chapter 49. Approach to Chest Pain Overview Approximately 5 percent of all U.S. ED visits, or about 5 million visits a year, are for chest pain, but accurate diagnosis remains a challenge.1,2 This chapter covers the approach to acute chest pain, with attention to identifying patients with potentially serious disorders. Pathophysiology of Chest Pain Stimulation of visceral or somatic afferent pain fibers results in two distinct pain syndromes. The dermis and parietal pleura are innervated by somatic pain fibers, which enter the spinal cord at specific levels and are arranged in dermatomal patterns. Visceral pain fibers are found in internal organs, such as the heart and blood vessels, the esophagus, and the visceral pleura. These visceral pain fibers enter the spinal cord at multiple levels and map to areas on the parietal cortex corresponding to the cord levels shared with the somatic fibers. Pain from somatic fibers is usually easily described, precisely located, and experienced as a sharp sensation, whereas pain from visceral fibers is more difficult to describe and is imprecisely localized. Accordingly, those experiencing visceral pain are more likely to use terms such as discomfort, heaviness, or aching. Patients frequently misinterpret the origin of visceral pain, because it is often referred to a different area of the body corresponding to an adjacent somatic nerve. For example, diaphragmatic irritation can present as shoulder pain, and arm pain may actually represent myocardial ischemia. Gender, age, comorbidities, medications, drugs, and alcohol may interact with psychological and cultural influences to affect the patients perception and communication of pain. Definitions The phrase acute chest pain, commonly used in emergency medicine, des