Chest Pain

• Chest pain is discomfort and/or soreness in or around the chest.
• In general, chest pain can be divided into heart-related chest pain (cardiac chest pain) and chest pain that is not from a heart condition (non-cardiac chest pain).
• If a person is having chest pain and does not know the cause, they should be immediately evaluated by emergency medical personnel.

Although there are many causes of chest pain, the two large groups of causes are cardiac-related problems and non-cardiac causes. Cardiac chest pain is caused by an imbalance between the blood supply to the heart and oxygen needs of the heart muscle. Cardiac chest pain is most commonly a result of atherosclerosis (leading to fixed narrowing of coronary arteries), but also can be caused by coronary spasms that narrow the arteries intermittently. Cardiac chest pain is also referred to as angina or angina pectoris.

Non-cardiac chest pain has many causes, ranging from infections and muscle or bone problems to conditions such as lung tumors, lung collapse, chest trauma, upper abdominal pain, and gastric reflux. Although some of the non-cardiac causes of chest pain may require emergency care (for examples, lung collapse and severe chest trauma), most do not.

This signs the symptoms of cardiac chest pain are chest discomfort, including pressure, squeezing, heaviness, or burning sometimes associated with a sensation of choking or shortness of breath. The discomfort is often described as ranging from sharp to dull and is usually located in the upper abdomen, back, neck, jaw, left arm, or shoulders. It can be precipitated by

• exertion,
• eating,
• exposure to cold, and/or
• emotional stress

and usually lasts about 1 to 5 minutes. For some, this pain is relieved by rest or from taking the medication nitroglycerin. The pain intensity usually doesn't change with respiration, cough or position change. Classically, cardiac chest pain is in the left chest. However, it may occur in the center or right chest.

Non-cardiac chest pain may have many of the above symptoms. However, non-cardiac chest pain may change with respiration, cough, or position. Regardless, chest pain is not normal and should be diagnosed by a doctor because it can represent a serious health risk.

Women may have somewhat different cardiac chest pain symptoms including more nausea and vomiting, lightheadedness, and pain or discomfort in one or both arms. Pregnant women may experience chest pain from heartburn, indigestion, enlarged breasts, pressure (baby putting pressure on diaphragm/ribs), widening of the rib cage, and stress. In children and teens, chest wall pain is the most common cause of chest pain. Rarely is there a heart problem in these ages, but it can occur with conditions such as Marfan syndrome or tearing of the aorta.

The conditions associated with chest pain are very numerous. The following is a list of conditions that may lead to chest pain. This list does not include every condition but is meant to outline some of the major conditions that are associated with chest pain (both cardiac and non-cardiac): Anxiety, atherosclerosis, aortic dissection, aortic stenosis, cardiomyopathy, cholecystitis, cocaine use, diabetes, spasm of the esophagus, gastritis, GERD, hiatal hernia, hypercholesterolemia, hypertension, hyperthyroid, lupus, mitral valve problems, Marfan syndrome, pericarditis, pleurisy, pneumothorax, polyarteritis nodosa, Pott disease, pulmonary embolism, rib fracture, scleroderma, and shingles.

Chest pain is diagnosed by history evaluation and physical examination. The health care professional initially wants to distinguish between cardiac and non-cardiac causes and sometimes can do so with the patient's history. This is important because heart-related chest pain may need immediate intervention and treatment. During the patient's history and physical exam, it is not unusual for medical personnel to obtain an electrocardiogram (EKG) and a chest X-ray. Elevated blood levels of troponin can indicate heart muscle damage. Other blood tests, such as a complete blood count (CBC) and a basic metabolic profile, are helpful in emergency evaluation.

In more complex situations, tests such as an exercise stress test, stress echocardiography, myocardial perfusion scintigraphy, or CT angiography can be used. Other tests and procedures that may be used include Holter monitoring and coronary angiography. Coronary artery disease is detected by coronary angiography that is used to identify atherosclerosis.

People with chest pain who are uncertain whether the chest pain is from a heart problem or not must be evaluated immediately in the emergency department.

Chest pain is treated according to the underlying cause of pain. Cardiac chest pain may be treated with medications and/or invasive procedures. Coronary angioplasty with stents is used to keep coronary arteries open and coronary bypass surgery is performed to bypass coronary artery blockage.

Non-cardiac chest pain is also treated depending upon the specific cause. In general, most non-cardiac chest pain is treated medically. Infrequently, non-cardiac chest pain may require surgical intervention (for example, lung tumor or chest tube placement for a collapsed lung segment).

Most often the prognosis for chest pain (both cardiac and non-cardiac) is good because there are several medications that work quite well for chest pain. However, the ultimate prognosis for the patient depends on the underlying cause of the chest pain. If the underlying cause for both cardiac and non-cardiac chest pain is not addressed, then the prognosis can be fair to poor.

Because cardiac chest pain is a symptom of heart problems, recurrent and longer-lasting cardiac chest pain is a sign that the heart problem might be getting worse.

Many forms of chest pain can be prevented. This is true for both cardiac and non-cardiac chest pain. For example, cardiac chest pain may be prevented in individuals that choose not to smoke and live a healthy lifestyle that includes low-fat foods, fiber, and exercise. Individuals that have risk factors for cardiac disease can reduce their risk and concomitant chest pain by following the instructions and medications provided by their doctor. Reducing atherosclerosis, the most common cause of cardiac chest pain, results in chest pain prevention.

Like cardiac chest pain, non-cardiac chest pain may be prevented by preventing the underlying causes of pain. For example, avoiding situations that may increase your risk for pneumonia, chest muscle strain, or chest trauma are ways to prevent non-cardiac chest pain.