Diseases

Chest Pain Information

Angina and heart attack (myocardial infarction)

The worry for patients and health care professionals is that any chest pain may originate from the heart. Angina is the term given to pain that occurs because the coronary arteries (blood vessels to the heart muscle) narrow and decrease the amount of oxygen that can be delivered to the heart itself. This can cause the classic symptoms of chest pressure or tightness with radiation to the arm or jaw associated with shortness of breath and sweating.Unfortunately, many people don't present with classic symptoms, and the pain may be difficult to describe -- or in some people may not even be present. Instead of angina or typical chest pressure, their anginal equivalent (symptom they get instead of chest pain) may be indigestion, shortness of breath, weakness, dizzyness, and malaise. Women and the elderly are at higher risk for having an atypical presentation of heart pain.The narrowing of blood vessels or atherosclerosis is due to plaque buildup. Plaque is a soft amalgam of cholesterol and calcium that forms along the inside lining of the blood vessel and gradually decreases the diameter of the blood vessel and restricts the flow of blood. If the plaque ruptures, it can cause a blood clot to form and completely block the vessel.When a coronary artery completely occludes (becomes blocked), the muscle it supplies blood to is at risk of dying. This is a heart attack or myocardial infarction. In most circumstances, this pain is more intense than routine angina, but again, there are many variations in signs and symptoms.The diagnosis of angina is a clinical one. After the health care professional takes a careful history and assesses the potential risk factors, the diagnosis is either reasonably pursued or else it is considered not to be present. If angina is the potential diagnosis, further evaluation may include electrocardiograms (EKG or ECG) and blood tests.Cardiac enzymes can be measured in the bloodstream when heart muscle is irritated or damaged. Common enzymes to measure include troponin, CPK, and myoglobin. Unfortunately, it takes time for these chemicals to be released into the bloodstream and turn a blood test positive. Interpretation of the test results may require that blood be taken more than once over a period of observation to confirm that they are normal. If these chemicals are not present, it may be reasonable to perform imaging studies of the heart in a variety of ways depending on the patient's past history:

• Stress tests in which the electrocardiogram is monitored during exercise. This can be done by actual exercise or by chemically stimulating the heart with injected medications. The stress test may be performed in association with an echocardiogram.
• Echocardiography (ultrasound evaluation) of heart structure and function
• Computerized cardiac angiography in which the CT scan can image the heart's blood vessels
• Coronary catheterization, in which tubes are floated through a major blood vessel into the heart and dye is used to directly image heart blood vessels looking for blockage

Aorta and aortic dissection

The aorta is the large blood vessel that exits the heart and delivers blood to the body. It is composed of layers of muscle that need to be strong enough to withstand the pressure generated by the beating heart. In some people, a tear can occur in one of the layers of the aortic wall, and blood can track between the wall muscles. This is called an aortic dissection, and is potentially life threatening. The type of dissection and treatment is dependent upon where in the aorta the dissection occurs. Type A dissections are located in the ascending aorta, which runs from the heart to the aortic arch where blood vessels that supply the brain and arms exit. Type B dissections are located in the descending aorta that runs through the chest and down into the abdomen.The majority of aortic dissections occur as a long-term consequence of poorly controlled high blood pressure. Other associated conditions include:

• Marfan's syndrome,
• trauma,
• pregnancy, and
• a late post-operative complication of open heart surgery.

Broken or bruised ribs

Bruised or broken ribs are common injuries. Symptoms of broken or bruised ribs include:

• tenderness over the site of injury;
• a broken rib may be palpated (the health care professional can feel the rib fracture move when pressed);
• the pain tends to be pleuritic (it hurts to take a deep breath and can be associated with shortness of breath); and
• because the surrounding muscles go into spasm, there is pain with any movement of the trunk.

• Pain control with anti-inflammatory medications like ibuprofen and narcotic pain medications to allow deep breaths to occur.
• Application of ice to the affected area and to periodically deep take breaths. An incentive spirometer may be provided to help visualize the amount of breath to take.
• Ribs are no longer wrapped or taped to help with comfort. Wrapping broken ribs decreases the ability of the lung underneath the injured area to fully expand, which increases the risk of developing pneumonia.
• Whether broken or bruised, rib injuries take 3 to 6 weeks to heal.

Chest pain definition and facts

• Chest pain is one of the most common symptoms that bring an individual to the emergency department. Seeking immediate care may be lifesaving, and considerable public education has been undertaken to get patients to seek medical care when chest pain strikes. You may be worried that you are having a heart attack, but there are many other causes of pain in the chest that the doctor will consider. Some diagnoses of chest pain are lifethreatening, while others are less dangerous.
• Deciding the cause of chest pain is sometimes very difficult and may require blood tests, X-rays, CT scans and other tests to sort out the diagnosis. Often though, a careful history taken by the doctor may be all that is needed.There are many causes of chest pain, and while many are not serious, it may be difficult to distinguish a heart attack, pulmonary embolus, or aortic dissection, from another diagnosis that is not life-threatening, like heartburn. For that reason, individuals are routinely advised to seek medical evaluation for most types of chest pain.
• While each cause of chest pain has classic symptoms and signs, there are enough variations in symptoms that it may take specific testing to reach a diagnosis. These tests will depend on the your current health and the healthcare professionals index of suspicion as to what the diagnosis might be.
• Treatment for chest pain depends upon the cause.
• It is best to be safe. Always seek medical care if you are having chest pain.

Costochondritis

On occasion, the joints and cartilage where ribs attach to the sternum (breastbone) may become inflamed. The pain tends to occur with a deep breath, and there is tenderness that can be felt when the sides of the sternum are palpated or touched. If there is swelling and inflammation associated with the tenderness, it is known as Tietze's syndrome.The most frequent cause for costochondritis is idiopathic or unknown, meaning there is no explanation for the pain. Other causes include trauma to the area, infection (often viral), and fibromyalgia.Though painful, the symptoms resolve with symptomatic care, including ice and/or warm compresses and anti-inflammatory medications (for example, ibuprofen). As with other chest wall pain, recovery may take weeks. Taking deep breaths to prevent the risk of pneumonia is very important.For more, please read the Costochondritis and Tietze Syndrome article.

Esophagus and reflux esophagitis

The esophagus is a muscular tube that carries food from the mouth to the stomach. The lower esophageal sphincter (LES) is a specialized band of muscle at the lower end of the esophagus that functions as a valve to keep stomach contents from spilling back into the esophagus. Should that valve fail, stomach contents, including acidic digestive juices, can reflux back and irritate the lining of the esophagus. While the stomach has a protective barrier lining to protect it from normal digestive juices, this protection is missing in the esophagus.Reflux esophagitis (also referred to as GERD, gastroesophageal reflux disease) can present with burning chest and upper abdominal pain that radiates to the throat and may be associated with a sour taste in the back of the throat called water brash. It may present after meals or at bedtime when the patient lies flat. There can be significant spasm of the esophageal muscles, and the pain can be intense. The pain of reflux esophagitis can be mistaken for angina, and vice versa.The physical examination is usually not helpful, and a clinical diagnosis is often made without further testing. Endoscopy may be performed to look at the lining of the esophagus and stomach. When symptoms are long-standing, they may be associated with, or cause, precancerous changes in the cells lining the lower esophagus. Manometry can be done to measure pressure changes in the esophagus and stomach to decide whether the LES is working appropriately. Barium swallow or gastrograph with fluoroscopy is a type of X-ray where the swallowing patterns of the esophagus can be evaluated.Treatment for reflux esophagitis includes:

• Dietary and lifestyle changes to limit the amount of acid that can backsplash from the stomach into the esophagus.
• Elevating the head of the bed allows gravity to keep acid from refluxing.
• Smaller meal sizes can limit stomach distention.
• Caffeine, alcohol, anti-inflammatory medications, and smoking are irritants to the lining of the stomach and esophagus and should be avoided.
• Acid blockers like omeprazole (Prilosec) or lansoprazole (Prevacid) can decrease the amount of stomach acid that is produced, and antacids like Maalox or Mylanta can help bind excess acid.

Pericarditis

The heart is contained in a sac called the pericardium. Just like in pleurisy, this sac can become inflamed and cause pain. As opposed to angina, this pain tends to be sharp and is due to the inflamed sac rubbing against the outer layers of the heart.The most common cause of pericarditis either is a viral illness or is unknown (idiopathic). Inflammatory diseases of the body (rheumatoid arthritis, systemic lupus erythematosus), kidney failure, and cancer are other conditions that can cause pericarditis. Trauma, especially from steering wheel injuries in motor vehicle accidents can also cause pericarditis.The pain with pericarditis is intense, sharp, tends to be worse when lying down, and is relieved by leaning forward. Because the pain can be so severe, radiate to the arm or neck, and cause some shortness of breath, it is sometimes mistaken for angina, pulmonary embolus, or aortic dissection. Associated symptoms may include fever and malaise depending upon the cause.History is helpful in making the diagnosis, looking for a recent viral illness, and asking about past medical history. Physical examination may reveal a friction rub when listening to the heart sounds.The electrocardiogram may show changes consistent with pericarditis, but on occasion, the EKG may mimic an acute heart attack. Echocardiogram is helpful if there is fluid in the pericardial sac associated with the inflammation.An anti-inflammatory medication like ibuprofen is the treatment for pericarditis. Addressing the underlying cause will also direct therapy.Cardiac tamponade is a complication of pericarditis. Pressure from excess fluid built up in the pericardial sac is so great that it prevents blood from returning to the heart. The diagnosis is made clinically with the triad of (Beck's triad):

• low blood pressure,
• distention of neck veins, and
• muffled heart tones.

Pleuritis or pleurisy

The lung slides along the chest wall when a deep breath is taken. Both surfaces have a thin lining called the pleura to allow this sliding to occur. On occasion, viral infections can cause the pleura to become inflamed, and then instead of sliding smoothly, the two linings scrape against each other, causing pain. This type of chest pain hurts with a deep breath, and feels like the pain of pleurisy.Viral infections are a common cause of pleurisy, although there are many other infectious causes including tuberculosis. Other diseases that can inflame the pleura include:

• collagen vascular diseases like sarcoidosis and systemic lupus erythematosus,
• cancer,
• kidney failure,
• rheumatoid arthritis,
• complications of radiation therapy,
• complications of chemotherapy, and
• complications of surgery.

Pneumonia

An infection of the lung is called pneumonia, in which inflammation can cause fluid buildup within a segment of the lung tissue, decreasing its ability to transfer oxygen from air to the bloodstream.Pneumonia presents with the typical symptoms of an infection:

• fever,
• chills, and
• malaise.

• cough,
• shortness of breath, and
• sputum production (coughing up mucus).

Pneumothorax

The lung is held against the chest wall by negative pressure in the pleura. If this seal is broken, the lung can shrink down, or collapse (known as pneumothorax). This may be associated with a rib injury or it may occur spontaneously. However, commonly seen in those who are tall and thin, other risk factors for a collapsed lung include emphysema or asthma. Small blebs or weak spots in the lung can break and cause the air leak that breaks the negative pressure seal.The common presentation is the acute onset of sharp chest pain associated with shortness of breath, with no preceding illness or warning. Physical examination reveals decreased air entry on the affected side. Percussion may show increased resonance with tapping. Chest X-ray confirms the diagnosis.Treatment is dependent upon what percentage of the lung is collapsed. If it is a small amount and vital signs are stable with a normal O2 sat, the pneumothorax may be allowed to expand on its own with close monitoring. If there is a larger collapse, a chest tube may have to be placed into the pleural space through the chest wall to suck the air out and re-establish the negative pressure. On occasion, thoracoscopy (thoraco=chest +scopy=see with a camera) may be considered to identify the bleb and to staple it shut. For more, please read the Pneumothorax article.Tension pneumothorax is a relatively rare life-threatening event often associated with trauma. Instead of a simple collapse of the lung, a scenario can exist in which the damaged lung tissue acts as a one-way valve allowing air to enter into the pleural space but not allowing it to escape. The pneumothorax size increases with each breath and can prevent blood from returning to the heart and allowing the heart to pump it back to the body. If not corrected quickly with placement of a chest tube, it can be fatal.

Pulmonary embolism

A blood clot to the lung can be fatal and is one of the diagnoses that should always be considered when a patient presents with chest pain.The classic signs and symptoms of a blood clot in the lung are pain when taking a deep breath, shortness of breath, and coughing up blood (hemoptysis); but more commonly, patients can have more subtle symptoms, and the diagnosis may be easily missed.Risk factors for pulmonary embolus include:

• prolonged inactivity like a long trip in a car or airplane,
• recent surgery or fracture,
• birth control pills (especially associated with smoking),
• cancer, and
• pregnancy.

• pleuritic chest pain from the inflamed lung,
• bloody sputum, and
• shortness of breath.

Referred abdominal pain

Conditions in the abdomen can present as pain referred to the chest, especially if there is inflammation along the diaphragm. Inflammation of the stomach, spleen, liver, or gallbladder can initially present with nonspecific pain complaints that may be associated with vague chest discomfort. Physical examination and time to allow the disease process to express itself often allow the appropriate diagnosis to be made. It is also the reason that the whole body is examined, even if the initial complaint is chest pain.

• Similarly, conditions in the chest may initially present as abdominal pain.
• Myocardial infarction of the inferior or lower portion of the heart can present as indigestion.
• Pneumonia can present as upper abdominal pain, especially if the lung inflammation is next to the diaphragm.
• Aortic dissection can present with chest pain, abdominal pain, or both, depending upon where the dissection occurs.

Shingles

Sihingles is caused by the varicella zoster virus, the same one that causes chickenpox. Once the virus enters the body, it hibernates in the nerve roots of the spinal column, only to emerge sometime in the future. The rash is diagnostic as it follows the nerve root as it leaves the back, and circles to the front of the chest, but never crosses the midline.Once the rash appears, the diagnosis is relatively easy for the health care professional. Unfortunately, the pain of shingles may begin a few days before the rash emerges and can be confusing to both patient and health care professional, since the pain and burning may seem out of proportion to the findings on physical examination.The treatment for shingles includes antiviral medications like acyclovir (Zovirax) along with pain control medication. The pain from the inflamed nerve can be can be quite severe. Some patients may develop postherpetic neuralgia, or chronic pain from the inflamed nerve, which may persist long after the infection has cleared. A variety of pain control strategies are available from medication to pain stimulators to surgery. For more, please read the Shingles article.