Chest Pain

Chest Pain Overview

 

If you are having severe pain, crushing, squeezing, or pressure in your chest that lasts more than a few minutes, or if the pain moves into your neck, left shoulder, arm, or jaw, go immediately to a hospital emergency department. Do not drive yourself. Call 911 for emergency transport.Chest pain is one of the most frightening symptoms a person can have. It is sometimes difficult even for a doctor or other medical professional to tell what is causing chest pain and whether it is life-threatening.

  • Any part of the chest can be the cause of the pain including the heart, lungs, esophagus, muscle, bone, and skin.
  • Because of the complex nerve distribution in the body, chest pain may actually originate from another part of the body.
  • The stomach or other organs in the belly (abdomen), for example, can cause chest pain.

Potentially life-threatening causes of chest pain are as follows:

  • Heart attack (acute myocardial infarction): A heart attack occurs when blood flow to the arteries that supply the heart (coronary arteries) becomes blocked. With decreased blood flow, the muscle of the heart does not receive enough oxygen. This can cause damage, deterioration, and death of the heart muscle.
  • Angina: Angina is chest pain related to an imbalance between the oxygen demand of the heart and the amount of oxygen delivered via the blood. It is caused by blockage or narrowing of the blood vessels that supply blood to the heart. Angina is different from a heart attack in that the arteries are not completely blocked, and it causes little or no permanent damage to the heart. “Stable” angina occurs repetitively and predictably while exercising and goes away with rest. “Unstable” angina results in unusual and unpredictable pain not relieved totally by rest, or pain that actually occurs at rest.
  • Aortic dissection: The aorta is the main artery that supplies blood to the vital organs of the body, such as the brain, heart, kidneys, lungs, and intestines. Dissection means a tear in the inner lining of the aorta. This can cause massive internal bleeding and interrupt blood flow to the vital organs.
  • Pulmonary embolism: A pulmonary embolus is a blood clot in one of the major blood vessels that supplies the lungs. It is a potentially life-threatening cause of chest pain but is not associated with the heart.
  • Spontaneous pneumothorax: Often called a collapsed lung, this condition occurs when air enters the saclike space between the chest wall and the lung tissue. Normally, negative pressure in the chest cavity allows the lungs to expand. When a spontaneous pneumothorax occurs, air enters the chest cavity. When the pressure balance is lost, the lung is unable to re-expand. This cuts off the normal oxygen supply in the body.
  • Perforated viscus: A perforated viscus is a hole or tear in the wall of any area of the gastrointestinal tract. This allows air to enter the abdominal cavity, which irritates the diaphragm, and can cause chest pain.
  • Cocaine-induced chest pain: Cocaine causes the blood vessels in the body to constrict. This can decrease blood flow to the heart, causing chest pain. Cocaine also accelerates the progression of atherosclerosis, a risk factor for a heart attack.

Causes of chest pain that are not immediately life-threatening include the following:

  • Acute pericarditis: This is an inflammation of the pericardium, which is the sac that covers the heart.
  • Mitral valve prolapse: Mitral valve prolapse is an abnormality of one of the heart valves in which the “leaves” of the valve bulge into the upper heart chamber during contraction. When this occurs, a small amount of blood flows backward in the heart. This is believed by some to be a cause of chest pain in certain people, although this has not been proven with certainty.
  • Pneumonia: Pneumonia is an infection of the lung tissue. Chest pain occurs because of inflammation to the lining of the lungs.
  • Disorders of the esophagus: Chest pain from esophageal disorders can be an alarming symptom because it often mimics chest pain from a heart attack.
    • Acid reflux disease (gastroesophageal reflux disease, GERD, heartburn) occurs when acidic digestive juices flow backward from the stomach into the esophagus. The resulting heartburn is sometimes experienced as chest pain.
    • Esophagitis is an inflammation of the esophagus.
    • Esophageal spasm is defined as excessive, intensified, or uncoordinated contractions of the smooth muscle of the esophagus.
  • Costochondritis: This is an inflammation of the cartilage between the ribs. Pain is typically located in the mid-chest, with intermittently dull and sharp pain that may be increased with deep breaths, movement, and deep touch.
  • Herpes zoster: Also known as shingles, this is a reactivation of the viral infection that causes chickenpox. With shingles, a rash occurs, usually only on one small part of the body. The pain, often very severe, is usually confined to the area of the rash. The pain may precede the rash by 4-7 days. Risk factors include any condition in which the immune system is compromised, such as advanced age, HIV, or cancer. Herpes zoster is highly contagious to people who have not had chickenpox or have not been vaccinated against chickenpox for the five days before and the five days after the appearance of the rash

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 at menopause. 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 crack cocaine 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:

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:
  • 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

Chest Pain 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.

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 experience palpitations (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:
    • 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

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 enzymes produced 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.

Self-Care at Home

 

Heart Attack

If you suspect that you or someone you are with may be having a heart attack, call 911 for emergency services or go to the nearest hospital emergency department.

  • While waiting for the ambulance, have the patient chew two baby aspirin or at least half of a regular aspirin – at least 160 mg. There is no evidence that taking more than this helps more, and the patient could have unwanted side effects if they take too much.
  • It is important to chew the aspirin before swallowing it because chewing decreases the time the medicine takes to have an effect.
  • Chewing an aspirin in the early stages of a heart attack may reduce the risk of death and it may also reduce the severity of the attack.

Angina

If the patient has had angina and has nitroglycerin tablets available, have the patient place one under the tongue. This may aid in increasing blood flow to blocked or narrowed arteries.

  • If the chest pain continues in the next five minutes, take another tablet under the tongue.
  • If, after three nitroglycerin tablets, the patient does not have relief of the chest pain, immediately call 911 or go to the nearest emergency department.

Esophagus

If the pain is from acid reflux (GERD), it may be relieved with antacids. Even if the patient’s pain goes away after taking an antacid, do not assume they are not having a heart attack. The patient should still be evaluated in a hospital emergency department.

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.

Follow-up

 

No matter what the cause of chest pain, regular follow-up visits with your healthcare provider are important. This will help you remain as healthy as possible and prevent worsening of your condition.

Prevention

 

Heart Attack Prevention

Prevention of heart attack and angina involves living what the American Heart Association calls a “heart healthy” lifestyle. Reducing your risk factors has a significant effect on reducing your risk.

  • Don’t smoke.
  • Maintain a healthy weight.
  • Eat nutritious, low-fat foods in moderate quantities.
  • If you drink alcohol, use alcohol moderately.
  • Engage in physical activity or exercise for at least 30 minutes every day.
  • Control high blood pressure and high cholesterol.
  • If you have diabetes, control your blood sugar every day.

Aortic Dissection Prevention

Aortic dissection may be prevented by controlling high blood pressure and getting proper screening if the patient has a familial disposition to this disorder.

Pulmonary Embolism Prevention

Prevention of pulmonary embolism includes living a heart healthy lifestyle.

  • No one should smoke, but women older than 35 years who use birth control pills are at especially high risk from smoking.
  • When traveling on extended trips that require sitting for long periods of time (plane, car, train, etc.) or other times of leg immobilization, get up and allow time for stretching and movement of the legs. Isometric contractions of the calves are helpful if getting out of the seat is not possible.
  • If the patient has leg swelling, particularly if one is disproportionate to the other, see the doctor or healthcare provider.
  • You should always receive preventive anticoagulant medication after surgery, especially after orthopedic surgery.

Spontaneous Pneumothorax Prevention

Smoking cessation decreases the risk of spontaneous pneumothorax.

Perforated Viscus Prevention

Treating peptic ulcers appropriately and avoiding swallowing foreign bodies reduces the risk of perforated viscus.

Pericarditis Prevention

Because many cases of acute pericarditis are caused by viruses, effective handwashing may reduce transmission of infectious viral agents.

Pneumonia Prevention

Effective handwashing and good hygiene will help reduce the transmission of infectious viruses and bacteria that can cause pneumonia.

Mitral Valve Prolapse Prevention

There is no prevention for mitral valve prolapse.

Esophagus Disease Prevention

Acid reflux (GERD) can be prevented to a certain extent in most people.

  • Avoid foods and other substances that bring on or worsen symptoms, especially fatty foods
  • Stop smoking
  • Use alcohol in moderation, if at all
  • Avoid eating large meals
  • Avoid eating for three hours before bedtime
  • Avoid lying down right after eating
  • Elevate the head of your bed

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