Chest pain

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Chest pain

Chest pain is one of the most frightening symptoms you can have. It is also difficult at times to assess the source of chest pain and whether it is life threatening. Each of these parts of the chest can cause chest pain: the heart, the lungs, the esophagus, muscle, bone, and skin. Also, because of the complex nerve distribution in the body, the cause of chest pain may come from sources not located in the chest. The stomach or other organs in the abdomen, for example, can cause chest pain.

Potentially life-threatening causes of chest pain

Heart attack (also known as an acute myocardial infarction): A heart attack occurs when blood flow to the arteries that supply the heart becomes blocked. With decreased blood flow, the muscle of the heart does not receive enough oxygen and begins to deteriorate.

Angina: Angina occurs when there is an imbalance between the oxygen demand of the heart and the amount delivered. Angina is different from a heart attack in that the arteries are not completely blocked. Also, permanent damage has not yet occurred to the heart.

Aortic dissection: The aorta is the main artery that supplies blood to the vital organs of the body (these are the brain, heart, kidneys, lungs, and intestines). An aortic dissection occurs when the inner lining of the aorta tears. Once the aorta is torn, blood flow to the major organs near the tear is disrupted.

Pulmonary embolus: 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: This condition occurs when air enters the 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 and remains collapsed.

Perforated viscus: Perforated viscus occurs when there is a disruption of the wall of any area of the gastrointestinal tract, which allows air to enter the abdominal cavity. Air in the abdominal cavity irritates the diaphragm, which can cause chest pain.

Non–life-threatening causes of chest pain
- Acute pericarditis: This is an inflammation of the pericardium, which is the sac that covers the heart.

Chest pain originating from the esophagus: Esophageal disorders can cause chest pain, which is an alarming symptom because it often mimics chest pain from a heart attack.
- Gastroesophageal reflux disease (GERD) occurs when acidic digestive juices backflow from the stomach into the esophagus.

Causes

A heart attack may be caused by cholesterol build-up in the coronary arteries, 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 young ages (younger than 60 years), previous heart attacks, male gender, postmenopausal women who are not taking hormone replacement therapy (estrogen), cocaine use, and obesity.

Angina may be caused by spasm of the arteries that supply the heart or by cholesterol build-up that affects blood flow but does not completely block the blood vessel.

Aortic dissection may be caused by conditions that damage the innermost lining of the aorta, such as uncontrolled high blood pressure, connective tissue diseases, cocaine use, advanced age, pregnancy, congenital heart disease, cardiac catheterization (a medical procedure), and the male gender.

A pulmonary embolus can be caused by use of birth control pills in conjunction with cigarette smoking, sedentary lifestyle, prolonged immobility, fracture of long bones of the legs, obesity, pregnancy, cancer, history or family history of blood clots, irregular heartbeat, heart attack, and congestive heart failure.

A spontaneous pneumothorax occurs when there is a disruption of the pressure balance across the chest wall. Risk factors are trauma to the chest, AIDS-related pneumonia, emphysema, severe asthma, cystic fibrosis, cancer, and marijuana and crack cocaine use.

A perforated viscus may be caused by trauma or indirect injury. 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 can be caused by a viral infection, a 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.

Mitral valve prolapse or MVP is thought to be an inherited birth disorder and affects up to 10% of the population, mostly women. People with connective tissue diseases and skeletal abnormalities (such as severe curvature or straightening of the spine or a concave chest) are at increased risk for this disorder.

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

Chest pain originating from the esophagus may have several causes.
- GERD may be caused by any factors that decrease the pressure on the lower part of the esophagus, decrease movement of the esophagus, or prolong 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 examples, nitrates, calcium channel blockers, anticholinergics, estrogen, progesterone), diabetes, or scleroderma.

S&S

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.

Angina is classified as chest pain that is similar to that of a heart attack but occurs with increased exercise and is relieved by nitroglycerin taken under the tongue. Angina becomes life-threatening when pain occurs at rest, has increased in frequency or intensity, or is not relieved with at least 3 nitroglycerin tablets each given 5 minutes apart. This is considered to be unstable angina, which may be a warning sign of an impending heart attack.

The chest pain associated with aortic dissection occurs suddenly and is described as "ripping." The pain may radiate to the back or between the shoulder blades. Because the aorta supplies blood to the entire body, people may experience symptoms such as chest pain, shortness of breath, fainting, abdominal pain, or symptoms of stroke.

Symptoms of a pulmonary embolus are sudden onset of shortness of breath, rapid breathing, and sharp mid-chest pain, which increases with deep breaths.

Signs and symptoms of pneumothorax are sudden onset of shortness of breath, sharp chest pain, rapid heart rate, and low blood pressure.

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

The pain of pericarditis is typically described as a sharp or stabbing pain in the mid-chest area, 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. However, when leaning forward, there is a space between the pericardium and the heart. Prior to the onset of the chest pain, people may note having a recent cold, fever, shortness of breath, or pain when swallowing.

Although mitral valve prolapse is not usually associated with symptoms, people may experience palpitations (feeling the heart beat) and chest pain. Chest pain associated with MVP differs from that of typical angina in that it is sharp, does not radiate, and is not related to physical exertion. Other associated symptoms include fatigue, lightheadedness, and shortness of breath. Anxiety also seems to be more common in people with MVP than in the general population. Complications of MVP include infection of the heart valves, migraine headaches, stroke or mini-stroke, and abnormal heart rhythms, which rarely cause sudden death.

Pneumonia may cause chest pain from the strain of the chest wall muscles during prolonged or forceful coughing.

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. People may appear comfortable or may experience profuse sweating, pallor, nausea, and vomiting. Pain from GERD is often relieved with antacids.
- Symptoms of esophagitis include difficulty swallowing, painful swallowing, or symptoms of GERD. The associated 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.

If you suspect that you may be having a heart attack, call 911 for emergency services or go to the nearest hospital Emergency Department.

If you think you are having a heart attack, it is advisable to chew at least 2 baby aspirin or 1/2 of a regular aspirin—that's a total of 160 mg. It is important to chew the aspirin as opposed to swallowing it because chewing decreases the time the medicine is delivered to the body. Aspirin chewed in the early stages of a heart attack may reduce the possibility of death by 23%.

If you have nitroglycerin tablets available, place one under your tongue. This may aid in increasing blood flow to blocked or narrowed arteries.
- If you have been previously diagnosed with angina and your doctor has prescribed nitroglycerin (sublingual, which means you place the tablets under your tongue), try placing one tablet under your tongue.
- If your chest pain continues in the next 5 minutes, you should take another tablet under the tongue.
- If after 3 sublingual nitroglycerin tablets, you do not have relief of the chest pain, you should immediately call 911 or go to the nearest Emergency Department.

Pain from GERD is often relieved with antacids. Even if your pain goes away, you may not safely assume you are not having a heart attack. Esophagitis and esophageal spasm are typically not relieved with antacids.

When to ask for help

If you suspect that you may be having a heart attack or any symptom of chest pain, call 911 or go to the nearest hospital's Emergency Department. Do not attempt to drive yourself.

When chest pain may be caused by a heart attack, time is muscle. If you are having a heart attack, the longer you wait to receive evaluation and treatment, the more heart muscle is damaged.

If there is something serious going on that is causing your chest pain, doctors can choose from many effective early interventions to reduce your chances of dying, of becoming severely ill

Diagnosis
- Doctors use 3 basic procedures to decide if you are having a heart attack.
  
  The first is the history of symptoms that you tell the doctor.
  
  The second is an ECG, which is 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 component is the measurement of enzymes given off by the heart when it does not receive enough oxygen. These enzymes are detectable via blood tests.
- Angina is diagnosed by the same methods doctors use to diagnose heart attacks. However, the results do not indicate permanent damage. The diagnosis is made only after the possibility of a heart attack has been ruled out, usually by 3 sets of negative cardiac enzymes. Although the EKG may show abnormalities, these changes are often reversible. Another possible way to diagnose angina is by exercise or radionucleotide stress tests to identify any obstructed blood vessels to the heart.
- The diagnosis of aortic dissection is based on history, 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 more specifically determined by a CT scan of the chest or angiography, which is a test that outlines the aorta and its branching vessels.
- The diagnosis of pulmonary embolism is made from a variety of indirect sources. History, an arterial blood gas, EKG, chest x-ray, evidence of a clot in the leg, and ventilation-perfusion scans all contribute to the diagnosis of pulmonary embolism. An angiogram offers definitive diagnosis.
- Spontaneous pneumothorax is diagnosed by physical examination and chest x-ray. A CT scan may be helpful in locating a small pneumothorax.
- A chest x-ray with the person upright or an abdominal x-ray while lying on the left side are ways to detect perforated viscus. X-rays in these positions allow air to rise to the diaphragm, where it can be detected. The person’s history, physical exam, and other lab tests also assist in diagnosis. The diagnosis of acute pericarditis is usually made by history, serial EKGs, and echocardiography. Certain lab tests may be helpful in diagnosing the cause.
- Diagnosis of mitral valve prolapse is made by physical exam and an echocardiogram, which is a ultrasound of the heart. Anyone with this condition may also have a variety of abnormal findings on EKG.
- Pneumonia is diagnosed by history, physical examination, and chest x-ray.
- Chest pain originating from the esophagus is a diagnosis of exclusion. Diagnosis is made based on prior history, after ruling out heart causes and observing whether you get pain relief from antacids.
Treatment
Treatment of angina is directed at relieving chest pain that occurs as the result of reduced blood flow to the heart. This is primarily accomplished by the use of nitroglycerin, which dilates the coronary arteries. People with a known history of angina may be treated with nitroglycerin tablets or spray for 3 doses, each 5 minutes apart. If the pain remains, a continuous infusion of nitroglycerin by IV is used, and the person is admitted to the hospital and monitored to rule out a concurrent heart attack.

People with suspected aortic dissection will often require medications that reduce blood pressure. This is accomplished by using medications that slow the heart rate and dilate the arteries. Close monitoring is required to avoid medication-induced hypotension (low blood pressure). Surgical repair is required for any dissection that involves the ascending portion of the aorta.

Anyone with the presumed or documented diagnosis of pulmonary embolism (PE) requires admission to the hospital, supplemental oxygen, and medication to prevent the clotting of blood (heparin is often used for this purpose). If the PE is massive, destruction of the clot is achieved with clot-busting medications. For some people, surgery may be done to place an umbrella-like filter in a blood vessel to prevent blood clots from the lower extremities from moving to the lungs.

Treatment of spontaneous pneumothorax without associated symptoms of shortness of breath, rapid breathing, low oxygenation, or chest pain involves 6 hours of hospital observation and repeat chest x-rays. If the size of the pneumothorax remains unchanged, and the person has no symptoms, a follow-up in 24 hours may be arranged. If the symptoms develop, or the pneumothorax enlarges, catheter aspiration or chest tube insertion and hospital admission is indicated.

Any disruption of the intestinal tract, with a perforated viscus, is a potentially life-threatening emergency. Immediate surgery may be required.

People with viral pericarditis usually respond to 7-21 days of therapy with nonsteroidal anti-inflammatory agents such as aspirin and ibuprofen. Another illness that may be the cause would be treated.

Treatment for mitral valve prolapse is usually conservative and involves medications to control palpitations and chest pain. When MVP is severe and does not respond to medical treatment, valve replacement is required. In addition, anyone diagnosed with MVP should receive antibiotics prior to any high-risk surgery or dental work. This will reduce the risk of endocarditis, which is an infection of the heart valves.

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

The 3 major esophageal disorders that cause chest pain—GERD, esophagitis, and esophageal spasm—are treated with antacid therapy, antibiotic, antiviral, or antifungal medication, or medicines that relax the muscles of the esophagus or some combination of medications.
Prognosis
Early medical intervention improves survival in potentially life-threatening illnesses involving chest pain.

Heart attack and unstable angina: Heart disease, which includes heart attacks and angina, is the leading cause of death for American adults. Almost 1 million people die each year from this disease. The prognosis for heart attack depends on the time it takes to get medical treatment, the region and extent of injury within the heart, and the presence of any other risk factors.

Aortic dissection: Quick action in getting medical treatment is essential with aortic dissection. Death occurs in up to 20% of people who receive medical treatment without surgical intervention. Those who undergo surgery have a 7% death rate.

Pulmonary embolism: Even with early treatment, 1 in 10 people with pulmonary embolism will die within the first hour. One-third will be diagnosed and treated with good outcome. Two-thirds go undiagnosed, and one-third of them will die.

Spontaneous pneumothorax: 95% fully recover. Other illnesses causing pneumothorax and complications from the chest tube placement may prolong or worsen the course.

Perforated viscus: With early detection and intervention, the prognosis for perforated viscus is good.

Acute pericarditis: Although the course may vary with each person, an estimated 60% have complete recovery within 1 week while another 20% recover within 3 weeks. Only 3% of people have symptoms more than 3 weeks before resolution. For about 15% of people, symptoms return within a year.

Mitral valve prolapse: Overall, the outlook is good. The complication rate is low.

Pneumonia: In young healthy adults, the prognosis for pneumonia is good with appropriate treatment. Prognosis is generally poorer in the elderly, in people with weakened immune systems such as those with AIDS.

Chest pain originating from the esophagus: GERD affects approximately one-fourth of the adult population and has a very low death rate. Esophagitis may lead to ulcerations, scarring, or stricture formation. With the exception of possible perforation, which has a high death rate, the overall prognosis is good. Esophageal spasm has a good outcome.
Prevention of heart attack and angina includes smoking cessation, exercise, diets low in cholesterol and saturated fats, control of diabetes and high blood pressure, and avoidance of obesity.

Aortic dissection may be prevented with adequate blood pressure control.

Prevention of pulmonary embolism includes smoking cessation in women older than 35 years who take oral contraceptive pills, avoidance of obesity, a physically active lifestyle, and preventive therapy after surgery, especially after orthopedic surgery.

Smoking cessation decreases the risk of spontaneous pneumothorax.

Risk of perforation with perforated viscus may be decreased with adequate treatment of ulcers and avoidance of foreign body ingestion.

There is no true prevention for acute pericarditis and mitral valve prolapse.

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

To prevent symptoms of GERD, avoid foods and other substances that aggravate the disease process: Avoid a high-fat diet, stop smoking, and decrease alcohol consumption. Also elevate the head of the bed and avoid eating 3 hours before bedtime.
No matter what the cause of chest pain, follow-up with your doctor is important to maintain a healthy life.
Other causes of chest pain
- Costochondritis: This is an inflammation of the cartilage between the ribs. Pain is typically located in the mid chest, with intermittently dull, sharp, and increased pain with deep breaths, movement, and deep touch. The mainstay of treatment is anti-inflammatory medications such as ibuprofen.
Bibliography

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Jouriles NJ: Atypical chest pain. Emerg Med Clin North Am 1998 Nov; 16(4): 717-40, v-vi[Medline].

Rosen P, Barkin RM, eds: Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998.

Snell RS, Smith MS: Clinical Anatomy for Emergency Medicine. St Louis, Mo: Mosby; 1993.

Tintinalli JE, Kelen GD, eds: Emergency Medicine: A Comprehensive Study Guide. 5th ed. New York NY: McGraw-Hill; 2000.

Zacovic JW, McGuirk TD, Knoop KJ: Bilateral hyphemas as a result of air bag deployment. Am J Emerg Med 1997 May; 15(3): 323-4[Medline].

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