Left side chest pain in most cases is considered as heart pain. Heart pain is caused by inadequate blood flow to heart muscles. In reality there are several other diseases that causes chest wall pain on left side. We will discuss differential causes, diagnosis and treatment of left side chest wall pain. The most chest pain is felt under the ribs, unless pain is caused by diseases of skin and subcutaneous tissue.
Which Chest Diseases or Illnesses Causes Pain Under Left Rib Cage ?
Pain Under Left Rib Cage Caused By Diseases Of Rib Cage:
- Fracture Rib
Pain Under Left Rib Cage Caused By Diseases Of Lung:
Pain Under Left Rib Cage Caused By Diseases Of Heart:
- Coronary vascular disease
- Coronary artery embolism
Pain Under Left Rib Cage Caused By Diseases Of Aorta:
Pain Under Left Rib Cage Caused By Irritation Or Pinch Of Intercostal Nerve:
- Post herpetic neuralgia
- Intercostal neuralgia
Pain Under Left Rib Cage Caused By Diseases Of Rib Cage:
- Fracture Rib
Costochondritis As a Cause of Pain Under Left Rib Cage-
The rib cage is formed by bones and cartilages. The cartilages are attached to sternum on one end and rib bone on opposite side. The inflammatory condition of cartilage is known as chondrites. The discomfort or pain in the ribs caused by inflammation of rib cartilage is known as costochondritis. Costochondritis is often caused by automobile accident or sport injury. Rarely costochondritis pain is triggered by infection or fibromyalgia.
Symptoms of Costochondritis-
- Chest Pain– Unilateral left side chest pain caused by costochondritis often mistaken for heart disease or heart attack. Pain increases with deep breath and lying on the side of inflamed rib.
- Cough- Cartilage inflammation in few cases triggers cough and pain. Similarly, chest pain intensity increases following episode of cough.
- Muscle Ache – Costochondritis associated with disease of fibromyalgia causes multiple skeletal muscle pain
- Fatigue – Most individual feel general fatigue and generalized weakness.
- Osteoporosis– Patient suffering with costochondritis may suffer with osteoporosis. History of multiple bone fracture and cartilage inflammation is observed in patient suffering with osteoporosis.
- Rheumatoid Arthritis– Patient may suffer with rheumatoid arthritis. History of autoimmune disease causing disease like rheumatoid arthritis also triggers inflammation of rib cartilage.
- X-Ray– X-Ray image may not show any bony or cartilage abnormalities. But, X-Ray image does show fracture of the rib.
- CT Scan & MRI– Images of CT scan and MRI may show swelling of inflamed cartilage. Images rules out hairline, non-displace and displace fracture. Such fracture causes pain that often misdiagnosed as costochondritis.
- Bone Scan- The bone scan image shows inflamed cartilage.
- Blood Examination- Blood examination results are normal.
Treatment of Pain Under Left Rib Cage Caused Due to Costochondritis:-
- Pain Medication-
- NSAIDS- Motrin, Naproxen or Celebrex
- Opioids- avoided
- Physical Therapy (PT)- PT is advised once the inflammation is healed. PT helps to rebuild intercostal muscles and improve chest wall movement.
Fractured Rib As A Cause of Pain Under Left Rib Cage:
An injury resulting in broken rib on the left side can cause excruciating or sharp pain under the left rib cage and needs immediate medical attention. Hairline and non-displaced rib fracture causes pain when chest wall is touched. Displaced fracture of rib causes severe pain at rest and with breathing.1 The pain caused by displaced fracture may last for 6 months.
History of Injury-
- Work Accident– The left rib cage pain following injury frequently caused by fracture or contusion of rib. Such injury is observed during work accident that results in fall from height on left chest wall or blunt impact caused by moving object.
- Car Accident– Automobile accident causes rib cage injury following impact with another moving car or roll-over accident. The impact causes whiplash movement of upper body. The objects in the car around the chest causes blunt or penetrating sharp injury of single or multiple ribs.
- Domestic Fall- Most domestic falls are caused by slipping over smooth slippery surface or tripping over carpet inside the house. Fall on left side chest wall causes left rib cage pain.
- Sport Injury- Contact sport which involves push and pull as well as bodily impact or a fall on the ground mostly causes rib cage injury.
- Pain- Severe, intermittent or continuous chest wall pain. Intensity of pain increases during cough and deep breathing. Most patient restricts deep breathing.
- Intercostal muscle in often contused when fracture is caused by injury. Most individuals suffer with intercostal muscle pain and muscle spasm.
- X-Ray- X-Ray image shows displaced fracture. X-Ray image may not show hairline and nondisplaced fracture.
- CT Scan & MRI- Images of CT scan and MRI shows hairline, non-displaced and displaced fracture.
- Bone scan- The bone scan image shows displaced fracture rib. But, hairline fracture is difficult to see over the bone scan image.
- Blood Examination- Blood examination results are normal.
Treatment of Pain Under Right Rib Cage Caused Due to Fractured Ribs-
Rest- Patient is advised to take rest until pain is tolerable. Patient is advised to lie on opposite side.
- NSAIDS- Anti-inflammatory medication prescribed are Motrin, Naproxen or Celebrex. Anti-inflammatory medications help to reduce the inflammation of rib that often follows rib injury.
- Tylenol- Tylenol may or may not relieve severe pain. Tylenol helps to control mild to moderate pain.
- Opioids- Severe pain under right rib cage due to fractured ribs is treated with opioid pain medications. The preferred opioid pain medications are hydrocodone and oxycodone. Hydrocodone is short acting pain medication prescribed for 2 to 3 weeks then discontinued. Opioid causes addiction and dependence when prescribed for prolonged period of time in most patients.
- Physical Therapy (PT)- PT is advised once the fracture is healed.
- Left Rib Cage Caused By Diseases Of Lungs-
Left Lung Pneumonia As A Cause of Pain Under Left Rib Cage
Pneumonia causes inflammation of alveoli and lower respiratory bronchi. Pneumonia is caused by viruses, bacteria and fungus. Most bacterial lung infection is caused by streptococcus pneumoniae. Walking pneumonia causes milder symptoms and caused by mycoplasma pneumoniae. The fungal lung infection is mostly observed in individual suffering with weak immune system. Pneumonia of left lung causes pain under left rib cage
Chronic Pain- Left side rib cage pain is felt when individual is suffering with left lung pneumonia. Pain intensity increases with deep breathing and coughing.
Fever- Fever is observed when pneumonia is caused by viral, bacterial and fungal infection. Temperature fluctuate between 98.5 0 F to 1020 F.
Cough with Expectoration- Cough is either dry cough or wet cough. Inflammation of alveoli and respiratory bronchi causes dry cough during initial phase. During later phase coughing causes discharge of mucus secretion known as expectorant. Dry cough is caused by irritation of mucosal membrane and surrounding tissue. Later the alveoli and bronchi start secreting mucus fluid. The mucus secretion is collected in alveoli and respiratory bronchi. The mucus secretion is coughed out as a mucus or serous-mucus sputum. Coughing is known as wet coughing when mucus secretion is discharged out with coughing.
- Sweating and Chills
- Fatigue and Generalize Weakness
- Shortness of breath also known as dyspnea.
Blood Examination- White blood cell count is increased. Erythrocyte sedimentation rate (ESR) is increased.
Bacterial culture and antibiotic sensitivity test- Blood and sputum sample are mixed with cultural media that contains nutrients for bacterial growth. The bacterial colonies is then treated with various antibiotics. The effect of antibiotics against growth of bacterial colony is examined to choose most effective antibiotics. The test is known as antibiotic sensitivity test.
- Sputum Examination- Sputum is treated with various stains to diagnose and differentiate bacterial, fungal and viral growth.
- X-Ray- Radio-opaque shadow is observed on left lung. The shadow is caused by pneumonia of lung.
- CT Scan and MRI- The images of CT scan and MRI shows radio-opaque shadow of pneumonia surrounded by normal lung tissue.
Treatment of Pain Under Right Rib Cage Caused Due to Left Lung Pneumonia-
- Anti-Inflammatory Medications (NSAIDs)- NSAIDs like Motrin, Naproxen and Celebrex helps to treat lung tissue inflammation and mild to moderate pain.
- Tylenol- Tylenol is prescribed for mild to severe pain.
- Cough Medications- Cough medication is available as cough suppressant or cough expectorant. Dry cough is treated with cough syrup that contains dextromethorphan. Wet cough is treated with syrup that contains guaifenesin. Dextromethorphan suppresses dry cough and prescribed for dry cough. Guaifenesin softens thick mucosal secretions that blocks the respiratory bronchi and alveoli. Guaifenesin is prescribed for wet cough. The soft expectorant is then easy to cough out.
- Antibiotics- Infection is treated with antibacterial (antibiotics), antiviral and antifungal medications.
Left Side Pleuritis (pleurisy) As a Cause of Pain Under Left Rib Cage
The pleura is thin mucosal membrane. Pleura is divided in parietal and visceral pleura. Visceral pleura is attached to lung and parietal pleura is attached to inner surface of chest wall. Pleuritis is an inflammation of parietal and visceral pleura. Pleuritis is caused by viral or bacterial infection. The other causes of inflammation of pleura is autoimmune disease, blood clot and lung cancer.
- Pain- The inflammation of left side parietal pleura causes left side rib cage pain.
- Fever- Viral and bacterial infection of parietal pleura causes fever.
- Cough- Character of cough is dry cough. Cough is caused by irritation of parietal pleura.
- Shortness of Breath- Deep breathing causes severe pain, thus most patient prefer to take shallow breath. Shortness of breath is also caused by pleural effusion. Pleural effusion is a collection of purulent secretion within pleural space. Pleural space is a space between lung and parietal pleura.
- Blood Examination- White blood cell count is high. ESR is high.
- X-Ray Chest- It is difficult to see the inflammatory changes of pleura. X-ray chest does show presence of fluid (pleural effusion) between lung and parietal pleura. X-Ray chest also shows radio-opaque shadow caused by cancer of lung.
- Computerized Tomography (CT) scan- Just like X-Ray, CT images show pleural effusion and cancer growth.
- Ultrasound- Ultrasound images show pleural effusion, thick layer of inflamed parietal pleura and lung cancer growth.
Left Pneumothorax As a Cause of Pain Under Left Rib Cage
Lung is formed by microscopic air sac. Air sac is known as alveoli. The air is inhaled into alveoli. Alveolar wall is extremely thin. The oxygen from alveolar air moves into surrounding capillaries and carbon dioxide from capillaries moves into alveoli. The air from alveoli leaks into pleural space when alveoli ruptures or gets injured by penetrating wound. The continuous air leak into pleural space causes large volume of air trapped in the pleural space. Such condition is known as pneumothorax. The trapped air is unable to escape into alveoli during expiration. The volume of air trapped increases with each breath. The diseases that weakens alveolar wall are chronic obstructive pulmonary disease,2 cystic fibrosis and pneumonia. The increased volume of air eventually generates increased pressure over lung and compresses lung. Thus, collapsed lung is frequently observed in patient suffering with pneumothorax.
- Pain- Pain is observed on left side under the rib cage. Intensity of pain increases during inspiration or inhalation. Character of pain is severe and stabbing pain.
- Dyspnea- Individual suffering with pneumothorax feels shortness of breath. The shortness of breath feeling is caused by left collapsed lung and also because of sudden feeling of severe pain with inspiration (inhaling air) .
- Cyanosis- Pneumothorax causes collapse of one lung and less oxygenated blood passes into circulation. The less oxygen supply causes discoloration of mucosa. The lips and skin looks blue because of circulation of deoxygenated blood. The condition is known as cyanosis.
- Palpitation- The heart rate increases since peripheral tissue does not get adequate oxygen.
- Tachypnea- Tachypnea is rapid breathing. Normal breathing rate is 16 to 20 breath per minute. Patient suffering with pneumothorax often breaths for 25 to 40 breath per minute.
- Blood Examination- White blood cell count is increased when cause of pneumothorax is lung infection and COPD. Erythrocyte sedimentation rate (ESR) is increased in patients suffering with COPD.
- X-Ray- X-ray image of chest shows shifting of normal lung on opposite side if pneumothorax is large in size. X-Ray also shows collapsed lung on same side as pneumothorax.
- CT Scan and MRI- The findings of X-Ray are confirmed with CT and MRI images.
- Ultrasound- Ultrasound images shows the same finding as X-Ray image.
Treatment of Pain Under Left Rib Cage Caused Due to Left Pnuemothorax
- Pain Medication- Pain is treated with Tylenol. Opioid is avoided, since opioid decreases rate of breathing.
- Antibiotics- Pneumonia is treated with appropriate antibiotics
- Insertion of Needle In Pleural Space- Total collapse of lung on one side as well as compression of opposite lung causes severe hypoxia and condition is considered emergency. The air pressure in pleural space is reduced by inserting needle through skin into pleural space. The air passes through needle in to atmosphere. In ER larger diameter needle is passed in pleural cavity and through needle a catheter is passed into pleural space. Catheter is left inside and connected to low pressure suction. If suction is not available, then periodic manual suction is performed to remove air. Once the lung is fully expanded the catheter is clamp and removed next day.
- Surgery- Large diameter chest tube is inserted following skin incision under sedation. The tube is connected to lower pressure suction to remove the air and allow lung to expand. Surgery is also performed to close the external wound to prevent air getting into pleural space.
Cancer of Left Lung: Cause of Pain Under Left Rib Cage
Lung cancer is one of the common cancer. The chances of suffering with lung cancer is higher among chronic smoker. Left lung cancer causes pain on left side under the rib. The lung cancer is classified as small cell and non-small cell lung cancer.
- Pain- Pain is felt under left rib cage if cancer growth is in left lung.
- Cough- Patient suffering with cancer of lung also suffer with chronic cough. Cough is often dry cough.
- Hemoptysis- Lung cancer erodes through the surrounding tissue and alveoli. Eroded tissue and cancer mass often bleeds into alveoli. The blood is coughed out when blood is collected in alveoli. The condition resulting in coughing blood is known as hemoptysis.
- Dyspnea or Shortness of Breath- The lung cancer mass closes several functioning alveoli and lobe of lung, depending on the growth of cancer. The wide spread of cancer in lung tissue eliminates several functional alveoli. The oxygen exchange amount is substantially decreased and individual feels like gasping for air. The symptom often causes feeling of short of breath and hypoxia. Such condition is also known as dyspnea.
- Loss of weight
- Bone pain- Most lung cancer causes bone metastasis that results in bone pain.
- Blood Examination- In advanced stages hemoglobin level is low. If cancer is associated with secondary bacterial infection of lung, then white blood cell count is high.
- Radiological Studies- X-ray, CT scan and MRI images of lungs shows the radio-opaque shadow of the cancer mass. The 3 dimensional images of CT scan and MRI shows lot more details of tumor mass than X-Ray. Following radiological studies are performed to diagnose as well as evaluate local spread of cancer.
- Computerized Tomography (CT) Scan and
- Magnetic Resonance Imaging (MRI)
- Ultrasound Studies- Ultrasound images show the pleural effusion and hematoma around the tumor mass.
- Sputum Cytology- Sputum is examined for cancer cells.
- Lung Biopsy- The sample of lung cancer cells are collected while performing bronchoscopy. Thoracotomy is performed to take a small piece of tumor mass. The sample of cells and tissue are stained to look for cancer cells.
Treatment of Pain Under Left Rib Cage Due to Cancer of Left Lung-
- Radiation Therapy
- Excision of Tumor
Cardiac Diseases As a Cause of Pain Under Left Rib Cage
- Coronary Vascular Disease
- Myocardial Infarction
Pain Under Left Rib Cage Caused Due to Coronary Vascular Disease:
Coronary artery supplies oxygenated blood to heart. Heart contracts anywhere from 60 to 80 beats per minute when individual is at rest and over 80 beats per minute up to 120 beats per minute during strenuous activities. Heart needs continuous supply of oxygen to keep working to pump blood to entire body. Narrowing of coronary artery causes decrease blood flow to heart and thus decreased oxygen supply. Individual start feeling pain on left side under the rib, once oxygen supply to heart is compromised.
The chest pain caused by ischemia (less oxygen supply) is known as angina. The narrowing or blockade of heart blood vessels is diagnosed as coronary vascular disease.
- Pain- Pain is felt on left side of chest under the ribs
- Dizziness- Individual feels dizzy because of hypotension (low blood pressure).
- Tachypnea- The condition is known as tachypnea, when breathing rate per minute increases. Patient suffering with left side chest pain because of coronary vascular disease also shows signs of tachypnea. Breathing rate goes up from 18 beats per minute to 30 per minute, the condition is also known as hyperventilation. Hyper ventilation (tachypnea) and low blood pressure causes feeling of shortness of breath.
- Blood Examination- Cardiac enzymes are elevated.
- Electrocardiogram (EKG)- Abnormal heartbeat and abnormal changes in EKG like elevated ST segment is observed.
- Stress Test– Stress test is performed under close supervision by cardiologist. Individual is asked to walk or run on treadmill so as to stress the heart. The exercise or injection of dye increases heart rate and heart contractility. Such condition increases oxygen demand by heart. Inadequate oxygen supply because of narrowed coronary artery causes less oxygen supply to heart. Because of narrowing of coronary blood vessels heart does not get adequate oxygen. Next blood pressure goes down (hypotension) and heart beats become irregular. Such results are considered abnormal and patient is diagnosed as suffering with angina.
- Echocardiogram– Sound waves are transmitted across chest wall to heart and rebound sound waves create the image. The images are studies to evaluate function of heart. Echocardiogram is abnormal in patient suffering with angina.
- Coronary Angiography- Procedure involves placing of tiny catheter in coronary artery and then dye is injected. The spread of dye is observed under live image intensifier X-ray images.
- Cardiac CT Scan- Computerized tomography scan of heart is performed to evaluate the calcium uptake and anatomy of coronary arteries.
Treatment of Pain Under Left Rib Cage Caused Due to Coronary Vascular Disease:
- Blood thinning medicine
- Beta blocker
- Calcium Channel Blocker
- Anti-hypertensive Medications
- Coronary angioplasty
- Coronary stent placement
- Coronary Bypass surgery
Myocardial Infarction As A Cause of Pain Under Left Rib Cage-
Myocardial infarction is the condition caused by complete blockage of branch of coronary artery. Infarction suggest the tissue or part of organ is dead and non-functioning. Infarction is observed when branch of artery is blocked and blood supply is stopped to certain area of heart. Lack of blood supply causes lack of nutrient and oxygen to heart muscles. The heart muscles become non-functional if ischemia lasts for more than 3 to 5 minutes. The heart muscle dies and become atrophied. Such condition is known as myocardial infarction. Myocardial infarction is rare disease. One of the common cause of myocardial infarction is blockade of coronary artery. One of the cause of coronary artery blockage is embolism.3 The emboli is a tiny collection of blood clot that float in blood and gets carried from place of origin to distant organ. The emboli is formed in heart of patient suffering with irregular heartbeats and heart fibrillation.4 The tiny blood clot passes from left ventricle to coronary artery and blocks one or more than one branch of coronary artery. Embolism is life threatening condition if several branches or main artery is blocked by emboli.
- Chest pain- Pain is felt under left rib cage
- Palpitation- Palpitation is feeling of heart beats. Palpitation is caused by atrial fibrillation and irregular heartbeat.
- Shortness of breath
- Cold sweat
Diagnosis depends on history, physical examination and lab studies. Elevated cardiac enzyme itself does not confirmed the diagnosis of myocardial infarction. The diagnosis depends on evaluation and analysis of abnormal finding of electrocardiogram, blood examination, stress test and echocardiogram. Coronary angiogram is performed if patient is stable. Coronary angiogram confirms the diagnosis of myocardial infarction
- Cardiac enzyme test- The enzyme levels are elevated following myocardial infarction. Enzymes checked in blood serum are CK, Isoenzyme CK- MB, SGOT, SGPT, LDH and HBDH
- EKG- abnormal rhythm is observed. Abnormality observed are elevated ST segment and bundle branch block.
- Echocardiogram- Echocardiogram helps to find the abnormal myocardial wall movement because of dead muscles following infarction.5 The test also helps to find the hemodynamic stability of heart.
- Coronary Angiogram6– Procedure involves passing small catheter into coronary artery. The catheter is passed through femoral artery following skin incision over the groin and upper thigh. The dye is injected into coronary artery through the catheter, once the tip of the catheter is in the coronary artery. The spread of dye shows the blocked coronary artery.
Treatment of Pain Under Left Rib Cage Caused Due to Myocardial Infarction –
- Aspirin- Aspirin is given to prevent further clot formation.
- Nitroglycerine- Nitroglycerine pills causes vasodilatation or increases the diameter of coronary artery.
- Clot Dissolving Drugs- These medications should be used within 3 hours of initial symptoms. Streptokinase or urokinase is used as clot dissolving drug to disrupt and dissolve the blood clot in coronary artery.7 Antihypertensive medications- In most cases anxiety, fear and chest pain increases blood pressure. Patient is given anti-hypertensive medication to control blood pressure.
Pain Under Left Rib Cage Caused By Diseases Of Aorta
Pain Under Left Rib Cage Caused Due to Thoracic Aortic Aneurysm:
Left ventricle continues in to aorta. Aorta is a largest blood vessel of diameter 2.5 to 3.5 cm. Several major blood vessels branch out from aorta along its course from heart to lower abdomen and pelvis. Aorta carries the oxygenated blood from left ventricle and distribute oxygenated blood to entire body. The muscles of the aorta continuously propel the blood forward. Cholesterol deposits and weak aortic muscles weakens the wall of aorta. The weak aortic wall expands and become thin. The thin and weak wall forms a bulge known as aneurysm. The thoracic aortic aneurysm of descending aorta causes pain behind left rib cage. If pain is ignored, then aneurysm may rupture and cause life threatening bleed. Ruptured thoracic aorta causes severe pain and dizziness. The condition is emergency and life threatening.
- Pain- Pain is predominantly felt over back of the chest. Occasionally aneurysm of descending aorta causes pain in left side behind the rib cage.
- Cough- The swelling of the aorta caused by aneurysm irritates the lung and causes cough.
- Shortness of Breath- Large aneurysm causes pressure on bronchi and lung, such condition frequently causes feeling of short of breath.
- Hoarseness of Voice- Recurrent laryngeal nerve takes a turn around the aorta. Swelling of aorta causes pinch or stretching of recurrent laryngeal nerve. Such condition results in hoarseness of voice. The swelling of aorta stretches the recurrent laryngeal nerve and that causes malfunction of voice box.
- Investigation- Radiological studies like X-Ray, CT scan and MRI of chest shows the radio-opaque shadow of thoracic aorta. Similarly, ultrasound images show the swelling of aorta suggesting possible aortic aneurysm.
- CT scan and MRI-
Treatment of Pain Under Left Rib Cage Caused Due to Thoracic Aortic Aneurysm
- Antihypertensive Medication- Patient suffering with hypertension and thoracic aortic aneurysm is treated with antihypertensive medications. Blood pressure control is necessary to prevent additional pressure on aorta.
- Surgery- The section of aorta which is swollen and weak is removed and replaced with graft.
- Pain Under Left Rib Cage Caused By Irritation Or Pinch Of Intercostal Nerve.
- Post Herpetic Neuralgia- Chickenpox is an infection caused by virus. The virus stays inactive in spinal cord and lies close to dorsal nerve root. The virus later in life become active when individual is suffering with immunodeficiency diseases, malnourishment or chronic condition that needs several days of bed rest. The virus multiplies and migrates along the nerve. Such migration causes severe pain that is felt along the course of the nerve. Such pain is known as post herpetic neuralgia.
- Traumatic Intercostal Neuralgia- Causes of traumatic intercostal neuralgia is fractured rib and surgical injury. Intercostal nerve gets pinched or irritated when loose end of fractured rib touches or penetrates the nerve. Similarly, intercostal nerve gets accidentally injured or cut during thoracotomy surgery. Rarely nerve gets entrapped in scar tissue after thoracotomy surgery.
- Left Side Chest Pain- Unilateral left side chest pain is felt when lesion is localized over left side.
- Short of breath
- Radiological Studies- Radiological studies such as X-Ray, CT Scan and MRI is performed to rule out fractured rib and other possible causes of chest wall pain.
- Ultrasound studies
- Treatment of Pain Under Left Rib Cage Caused By Irritation Or Pinch Of Intercostal Nerve –
- Pain Medication
- Physical therapy
- Intercostal nerve block
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- Coronary artery embolism and myocardial infarction. Prizel KR, Hutchins GM, Bulkley BH., Ann Intern Med. 1978 Feb;88(2):155-61.
- Acute myocardial infarction due to coronary artery embolism in a patient with atrial fibrillation Camaro1and W.R.M. Aengevaeren2, Neth Heart J. 2009 Aug; 17(7-8): 297–299.
- The Role of Echocardiography in Coronary Artery Disease and Acute Myocardial Infarction Maryam Esmaeilzadeh, MD, FACC, FCAPSC, Mozhgan Parsaee, MD, and Majid Maleki, MD, FACC, FCAPSC*, J Tehran Heart Cent. 2013 Jan; 8(1): 1–13.,
- A decision scheme for coronary angiography after acute myocardial infarction. Ross J Jr1, Gilpin EA, Madsen EB, Henning H, Nicod P, Dittrich H, Engler R, Rittelmeyer J, Smith SC Jr, Viquerat C., Circulation. 1989 Feb;79(2):292-303.
- Myocardial Infarction: Symptoms and Treatments. Lu L1, Liu M1, Sun R1, Zheng Y1, Zhang P2,3,4., Cell Biochem Biophys. 2015 Jul;72(3):865