Chest Pain & It’s Causes

When we hear the word emergency, one of the most striking associations we tend to make is with chest pain and heart attacks. However all chest pain is not due to heart attacks and one needs to be aware of what the different kinds of chest pain are – as well as what the possible consequences are.

Though chest pain is one of the cardinal manifestations of cardiac disease, it is important to recognize that it may originate not only from the heart but also from other structures within the thorax (chest cavity) such as the aorta and pulmonary artery, lungs, pleura, mediastinum, esophagus, diaphragm, skin, muscles, cervicodorsal spine, costochondral junction, breasts, sensory nerves, spinal cord, stomach, duodenum, pancreas and gall bladder.

When evaluating chest pain, it is most important to obtain a proper history, delving into details of its location, spread (radiation), character, aggravating and relieving factors, time, duration & frequency, recurrence pattern, setting and associated symptoms.

It is also important to observe the patient’s gestures. Clenching the fist in front of the chest when describing the pain is a strong indication of cardiac origin of pain.

Typical Cardiac Pain

The chest pain of cardiac ischemia and an impending heart attack is described variously as pressing, squeezing, strangling, constrictive, bursting, or burning. “Band across chest”, “Weight in center of chest” is another description.

The pain normally spreads from the center of the chest to the shoulders, the arms (especially the inner aspect of the left arm) neck, jaws and teeth. Emotions / effort / heavy meals / stress may precipitate it. The pain is normally relieved by rest. Such pain lasting for longer than 20 minutes may imply significant ischemia leading to a heart attack. A Nitroglycerine tablet kept under the tongue relieves the pain.

Not all cardiac pains have descriptions as above. There are some symptoms called ‘Anginal equivalents’ such as shortness of breath, discomfort localized to left arm, lower jaw, teeth (with people seeking a Dental opinion!) neck belching, indigestion, sweating or dizziness.

Other causes of chest pain

• Pulmonary Hypertension (PAH)
  High pressure in the pulmonary arteries reaching the lungs: The pain may be similar in quality to that of angina in character but it is more widespread in the chest and has no precipitating factors. Rest or Nitroglycerine does not relieve it.
• Pericarditis
  Inflammation of the tissue covering the heart is usually precipitated by a viral respiratory infection. Pain is sharper; more left sided and may be referred to the neck. It lasts for hours and is aggravated by breathing, twisting of the body and swallowing.
• Aortic Dissection
  Splitting of the wall of the major blood vessel arising from left ventricle usually causes pain radiating to the back and most often there is a history of high blood pressure.
• Aortic Aneurysm
  Dilatation of aorta can cause erosion of the spine and may cause localized boring pain, which may be worse at night.
• Esophageal Pain
  Pain behind the chest bone and upper abdominal (epigastric) discomfort during swallowing may be due to spasm of the esophagus (food pipe) or inflammation of the esophagus. Usually the patient has acid reflux with Hiatus hernia (Herniation of stomach into the chest). Pain may be relieved with antacids. Difficulty in swallowing or acid brash (acid reflux in mouth) point to esophageal disease. It is most commonly present after meals and in supine position or bending. The pain may radiate to the back. Angina and esophageal disease may coexist and pose problems in differentiating the two from each other.
• Peptic Ulcer Disease
  Pain may resemble cardiac pain but is often associated with food ingestion and is relieved by antacids.
• Acute Pancreatitis
  The pain may resemble cardiac pain but it is usually precipitated by alcohol use (or) biliary tract disease. The location is normally in the upper abdomen and radiates to the back and may be relieved by leaning forward.
• Cervical Disc Disease
  Superficial, dull, aching pain that lasts for variable duration and is provoked by movement of head and neck, relieved by analgesics and relieved by rest.
• Chest Wall Pain
  Costochondritis or myositis is common in patients with fear of heart disease. There is always local muscle or costochondral tenderness, which is aggravated by moving or coughing. It may be due to Herpez zoster / chest wall injury or inflammation of costochondral joints.
• Chest Pain accompanied by Coughing of Blood (Hemoptysis)
  This suggests lung tumor or pulmonary embolism.
• Chest Pain by Fever
  This suggests pleurisy, pneumonia or pericarditis.
• Psychogenic Chest Pain
  This pain may be caused due to anxiety. Localized, dull, persistent ache is associated with emotional strain and is accompanied by palpitation, hyperventilation, numbness and tingling of extremities, sighing, weakness, panic attack. Pain may not be relieved by any medication. It is attenuated by rest, tranquilizers and Placebos.

Tumulty has aptly likened obtaining a meaningful clinical history to playing a game of Chess: “The patient makes a statement and based upon its content, and mode of expression, the Physician asks a counter question. One answer stimulates yet another question until the clinician is convinced that he understands precisely all of the circumstances of the patient’s illness.”

So when chest pain occurs, the best option is to seek medical help immediately and be cooperative and clear in describing the symptoms to your doctor. Not all chest pain is related to the heart. But remember – never ignore chest pain and always seek medical help. It could save your life.