Chest Pain – Types, Causes, Symptoms, Treatment

Chest pain
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Chest pain is pain in any region of the chest. Chest pain may be a symptom of a number of serious disorders and is, in general, considered a medical emergency. Chest pain can be differentiated into heart-related and non-heart-related chest pain. Cardiac chest pain is called angina pectoris.

Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a physician considers more benign causes.

Chest pain basically two types

  • Heart-related
  • Nonheart related or GI tract related

Symptoms of Chest pain

Chest pain can cause many different sensations depending on what’s triggering the symptom. Often, the cause has nothing to do with your heart — though there’s no easy way to tell without seeing a doctor.

Heart-related chest pain

Although chest pain is often associated with heart disease, many people with heart disease say they experience a vague discomfort that isn’t necessarily identified as pain. In general, chest discomfort related to a heart attack or another heart problem may be described by or associated with one or more of the following:

  • Pressure, fullness, burning or tightness in your chest
  • Crushing or searing pain that radiates to your back, neck, jaw, shoulders, and one or both arms
  • Pain that lasts more than a few minutes, gets worse with activity, goes away and comes back, or varies in intensity
  • Shortness of breath
  • Cold sweats
  • Dizziness or weakness
  • Nausea or vomiting

Other types of chest pain

It can be difficult to distinguish heart-related chest pain from other types of chest pain. However, chest pain that is less likely due to a heart problem is more often associated with:

  • A sour taste or a sensation of food re-entering your mouth
  • Trouble swallowing
  • Pain that gets better or worse when you change your body position
  • Pain that intensifies when you breathe deeply or cough
  • Tenderness when you push on your chest
  • Pain that is persistently present for many hours

The classic symptoms of heartburn — a painful, burning sensation behind your breastbone — can be caused by problems with your heart or your stomach.

  • Shortness of breath
  • Nausea and vomiting
  • Fever
  • Diaphoresis
  • Cough
  • Dyspepsia
  • Edema
  • Calf pain or swelling
  • Recent illness

Causes of Chest pain

Chest pain has many possible causes, all of which need medical attention.

Heart-related causes

Examples of heart-related causes of chest pain include:

  • Heart attack – A heart attack results from blocked blood flow, often from a blood clot, to your heart muscle.
  • Angina – Angina is the term for chest pain caused by poor blood flow to the heart. This is often caused by the buildup of thick plaques on the inner walls of the arteries that carry blood to your heart. These plaques narrow the arteries and restrict the heart’s blood supply, particularly during exertion.
  • Aortic dissection – This life-threatening condition involves the main artery leading from your heart (aorta). If the inner layers of this blood vessel separate, blood is forced between the layers and can cause the aorta to rupture.
  • Pericarditis – This is the inflammation of the sac surrounding your heart. It usually causes sharp pain that gets worse when you breathe in or when you lie down.

Digestive causes

Chest pain can be caused by disorders of the digestive system, including:

  • Heartburn – This painful, burning sensation behind your breastbone occurs when stomach acid washes up from your stomach into the tube that connects your throat to your stomach (esophagus).
  • Swallowing disorders – Disorders of the esophagus can make swallowing difficult and even painful.
  • Gallbladder or pancreas problems – Gallstones or inflammation of your gallbladder or pancreas can cause abdominal pain that radiates to your chest.

Muscle and bone causes

Some types of chest pain are associated with injuries and other problems affecting the structures that make up the chest wall, including:

  • Costochondritis – In this condition, the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed and painful.
  • Sore muscles – Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain.
  • Injured ribs – A bruised or broken rib can cause chest pain.

Lung-related causes

Many lung disorders can cause chest pain, including:

  • Pulmonary embolism – This occurs when a blood clot becomes lodged in a lung (pulmonary) artery, blocking blood flow to lung tissue.
  • Pleurisy – If the membrane that covers your lungs becomes inflamed, it can cause chest pain that worsens when you inhale or cough.
  • Collapsed lung – The chest pain associated with a collapsed lung typically begins suddenly and can last for hours, and is generally associated with shortness of breath. A collapsed lung occurs when air leaks into the space between the lung and the ribs.
  • Pulmonary hypertension – This condition occurs when you have high blood pressure in the arteries carrying blood to the lungs, which can produce chest pain.
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Other Causes

Chest pain can also be caused by:

  • Panic attack – If you have periods of intense fear accompanied by chest pain, a rapid heartbeat, rapid breathing, profuse sweating, shortness of breath, nausea, dizziness and a fear of dying, you may be experiencing a panic attack.
  • Shingles – Caused by a reactivation of the chickenpox virus, shingles can produce pain and a band of blisters from your back around to your chest wall.

Sources of chest pain

The following anatomic locations can all be potential sources of chest pain:

  • the chest wall including the ribs, the muscles, and the skin;
  • the back including the spine, the nerves, and the back muscles;
  • the lung, the pleura (the lining of the lung), or the trachea;
  • the heart including the pericardium (the sac that surrounds the heart);
  • the aorta;
  • the esophagus;
  • the diaphragm, the flat muscle that separates the chest and abdominal cavities; and
  • referred pain from the abdominal cavity including organs like the stomach, gallbladder, and pancreas, as well as irritation from the underside of the diaphragm due to infection, bleeding or other types of fluid.

Diagnosis of Chest pain

History

Like all workups, chest pain evaluation starts with taking a complete history. Start by getting a good understanding of their complaint.

  • Onset – In addition to when the pain started, ask what the patient was doing when the pain started. Was the pain brought on by exertion or were they at rest?
  • Location – Can the patient localize the pain with one finger or is it diffuse?
  • Duration – How long did the pain last?
  • Character – Let the patient describe the pain in his or her own words.
  • Aggravation/alleviating factors – It is very important to find out what makes the pain worse. Is there an exertional component, is it associated with eating or breathing? Is there a positional component? Don’t forget to ask about new workout routines, sports, and lifting. Ask what medications they have tried.
  • Radiation – This may clue you into visceral pain.
  • Timing – How many times do they experience this pain? For how long does it let up?

Evaluation

Many facilities have protocols in place to evaluate for chest pain, but at a minimum, the provider should order the following:

  • Complete blood count (CBC) – basic metabolic panel (BMP), troponin level (consider serial troponin levels 4hr apart), lipase
  • Computed tomography pulmonary angiography (CTPA) – if you are considering PE or ventilation-perfusion (VQ) scan if CTPA is contraindicated
  • Bedside ultrasound (US) –  if you are considering pericardial tamponade. Ultrasonography of the whole abdomen
  • Endoscopy
  • Urine & stool examination
  • Electrocardiogram (ECG) – Electrocardiogram (ECG) preferably in the first 10min of arrival, (consider serial ECGs). This test records the electrical activity of your heart through electrodes attached to your skin. Because injured heart muscle doesn’t conduct electrical impulses normally, the ECG may show that you have had or are having a heart attack.
  • Chest X-ray An X-ray of your chest allows doctors to check the condition of your lungs and the size and shape of your heart and major blood vessels. A chest X-ray can also reveal lung problems such as pneumonia or a collapsed lung.
  • Computerized tomography (CT scan) – CT scans can spot a blood clot in your lung (pulmonary embolism) or make sure you’re not having aortic dissection.
  • Stress tests These measures how your heart and blood vessels respond to exertion, which may indicate if your chest pain is heart-related. There are many kinds of stress tests. You may be asked to walk on a treadmill or pedal a stationary bike while hooked up to an ECG. Or you may be given a drug intravenously to stimulate your heart in a way similar to exercise.
  • Blood tests
    • Troponin I or T (to indicate myocardial damage)
    • Complete blood count
    • Electrolytes and renal function (creatinine)
    • Liver enzymes
    • Creatine kinase (and CK-MB fraction in many hospitals)
    • D-dimer (when suspicion for pulmonary embolism is present but low)
    • serum lipase to exclude acute pancreatitis

Differential diagnosis

Causes of chest pain range from non-serious to serious to life-threatening.

  • In adults, the most common causes of chest pain include gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%), and pulmonary embolism (2%). Other less common causes include pneumonia, lung cancer, and aortic aneurysms. Psychogenic causes of chest pain can include panic attacks, however, this is a diagnosis of exclusion.
  • In children, the most common causes of chest pain are musculoskeletal (76-89%), exercise-induced asthma (4-12%), gastrointestinal illness (8%), and psychogenic causes (4%). Chest pain in children can also have congenital causes.

Cardiovascular

Blockage of coronary arteries can lead to a heart attack
Acute coronary syndrome
  • Stable or unstable angina
  • Myocardial infarction (“heart attack”) – People usually complained of pressure or squeezing sensation over the chest. Other associated symptoms are: excessive sweating, nausea, vomiting, and weakness. Chest pain is more commonly associated with anterior infarction because of left ventricular impairment; inferior infarction is more commonly associated with nausea, vomiting, and excessive sweating due to irritation of vagus nerve; lateral infarction is associated with left arm pain.
  • Prinzmetal’s angina – Chest pain is caused by coronary vasospasm. More common in women younger than 50 years. Person usually complain of chest pain at rest. It may occur early in the morning which awaken a person from sleep.
  • Cocaine abuse – This condition is suspected when a person with few or no risk of arteriosclerosis presented with non-traumatic chest pain. Ingestion of cocaine can cause vasoconstriction of coronary arteries, thus producing chest pain similar to a heart attack. Symptoms can appear within one hour of cocaine use.
  • Aortic stenosis – This condition happens when the person has an underlying congenital bicuspid valve, aortic sclerosis, or a history of rheumatic fever. Chest pain usually happens during physical activity. Syncope is a late symptom. Signs and symptoms of heart failure may also present. On auscultation, a loud ejection systolic murmur can be best heard at the right second intercostal space and radiates to the carotid artery in the neck. Splitting of second heart sound is heard in severe stenosis.
  • Hypertrophic cardiomyopathy – It is the hypertrophy of interventricular septum that causes outflow obstruction of the left ventricle. Dyspnea and chest pain commonly occurs during daily activities. Sometimes, syncope may happen. On physical examination, significant findings include loud systolic murmur and palpable triple apical impulse due to palpable presystolic fourth heart sound.
  • Aortic dissection – is characterized by severe chest pain that radiates the back. It is usually associated with Marfan’s syndrome and hypertension. On examination, the murmur of aortic insufficiency can be heard with unequal radial pulses.
  • Pericarditis – This condition can be the result of a viral infection such as coxsackievirus and echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial infarction (Dressler syndrome). The chest pain is often pleuritic in nature (associated with respiration) which is aggravated when lying down and relieved on sitting forward, sometimes, accompanied by fever. On auscultation, pericardial friction rub can be heard.
  • Arrhythmia – atrial fibrillation and a number of other arrhythmias can cause chest pain.
  • Myocarditis
  • Mitral valve prolapse syndrome – Those affected are usually thin females presented with chest pain which is sharp in quality, localized at the apex, and relieved when lying down. Other symptoms include shortness of breath, fatigue, and palpitations. On auscultation, mid systolic click followed by late systolic murmur can be heard, louder when a person is in standing position.
  • Aortic aneurysm
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Respiratory

  • Bronchitis
  • Pulmonary embolism – Common signs and symptoms are shortness of breath, pleuritic chest pain, blood in sputum during cough (hemoptysis), and lower limb swelling. Risk factors include recent surgery, malignancy, and bedridden state. Source of embolus usually comes from venous thromboembolism.
  • Pneumonia
  • Hemothorax
  • Pneumothorax – Those who are at a higher risk of developing pneumothorax are tall, thin, male smokers who had underlying lung diseases such as emphysema. Those affected can have sharp chest pain which radiates to the shoulder of the same side. Physical examination revealed absent breath sounds and hyper resonance on the affected side of the chest.
  • Pleurisy
  • Tuberculosis
  • Tracheitis
  • Lung malignancy

Gastrointestinal

GERD is a common cause of chest pain in adults
  • Gastroesophageal reflux disease (GERD) – The pain is aggravated when lying down or after meals. Persons may describe this as heartburn. Besides, they may also complain of tasting bitter contents from the stomach.
  • Achalasia, nutcracker esophagus, and other motility disorders of the esophagus
  • Diffuse esophageal spasm – Unlike cardiac chest pain, esophageal pain is not related to the activity. The pain is usually associated with swallowing of hot or cold water.
  • Esophageal rupture – Those affected usually complained of sudden, severe, and constant pain that starts from the neck to the upper abdomen. The pain is aggravated by swallowing. On examination, neck swelling and crepitations can be felt due to subcutaneous emphysema as free air is entering from the esophagus into the subcutaneous tissue.
  • Esophagitis – There are many causes of esophagitis. Esophagitis caused by Candida albicans is usually found in chemotherapy or HIV patients. Medication such as nonsteroidal anti-inflammatory drug (NSAIDs) and alendronate can induce esophagitis if not swallowed properly.
  • Functional dyspepsia
  • Hiatus hernia
  • Jackhammer esophagus
  • Acute cholecystitis – Characterized by positive Murphy’s sign where the person had a cessation of inhalation when the doctor placed his finger at the right subcostal region of the abdomen.
  • Acute pancreatitis – History of alcohol abuse, cholelithiasis (stones in the gallbladder), and hypertriglyceridemia are risk factors for pancreatitis. It is a constant, boring pain in the upper abdomen.
  • Perforated peptic ulcer – Sudden onset of severe pain in the upper abdomen which later developed into peritonitis (inflammation of tissues that lines the abdominal organs).
  • Acute gastritis

Chest wall

  • Costochondritis or Tietze’s syndrome – an inflammation of costochondral junction. Any movements or palpation of the chest can reproduce the symptoms.
  • Spinal nerve problem
  • Fibromyalgia
  • Chest wall problems
  • Radiculopathy
  • Precordial catch syndrome – another benign and harmless form of a sharp, localized chest pain often mistaken for heart disease
  • Breast conditions
  • Herpes zoster commonly known as shingles – It is usually described as a burning sensation over the chest in a unilateral dermatome distribution. However, diagnosis can be difficult because the pain usually appears before the characteristic rash is visible.
  • Tuberculosis
  • Osteoarthritis
  • Bornholm disease
  • Rib fracture

Psychological

  • Panic attack – Chest pain is a common symptom of panic attacks, with as high as 78% of persons describing chest pain with their worst panic attacks. Overall chest pain is a symptom of up to 48% of sudden-onset panic attacks, and 10% of gradual-onset panic attacks.[rx]
  • Anxiety
  • Clinical depression
  • Somatization disorder
  • Hypochondria

Others

  • Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth.
  • Da costa’s syndrome
  • Carbon monoxide poisoning
  • Sarcoidosis
  • Lead poisoning
  • Prolapsed intervertebral disc
  • Thoracic outlet syndrome
  • The adverse effect from certain medications

Treatment of Chest pain

  • aspirin
  • drugs to break up clots
  • antiplatelet and anticoagulants (also known as blood thinners)
  • painkillers
  • nitroglycerin
  • blood pressure medication
  • Artery relaxers – Nitroglycerin is usually taken as a tablet under the tongue — relaxes heart arteries, so blood can flow more easily through the narrowed spaces. Some blood pressure medicines also relax and widen blood vessels.
  • Aspirin – If doctors suspect that your chest pain is related to your heart, you’ll likely be given aspirin.
  • Thrombolytic drugs –If you are having a heart attack, you may receive these clot-busting drugs. These work to dissolve the clot that is blocking blood from reaching your heart muscle.
  • Blood thinners –If you have a clot in an artery feeding your heart or lungs, you’ll be given drugs that inhibit blood clotting to prevent the formation of more clots.
  • Acid-suppressing medications –If your chest pain is caused by stomach acid splashing into your esophagus, the doctor may suggest medications that reduce the amount of acid in your stomach.
  • Antidepressants – If you’re experiencing panic attacks, your doctor may prescribe antidepressants to help control your symptoms. Psychological therapy, such as cognitive-behavioral therapy, also might be recommended.
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Surgery

  • Angioplasty  opens the blocked artery by using a balloon or by removing the plaque buildup
  • stent: a wire mesh tube is inserted into the artery to keep it open after angioplasty
  • Bypass surgery  reroutes the blood around the blockage
  • Heart valve surgery  replaces leaky valves to help the heart pump
  • Pacemaker – a device designed to help your heart maintain a normal rhythm is implanted beneath the skin

Home Remedies for chest pain

 Keel On The Bed

  • In the case of chest pain, immediately kneel down on the bed. In this position, the head has to face down, and your buttocks have to be up in the air. Gas automatically passes out of your system.

 Drink Some Fluid

  • If the pain is due to gas build up in your abdomen, drink a cup of hot water or any other hot beverage like tea. As you drink the hot liquid, the gas from your body goes out relieving you of the chest pain.

The Cold Pack

  • If the chest pain is due to strained muscles (you know this because an area of your chest swells), apply an ice pack to your chest. You can make a cold pack by clubbing together the ice cubes and wrapping them in a cloth. Keep the pack on your chest for about 10 to 20 minutes. Repeat the process for three times a day. The swelling reduces after 48 to 72 hours. When it does, cover the area that hurts with a warm towel for some time.

Garlic In Milk

  • Take a glass of milk. To it, add 6 to 8 chopped garlic pieces. Now, boil the milk and drink it along with the garlic pieces (make sure to chew the garlic pieces, and not gulp them down). It will relieve you of chest pain.

Turmeric In Milk

  • Like garlic, turmeric is another herb that is useful to relieve you of chest pain. Take ½ tea spoon of turmeric powder and mix it with a cup of milk. Ensure the milk is hot. To the drink, add two spoons of honey and a bit of black pepper.

Aspirin

  • This is the simplest method to reduce chest pain immediately. Take a tablet of aspirin with a glass of water.

Baking soda

  • Another easy home remedy for chest pain is to add baking soda in a hot cup of water. Drinking it releases your body of acidity, thereby giving you relief from chest pain.

Apple Cider Vinegar

  • Consume two teaspoons of apple cider vinegar. Apple cider vinegar is a type of vinegar that helps in digestion, thereby preventing the production of gas in your abdomen area. This in turn reduces the pain in your chest.

Lie Down

  • When your body complains of chest pain, immediately lie down on your bed with the head elevated. If the pain is due to acidity, the position releases the gas of your body. Stay in this position for a while before you feel comfortable and free of pain.

Back Massage

  • When you have sudden chest pain, get someone to massage your back. Lay with your face down and get your upper back strongly massaged. This will ease you of chest pain and also of any other physical pains.
  • The above tips are for the chest pain that is usually not fatal. However, if the pain is too strong and keeps recurring, it’s always best to consult a doctor.

Medical tests

On the basis of the above, a number of tests may be ordered

  • An electrocardiogram (ECG)
  • Chest radiograph or chest x rays are frequently performed
  • Echocardiography can be useful in patients with known cardiac disease or aortic dissection
  • CT scanning is used in the diagnosis of aortic dissection
  • V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is suspected)

References

Chest pain

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