By Michael Barrie, OSU EM Assistant Professor
As Emergency Physicians we are experts in evaluating acute chest pain. In our sleep we can recite the dangerous causes of chest pain such as acute coronary syndrome, aortic dissection, pulmonary embolism, myocarditis, pneumothorax, etc, etc. In medical school and residency we spent a huge amount of brain power devoted to learning how to diagnose and manage dangerous causes of chest pain. But as a practicing ED doc what I actually see a majority of the time is atypical chest pain.
While we always think “worst first”, it’s worth your time to remember some of the more benign causes, such as reflux, musculoskeletal pain, esophageal spasm so you can give a patient a more specific diagnosis. Let’s take a moment to discuss one of my favorite presentations of atypical chest pain – Precordial Catch Syndrome.
A 24 year old female presents to the emergency department with intense chest pain. She has experienced spells of stabbing chest pain intermittently over the last few months. It is located over the left side of the chest, just inferior and lateral to the breast. The pain is knife-like, with a stabbing feeling between the ribs. Pain is worse on deep inspiration. The intense pain lasts a few moments, and then improves to dull aching pain that gradually resolves over hours. Tonight, she experienced the worst episode yet so she came to the emergency department for evaluation. After her ED wait the pain completely resolves.
She denies any prior medical problems and her only medication is an oral contraceptive. No prior surgical history. She never smoked, denies regular alcohol or recreational drug use.
Here her vital signs are normal with a pulse of 65, blood pressure 102/75, spo2 100% on room air and she is afebrile. On exam she appears somewhat anxious, however in no respiratory distress and without diaphoresis. Cardiac auscultation reveals regular rate without murmurs, breath sounds are clear. She does have mild tenderness to palpation on the chest wall just over the cardiac apex.
What’s your differential diagnosis? Planned workup?
Providers would likely approach this patient differently based on their risk tolerance. As EM trained physicians, its hard to resist a workup in this patient on birth control who is complaining of pleuritic chest pain. However, in a well appearing patient with spells of stabbing chest pain over the cardiac apex that resolves spontaneously, it is reasonable to do very little workup and reassure the patient that this is a benign condition.
Key Components of Precordial Catch Syndrome
- Brief episodes that last seconds to a few minutes
- Sharp quality initially, but can improve to dull aching pain
- Localized with the fingertip to one interspace at the left sternal border or cardiac apex
- The pain has a sudden onset, typically at rest or during mild activity
- Increases with inspiration
Precordial catch syndrome has been well known since at least 1955 when it was described by Dr. Texidor, however it generally receives no more than 1-2 sentences worth of explanation during medical school and is unlikely to show up on any board exam. However, it is very common. My wife has it. When I explained this to my patient, her boyfriend in the room also explained he had it once years ago. When I brought it up to the ED team that night one of the nurse practitioners said that she gets the same symptoms but never knew why. So if it’s this common, why do we not teach it? One problem is we don’t know what causes it. And it’s unlikely that we’ll ever know the etiology because who will fund the research to treat a self-limiting disease?
So, the next time you treat a young person for stabbing chest pain, of course don’t forget to think about the dangerous causes, but also keep Dr. Texidor in the back of your mind to help you actually make the diagnosis.
- Sert A, Aypar E, Odabas D, Gokcen C. Clinical characteristics and causes of chest pain in 380 children referred to a paediatric cardiology unit. Cardiol Young. 2013;23(3):361-7.
- Gumbiner CH. Precordial catch syndrome. South Med J. 2003;96(1):38-41.
- Sparrow MJ, Bird EL. “Precordial catch”: a benign syndrome of chest pain in young persons. N Z Med J. 1978;88(622):325-6.
- Miller AJ, Texidor TA. Precordial catch, a neglected syndrome of precordial pain. J Am Med Assoc. 1955;159(14):1364-5.