Chest Pain

What is Chest pain ?

Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.

Differential Diagnosis :

Cardiovascular

• Acute coronary syndrome
• Unstable Angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction
• Myocardial infarction ("heart attack")

[Angina pectoris]

• Aortic dissection
• Pericarditis and cardiac tamponade
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Stable Angina Pectoris - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense

Pulmonary

• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Pleurisy - an inflammation which can cause painful respiration

GI

• Gastroesophageal reflux disease (GERD) and other causes of heartburn
• Hiatus hernia (which may not accompany GERD)
• Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus
• Functional dyspepsia

Chest wall

• Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
• Spinal nerve problem
• Fibromyalgia
• Chest wall problems
• Radiculopathy
• Precordial catch syndrome
• Breast conditions
• Herpes zoster commonly known as shingles

Psychological

• Panic attack
• Anxiety
• Clinical depression
• Somatization disorder
• Hypochondria

Others

• Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
• Da costa's syndrome
• Bornholm disease - a viral disease that can mimic many other conditions
• Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
• Carbon Monoxide Poisoning
• Sarcoidosis
• Lead Poisoning
• High abdominal pain may also mimic chest pain

Causes :

Heart Attack Causes

A heart attack is caused by coronary heart disease, or coronary artery disease. Heart disease may be caused by cholesterol buildup in the coronary arteries (atherosclerosis), blood clots, or spasm of the vessels that supply blood to the heart.

Risk factors for a heart attack are:

• high blood pressure
  
  
• diabetes
  
  
• smoking
  
  
• high cholesterol
  
  
• family history of heart attacks at ages younger than 60 years, one or more previous heart attacks, male gender
  
  
• obesity
  
  
• Postmenopausal women are at higher risk than premenopausal women. This is thought to be due to loss of the protective effects of the hormone estrogen atmenopause. It was previously treated by hormone supplements (hormone replacement therapy, or HRT). However, research findings have changed our thinking on HRT; long-term HRT is no longer recommended for most women.
  
  
• Use of cocaine and similar stimulants.

Angina Causes

• Angina may be caused by spasm, narrowing, or partial blockage of an artery that supplies blood to the heart.
  
  
• The most common cause is coronary heart disease, in which a blood clot or buildup of fatty material inside the blood vessel (atherosclerosis) reduces blood flow but does not completely block the blood vessel.
  
  
• Angina can be triggered by exercise or physical exertion, by emotional stress, or by certain heart rhythm disorders (arrhythmias) that cause the heart to beat very fast.

Aortic Dissection Causes

• Aortic dissection may be caused by conditions that damage the innermost lining of the aorta.
  
  
  • These include uncontrolled high blood pressure, connective-tissue diseases, cocaine use, advanced age, pregnancy, congenital heart disease, and cardiac catheterization (a medical procedure).
    
    
• Men are at higher risk than women.
  
  
• A similar condition is aortic aneurysm. This is an enlargement of the aorta that can rupture, causing pain and bleeding. Aneurysms can occur in the aorta in the chest or the abdomen.

Pulmonary Embolism Causes

Pulmonary embolism risk factors include:

• sedentary lifestyle,
  
  
• obesity,
  
  
• prolonged immobility,
  
  
• fracture of a long bone of the legs,
  
  
• pregnancy,
  
  
• cancer,
  
  
• history or family history of blood clots,
  
  
• irregular heartbeat (arrhythmias),
  
  
• heart attack, or
  
  
• congestive heart failure.

Women who use birth control pills and smoke cigarettes are at higher risk than women who have only one or neither of these risk factors (especially over the age of 35).

Spontaneous Pneumothorax Causes

Spontaneous pneumothorax (collapsed lung) occurs when the pressure balance between the sac that contains the lung and the outside atmosphere is disrupted.

• Injury to the chest that pierces through to the lung sac is the most common cause of this condition.
  
  
• This can be caused by trauma, as in a car wreck, bad fall, gunshot wound or stabbing, or in surgery.
  
  
• Some very thin and tall people may suffer a spontaneous pneumothorax due to stretched lung tissues and abnormal air sacs in the upper portions of their lungs. It is possible for these abnormal air sacs to rupture with even a sneeze or excessive coughing.
  
  
• Other risk factors for pneumothorax include AIDS-related pneumonia,emphysema, severe asthma, cystic fibrosis, cancer, and marijuana and crackcocaine use
  

Perforated Viscus Causes

Perforated viscus may be caused by direct or indirect injury. Irritation to the diaphragm in this case comes from below the chest. The diaphragm is the muscle that allows us to breathe. It is located up under the ribs and separates the chest and abdominal cavity. Any irritation to the diaphragm, even from below it, can cause pain to be felt in the chest.

Risk factors not related to trauma are:

• untreated ulcers,
  
  
• prolonged or forceful vomiting,
  
  
• swallowing a foreign body,
  
  
• cancer,
  
  
• appendicitis,
  
  
• long-term steroid use,
  
  
• infection of the gallbladder,
  
  
• gallstones, and
  
  
• AIDS.

Pericarditis Causes

Pericarditis can be caused by viral infection, bacterial infection, cancer, connective-tissue diseases, certain medications, radiation treatment, and chronic renal failure.

• One life-threatening complication of pericarditis is cardiac tamponade.
  
  
  • Cardiac tamponade is an accumulation of fluid around the heart. This prevents the heart from effectively pumping blood to the body.
    
    
  • Symptoms of cardiac tamponade include sudden onset of shortness of breath, fainting, and chest pain.

Pneumonia Causes

Pneumonia may be caused by viral, bacterial, or fungal infections of the lungs.

Esophagus Related Causes

Chest pain originating from the esophagus may have several causes.

• Acid reflux (GERD) may be caused by any factors that decrease the pressure on the lower part of the esophagus, decreased movement of the esophagus, or prolonged emptying of the stomach. This condition may be brought on by:
  • consumption of high-fat foods,
    
    
  • nicotine use,
    
    
  • alcohol use,
    
    
  • caffeine, pregnancy,
    
    
  • certain medications (for example, nitrates, calcium channel blockers, anticholinergics, estrogen, progesterone),
    
    
  • diabetes, or
    
    
  • scleroderma.
    
    
• Esophagitis may be caused by yeast, fungi, viruses, bacteria, or irritation from medications.
  
  
• Esophageal spasm is caused by excessive, intensified, or uncoordinated contractions of the smooth muscle of the esophagus. Spasm may be triggered by emotional upset or swallowing very hot or cold liquids.

Symptoms :

Heart Attack Symptoms

Typical heart attack pain occurs in the mid to left side of the chest and may also extend to the left shoulder, the left arm, the jaw, the stomach, or the back.

• Other associated symptoms are shortness of breath, increased sweating, nausea, and vomiting.
  
  
• Symptoms vary considerably from person to person.
  
  
• Women may experience symptoms of heart attack similar to men (chest pain), but they also may be more atypical. Atypical symptoms include:
  
  
• neck,
  
  
• jaw,
  
  
• shoulder,
  
  
• upper back
  
  
• abdominal discomfort,
  
  
• shortness of breath,
  
  
• nausea or vomiting,
  
  
• abdominal pain,
  
  
• heartburn,
  
  
• sweatiness,
  
  
• lightheadedness,
  
  
• dizziness, or
  
  
• unexplained fatigue.

Angina Symptoms

Angina is similar to heart attack pain but occurs with physical exertion or exercise and is relieved by rest or nitroglycerin.

• Angina becomes life threatening when pain occurs at rest, has increased in frequency or intensity, or is not relieved with at least three nitroglycerin tablets taken five minutes apart.
  
  
• This is considered to be unstable angina, which may be a warning sign of an impending heart attack.

Aortic Dissection Symptoms

The chest pain associated with aortic dissection occurs suddenly and is described as "ripping" or "tearing."

• The pain may radiate to the back or between the shoulder blades.
  
  
• Because the aorta supplies blood to the entire body, symptoms may also include:
  
  • angina-type pain,
    
    
  • shortness of breath,
    
    
  • fainting,
    
    
  • abdominal pain, or
    
    
  • symptoms of stroke.

Pulmonary Embolism Symptoms

Symptoms of a pulmonary embolus include:

• the sudden onset of shortness of breath,
  
  
• rapid breathing, and
  
  
• sharp pain in the mid chest, which increases with deep breaths.

Pneumothorax Symptoms

Symptoms of pneumothorax include:

• the sudden onset of shortness of breath,
  
  
• sharp chest pain,
  
  
• rapid heart rate,
  
  
• dizziness,
  
  
• lightheadedness, or
  
  
• faintness.

Perforated Viscus Symptoms

Perforated viscus comes on suddenly with severe abdominal, chest, and/or back pain. Abdominal pain may increase with movement or when breathing in and may be accompanied by a rigid, boardlike abdominal wall.

Pericarditis Symptoms

The pain of pericarditis is typically described as a sharp or stabbing pain in the mid-chest, worsened by deep breaths.

• This pain may mimic the pain of a heart attack, because it may radiate to the left side of the back or shoulder.
  
  
• One distinguishing factor is that the pain is worsened by lying flat and improved by leaning forward. When lying flat, the inflamed pericardium is in direct contact with the heart and causes pain. When leaning forward, there is a space between the pericardium and the heart.
  
  
• Many people report a recent cold, fever, shortness of breath, or pain when swallowing just before developing pericarditis.

Mitral Valve Prolapse Symptoms

Mitral valve prolapse usually has no symptoms, but some people experiencepalpitations (sensation of rapid or strong heartbeat) and chest pain.

• Chest pain associated with mitral valve prolapse differs from that of typical angina in that it is sharp, does not radiate, and is not related to physical exertion.
  
  
• Other symptoms include fatigue, lightheadedness, and shortness of breath.
  
  
• Complications include infection of the heart valves, mitral valve regurgitation(an abnormal blood flow within the chambers of the heart), and abnormal heart rhythms, which rarely cause sudden death.

Pneumonia Symptoms

The chest pain of pneumonia occurs during prolonged or forceful coughing.

• The pain is usually one-sided an is worsened by coughing.
  
  
• Other associated symptoms include fever, coughing up mucus (sputum), and shortness of breath.

Esophagus Related Symptoms

With chest pain originating from the esophagus, symptoms depend on the source.

• Symptoms of gastroesophageal reflux disease (GERD) include:
  
  
  • heartburn,
    
    
  • painful swallowing,
    
    
  • excessive salivation,
    
    
  • dull chest discomfort,
    
    
  • chest pressure, or
    
    
  • severe squeezing pain across the mid chest.
    
    
  • You may feel uncomfortable or may experience:
    
    
    • profuse sweating,
      
      
    • pallor,
      
      
    • nausea, and
      
      
    • vomiting.
      
      
  • Other symptoms include:
    
    
    • sore throat,
      
      
    • sour or bitter taste in the mouth or throat,
      
      
    • hoarseness, and
      
      
    • persistent dry cough.
      
      
  • Pain from GERD is often relieved with antacids.
    
    
• Symptoms of esophagitis include difficulty swallowing, painful swallowing, or symptoms of GERD. The chest pain comes on suddenly and is not relieved by antacids.
  
  
• The pain of esophageal spasm is usually intermittent and dull. It is located in the mid-chest and may radiate to the back, neck, or shoulders.

Diagnosis :

The key to diagnosis remains history. Learning about the nature of the pain will give the healthcare provider direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the care provider assess the probability of what potential diagnoses should be considered and which should be discarded.

Differential diagnosis is a thought process that healthcare providers use to consider and then eliminate potential causes for an illness. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved. As well, the patient's response to therapy can expand or narrow the differential diagnosis list. In patients with chest pain, many potential diagnoses may exist, and the healthcare provider will want to first consider those that are life-threatening. Tests to rule out heart attack, pulmonary embolus, or aortic dissection may not be necessary; when clinical skill and judgment may be all that is needed to consider or discard a diagnosis.

The patient may be asked a variety of questions to help the healthcare provider understand the patient's pain. Patients use different words to describe pain, and it is important that the healthcare provider get an accurate impression of the situation. The questions may also be asked in different ways.

Questions the doctor may ask about chest pain

• When did the pain start?
  
  
• What is the quality of the pain?
  
  
• How long does the pain last?
  
  
• Does the pain come and go?
  
  
• What makes the pain better?
  
  
• What makes the pain worse?
  
  
• Does the pain radiate somewhere (move to another area of the body)?
  
  
• Has there been any preceding illness?
  
  
• Has there been any trauma?
  
  
• Have there been similar episodes of pain in the past?

Questions about the associated symptoms

• Is there shortness of breath?
  
  
• Fever or chills?
  
  
• Cough?
  
  
• Nausea or vomiting?
  
  
• Sweating?

Questions about risk factors for disease

Risk factors for heart disease

• Smoking
  
  
• High blood pressure
  
  
• High cholesterol
  
  
• Diabetes
  
  
• Family history

Risk factors for pulmonary embolus (blood clot to the lung)

• Prolonged inactivity such as bed rest, long car or airplane trips
  
  
• Recent surgery
  
  
• Fractures
  
  
• Birth control pill use (particularly if the patient smokes cigarettes)
  
  
• Cancer

Risk factors for aortic dissection

• High blood pressure
  
  
• Marfan syndrome
  
  
• Ehlers-Danlos syndrome
  
  
• Polycystic kidney disease
  
  
• Cocaine use
  
  
• Pregnancy

Physical examination helps refine the differential diagnosis. While chest pain may be the initial complaint, often the whole body needs to be examined. Example components of the physical exam may include:

Vital signs

• Blood pressure (BP), pulse rate (PR), respiratory rate (RR), temperature, and
  
  
• Oxygen saturation (O2 sat)

Head and neck

• Looking for neck vein distension or bulging
  
  
• Listening over the carotid arteries for bruits (abnormal sounds) or murmurs

Chest wall

• Palpate for rib or muscle tenderness
  
  
• Look for rashes

Lungs

• Listen for abnormal lung sounds or decreased air entry

Heart

• Listen for abnormal heart sounds, murmurs or rubs (a friction sound made by two rough surfaces rubbing against each other, which may be seen with inflammation of the heart lining, called pericarditis)
  
  
• Listen for muffled heart tones

Abdomen

• Palpate for tenderness or masses
  
  
• Listen for bruits over the aorta

Extremities

• Feel for pulses

Exams and Tests :

Heart Attack

In the hospital emergency department, the healthcare providers use three basic procedures to decide if a patient is having a heart attack.

• The first is the symptoms reported by the patient.
  
  
• The second is an electrocardiogram (ECG or EKG), an electrical tracing of the heart's activity. On the ECG, it may be possible to tell which vessels in the heart are blocked or narrowed.
  
  
• The third is measurement of enzymesproduced by the heart muscle cells when they do not receive enough oxygen. These enzymes are detectable with blood tests and are called cardiac enzymes.

Angina

Angina is diagnosed by the same methods doctors use to diagnose heart attacks.

• In angina, the test results reveal no permanent damage to the heart.
  
  
• The diagnosis is made only after the possibility of a heart attack has been ruled out, usually by negative results on three sets of cardiac enzyme tests.
  
  
• Although the ECG may show abnormalities, these changes are often reversible.
  
  
• Another way to diagnose angina is the stress test: these tests monitor your ECG during exercise or other stress to identify blockages in blood vessels to the heart.
  
  
• Cardiac catheterization is used to identify blockages. This is a special type of x-ray (angiography or arteriography) that uses a harmless dye to highlight blockages or other abnormalities in blood vessels.

Aortic Dissection

The diagnosis of aortic

dissection is based on the symptoms the patient describes,chest x-ray, and other special imaging tests.

• On a chest x-ray, the aorta will have an abnormal contour or appear widened.
  
  
• Transesophageal echocardiography is a specialized ultrasound of the heart in which a probe is inserted into the esophagus. The technique is performed under sedation or general anesthesia.
  
  
• The dissection may be identified very accurately by a CT scan of the chest or angiography.

Pulmonary Embolism

The diagnosis of pulmonary embolism is made from a variety of sources.

• Description of the patient's symptoms and results of ECG and chest x-ray all may contribute to the diagnosis, but are not definitive.
  
  
• The patient will be asked if they have had any symptoms of a blood clot in the leg.
  
  
• The healthcare provider may draw blood drawn from the patient's artery to check the levels of oxygen and other gases. Abnormalities in blood gases indicate a problem in the lungs that is preventing the patient from getting enough oxygen.
  
  
• A ventilation-perfusion scan (V/Q scan) compares blood flow to oxygen intake in different segments of the lung. An irregularity in just one segment can indicate an embolism.
  
  
• A CT scan of the lungs is another way to determine if a patient has a pulmonary embolus. It may be done instead of the V/Q scan.

Spontaneous Pneumothorax

Spontaneous pneumothorax is diagnosed by physical exam and chest x-ray. A CT scan may be helpful in locating a small pneumothorax.

Perforated viscus usually can be identified by a chest x-ray with the patient standing upright or an abdominal x-ray lying on the left side.

• X-rays in these positions allow air to rise to the diaphragm, where it can be detected.
  
  
• The symptoms and the results of the physical exam and other lab tests also assist in diagnosis.

Pericarditis

Acute pericarditis is usually diagnosed by the patient's symptoms, serial ECGs, and echocardiography. Certain lab tests may be helpful in determining the cause.

Pneumonia

Pneumonia is diagnosed by the patient's symptoms and medical history, physical examination, and chest x-ray.

Esophagus

Disorders of the esophagus causing chest pain are diagnosed by a process of elimination. The diagnosis is made on the basis of the patient's symptoms and medical history, after ruling out cardiac causes and observing whether the patient experiences pain relief from antacids.

Medical Treatment :

Heart Attack Treatment

Treatment for a heart attack is aimed at increasing blood flow by opening arteries blocked or narrowed by a blood clot.

• Medicines used to achieve this include aspirin, heparin, and clot-busting (thrombolytic) drugs.
  
  
• Other medications can be used to slow the heart rate, which decreases the workload of the heart and reduces pain.
  
  
• Angioplasty is a way of unblocking an artery. Angiography is done first to locate narrowing or blockages. A very thin plastic tube called a catheter is inserted into the artery. A tiny balloon on the end of the catheter is inflated. This expands the artery, providing a wider passage for blood. The balloon is then deflated and removed. Sometimes a small metal scaffold called a stent is placed in the artery to keep it expanded.
  
  
• Surgery may be required if medical treatment is unsuccessful. This could include angioplasty or cardiac bypass.

Angina Treatment

Treatment of angina is directed at relieving chest pain that occurs as the result of reduced blood flow to the heart.

• The medication nitroglycerin is the most widely used treatment. Nitroglycerin dilates (widens) the coronary arteries. It is often taken under the tongue (sublingually).
  
  
• People with known angina may be treated with nitroglycerin for three doses, five minutes apart.
  
  
• If the pain remains, nitroglycerin is given by IV, and the patient is admitted to the hospital and monitored to rule out a heart attack.
  
  
• Long-term treatment after the first episode of angina focuses on reducing risk factors for atherosclerosis and heart disease.

Aortic Dissection Treatment

Suspected aortic dissection often is treated with medications that reduce blood pressure.

• Medications that slow the heart rate and dilate the arteries are the most widely used.
  
  
• Close monitoring is required to avoid lowering the blood pressure too much, which can be dangerous.
  
  
• Surgical repair is required for any dissection that involves the ascending (upward) portion of the aorta.

Pulmonary Embolism Treatment

Anyone with a presumed or documented pulmonary embolism requires admission to the hospital.

• Treatment usually includes supplemental oxygen and medication to prevent further clotting of blood, typically heparin.
  
  
• If the embolism is very large, clot-busting medications are given in some situations to dissolve the clot.
  
  
• Some people undergo surgery to place an umbrella-like filter in a blood vessel to prevent blood clots from the lower extremities from moving to the lungs.

Pneumothorax Treatment

A pneumothorax without symptoms involves six hours of hospital observation and repeat chest x-rays.

• If the size of the pneumothorax remains unchanged, the patient is usually discharged with a follow-up appointment in 24 hours.
  
  
• If the patient develop symptoms or the pneumothorax enlarges, they will be admitted to the hospital. The patient will undergo catheter aspiration or have a chest tube inserted to restore negative pressure in the lung sac.

Perforated Viscus Treatment

Any disruption or perforation of the intestinal tract (viscus) is a potentially life-threatening emergency. Immediate surgery may be required.

Pericarditis Treatment

Viral pericarditis usually improves with 7-21 days of therapy with nonsteroidal anti-inflammatory agents such as aspirin and ibuprofen (for example, Motrin).

Pneumonia Treatment

Pneumonia is treated with antibiotics, and pain medication is given for chest wall tenderness.

Costochondritis Treatment

Costochondritis is usually treated with nonsteroidal anti-inflammatory medication such as ibuprofen.

Esophageal Conditions Treatment

The three major esophageal disorders that cause chest pain; 1) acid reflux (GERD), 2) esophagitis, and 3) esophageal spasm, are treated with antacid therapy; antibiotic, antiviral, or antifungal medication; medication to relax the muscles of the esophagus; or some combination of these.

Chest Pain At A Glance :

• There are many causes of chest pain, and while many are not serious, it may be difficult to distinguish between heart attack, pulmonary embolus or aortic dissection, and another diagnosis that is not life-threatening. For that reason, patients are routinely advised to seek medical care for most types of chest pain.
  
  
• While each cause of chest pain has a classic presentation, there are enough variations that it may take specific testing to come to a diagnosis. These tests will depend on the patient's presentation and the healthcare provider's index of suspicion as to what the diagnosis might be.
  
  
• Treatment for chest pain depends upon the cause.
  
  
• It is best to be safe. Always seek medical care for the assessment of chest pain.