Other precipitating factors include emotional tension, cold weather, and a large meal. Many patients manifest atypical chest pain, which complicates the differential diagnosis. Pain that originates in the chest wall is classically fleeting, exacerbated by chest wall movement, and associated with tenderness over the involved area, which is frequently a costochondral joint. Exertion that increases chest wall movement can bring on such pain, which may radiate to the left arm. Unfortunately, chest wall pain is often incorrectly interpreted as angina because of a failure to examine each costochondral junction for tenderness in an effort to reproduce the patient's complaints.
Esophageal spasm can produce a severe substernal pressure that often radiates to the back.
Radiation to the left arm is unusual. Because the esophagus is a smooth muscle structure, the pain of esophageal spasm, like that of angina pectoris, can be relieved by nitroglycerin or calcium channel blockers. A sharp pain exacerbated by deep breathing and coughing or by variation in position suggests pericarditis or pleurisy, the latter perhaps the result of a pulmonary embolus. A transient S 4 gallop or paradoxical splitting of the second heart sound indicates that left ventricular function is altered during pain, a finding that strongly argues for an ischemic cause. An S 3 gallop or a transient systolic murmur caused by papillary muscle dysfunction is less common.