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Updated 11 February 2013

Chest pain

Chest pain can be due to a heart attack or angina or could be caused by other factors: Chest pain can be an important warning symptom of a heart attack.

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Contents

  • Summary
  • Description
  • What is it?
  • What causes it? Associated factors:
  • Cardiovascular
  • Chest wall
  • Lung
  • Gastro-intestinal
  • Psychiatric
  • Symptoms and signs
  • Diagnosis
  • Clinical
  • Special investigations
  • How is it treated?
  • What is the outcome?
  • Prevention
  • When to see a doctor.

Summary

Chest Pain is a common symptom, which may be due to many different conditions. Any of the organs in the chest may cause pains which are similar in nature. Without certain tests, therefore, it may be difficult to identify the causing factor. Some may need emergency attention.

Organs outside the chest may also cause pain in the chest.

ALL causes of chest pain must be investigated as some may be life-threatening. Self-diagnosis is thus inappropriate.

Description

What is it?

Chest pain is simply any pain or discomfort felt anywhere in the chest. This includes any pain which may start in the chest and then spreading to other areas such as the neck, jaw, arms. Most people regard a chest pain as one felt in the front of the chest only, and regard pain in the back of the chest as ‘Back Pain’.

The pain may be continuous or intermittent, and of several types: crushing, burning, stabbing, tingling, etc.. The nature of the pain is relevant in making the diagnosis. There may also be other symptoms such as sweating, dizziness, pulse disturbances, nausea etc.

What causes it? Associated factors

As already stated, there are many possible causes of chest pain, related to the different organs contained within the chest.

Cardiovascular problems
  • Ischaemic Heart Disease (IHD) is the commonest cause, and requires emergency attention. IHD is due to narrowing or obstruction of the coronary arteries, which deprives the heart muscle of adequate oxygen. The pain associated with this is called Angina. With a few exceptions, angina is a typical recognizable pain.
  • Aortic dissection can be life-threatening. Here a split occurs between the layers of the Aorta, usually due to uncontrolled high blood pressure. Separation of the layers causes intense pain, often coming on quite suddenly. Trauma, such as due to a car accident, may also cause damage to the aorta, resulting in a dissection.
  • Myocarditis (inflammation of the heart muscles) and Pericarditis (inflammation of the protective membrane around the heart) can also cause chest pain.
  • Mitral valve prolapse may also cause chest pain.
Chest wall problems Inflammation of joints, fibrous tissues or the rib cartilages, eg costochondritis
  • Herpes zoster (shingles)
  • Rib fractures or other forms of trauma.
  • Disc problems of the spine, even in the neck regions.
  • Nerve problems eg pinched, inflamed or a degenerative nerve in the chest wall/shoulder/neck
  • Diaphragm problems

Lung problems

  • Pulmonary embolism, due to to a large blood clot lodging in the lungs can be life-threatening
  • Tension pneumothorax (an air leak into the chest cavity)
  • Pneumonia or pleurisy

Gastro-intestinal problems

  • Oesophageal –rupture, spasm, inflammation, reflux
  • Gall bladder: gall-stones, colic, inflammation
  • Pancreatitis
  • Peptic ulcer disorders: heartburn/indigestion
Psychiatric disorders
  • Disorders of mood eg depression
  • Anxiety disorders, eg hyperventilation, panic attacks, anxiety
  • Delusional states

Symptoms and signs

Chest pain may be due to many different causes, hence it is very important to have an accurate description of the pain to assist in the diagnosis. As some of the causes are potentially life-threatening, and must always be considered first, a brief list of important questions is given here to help decide upon the possible diagnosis.

Diagnosis

Clinical

The initial diagnosis is always clinical, based on the following questions:

    1. What is the nature of the pain? sharp, stabbing, crushing, dull, an ache, a heaviness, burning?
    Crushing central chest pain may be due to a heart attack. A burning pain at the lower end of the chest may be due to excess acid in the stomach or oesophagus. Sharp one-sided pain may be due to a pneumothorax (air leak).


    2. How long does it last?
    A sharp pain lasting only a few seconds may be due to chest wall muscle problems. Pain which persists for many minutes must always be considered as important.

    3. Does the pain spread to other parts of the body?
    The pain of angina often spreads to the jaw, shoulder or arm. However, pain may start elsewhere, such as in the upper abdomen, and may later be felt in the chest. This may also happen with pancreatic, gall-bladder or stomach problems.

    4. Are there other associated symptoms?
    A combination of chest pain with shortness of breath, dizziness, nausea, changes in blood pressure, change in pulse rate/rhythm, and sweating is highly suggestive of a heart attack or a pulmonary embolus.

    5. Are there any injuries?
    Car accidents may cause injuries to the chest wall, and even cause a dissection or rupture of the oesophagus or aorta. This will need emergency attention.

    6. What makes the pain better or worse?
    Eating can worsen the pain caused by ulcers or gall-bladder problems. Deep breathing, coughing or sneezing will worsen the pain of lung-related problems such as pleurisy or pneumothorax. If direct pressure on an area of the chest wall elicits pain, it is probably due to muscle or rib problems.

Special investigations

These are very important, due to the overlap of symptoms caused by different conditions. Once the clinical diagnosis indicates which organ is likely to be the cause, the appropriate investigations are done.

The most important investigations done initially are an ECG and a chest X-ray : these will indicate whether there is a

  • Heart condition, such as heart attack, coronary artery disease, pericarditis
  • Lung condition such as pneumothorax
  • Aortic dissection
  • Rib fractures

If these first investigations rule out the important conditions needing emergency attention, then other tests are done, such as blood tests, gastroscopy, abdominal ultrasound. These tests may detect problems related to peptic ulcer disease, the gall-bladder or oesophagus.

Other special investigations may include computerised scans, or even surgery to obtain tissue samples for examination.

How is it treated?

Chest pain which is mild, localised, short-lived or associated with a minor injury may be treated with pain-killers or anti-inflammatories (e.g. Panado, Brufen) provided there are no contra-indications, such as the patient’s allergy to these drugs. The pain of muscle injuries may be alleviated with ice-pack applications. If these home remedies do not relieve the pain, then a doctor should be consulted.

All serious chest pain will be treated according to the diagnosis eg:

  • heart attack will require admission to a coronary care unit
  • A pneumothorax will require the insertion of a special chest tube
  • Peptic ulcer disease will need drugs to reduce the amount of stomach acid produced, and possibly a special antibiotic in addition
  • Gall-bladder problems are managed by surgeons, though not all will require immediate surgery
  • Disc and nerve compression problems are managed by neurosurgeons
  • Psychiatric disorders are treated by psychiatrists, but acute anxiety states with hyperventilation can be relieved immediately by breathing into and out of a paper bag for a few minutes at a time. This technique helps to restore the normal blood levels of carbon dioxide, which drop rapidly during hyperventilation.

What is the outcome?

The outcome will depend largely on how soon after the onset of serious pain the patient receives correct medical attention, and how quickly an accurate diagnosis is made. Even in cases of heart attack, the outcome can be favourable if the correct treatment is given quickly, and the patient handed to a specialist cardiologist for further care. This further care may involve conservative treatment only, or may include an angiogram with stenting, or even coronary artery bypass graft surgery.

For patients with aortic dissection/rupture, the outcome is not always good. Of those patients with aortic dissection, only about 50% will survive long enough to reach the operating theatre, and of these, only a further 50% will survive the surgery.

Immediate drainage of a pneumothorax is almost 100% successful, although many symptoms recur if the underlying cause is not treated. Smoking with underlying lung damage is the commonest cause. This can cause bullae (weak areas with ‘blowouts’ in the lung). If these bullae are not found and closed,(this requires surgery), the pneumothorax may recur.

Treatment of gastro-intestinal disorders is highly successful, often using medication only. If surgery is needed, many surgeons use endoscopic techniques to avoid major surgery. Here, the patient is not cut open. Instead, the surgeon uses special instruments to look inside the abdomen, and is able to perform many types of operations through these instruments.

Prevention

As there are so many possible causes of chest pain, it will be impossible to prevent it happening all together. Many of the causes, e.g. trauma, are beyond the individual’s control. However, bearing in mind the known important causes, it would be prudent to adopt a healthy lifestyle, paying attention to

  • Diet
  • Not smoking
  • keeping blood pressure and cholesterol under control.

When to see a doctor

If there is a known heart or lung condition, and a pain is experienced which is worse than usual, which does not respond to usual treatment or new associated symptoms develop, then medical help should be sought immediately.

For patients with a first episode of chest pain which is persistent and spreading to other parts of the body or associated with symptoms such as sweating, nausea, dizziness and palpitations, urgent medical attention will be needed.

Mild chest pain may be relieved by home remedies. If not, and especially if the pain persists for several days or worsens, then a doctor should be consulted.

(Reviewed by Dr. AG Hall)

 
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