Chest Pain: Causes and Treatment

Chest pain or discomfort is a very commonly experienced symptom and is the third most common reason for emergency visits in the United states and accounts for up to 6 to 7 million visits each year.

Any discomfort in the chest can often causes a lot of anxiety as the immediate fear is that this could be a sign of heart disease. While this is one of the major concerns, there are several other underlying causes. Upon evaluation of chest pain, fewer than 25% of patients are finally diagnosed with Acute Coronary Syndrome (ACS), which is the spectrum of conditions that lead to heart attack. The remaining are usually due to gastrointestinal conditions.

Major Causes of Chest Pain

1. Cardiovascular

• Myocardial ischemia: This is due to reduced supply of nutrients and oxygen rich blood to the muscles of the heart. Complete lack of blood supply to an area can lead to myocardial infarction or heart attack.
• Pericarditis: This is inflammation of the lining of the heart. It can occur from viral infections, metabolic diseases and secondary to heart attacks
• Aortic Dissection: This is a dangerous condition that can occur suddenly from the tearing of the wall of the aorta with a seepage of blood between the divided walls.
• Pulmonary Embolism: This is due to obstruction of the pulmonary blood vessels from a blood clot arising elsewhere in the body, most commonly the lower legs.

2. Respiratory

• Pneumonia or Pleurisy: Infection of the lung tissue and subsequent inflammation of the lining membrane surrounding the lungs can cause chest discomfort which is aggravated by breathing.
• Pneumothorax: This is the collection of air within the pleura or the membrane lining the lungs. This can occur following trauma to the chest or spontaneously from rupture of subpleural blebs (air pockets developing due to lung damage from smoking or other conditions).

3. Gastrointestinal

• Peptic Ulcer disease: Disease of excess acid production can lead to ulcer formation in the stomach and duodenum. This pain is generally present in the upper abdomen but can often present with chest pain.
• Gall Stone Disease: The presence of gallstones and inflammation of the gall bladder can occasionally present with chest pain. However, the finding of gall stones in a patient with chest pain does not rule out a cardiac cause as gallstones can co-exist with heart problems.

• Reflux disease: This occurs from the reflux of the acidic contents of the stomach into the esophagus (food pipe).
• Esophageal spasm: Abnormal contractions of the muscles lining the esophagus can cause chest discomfort.

4. Musculoskeletal

• Tietze’s Disease or costochondritis: This is inflammation of the region where the ribs attach to the sternum (breast bone). This is associated with tenderness in that region and pain on moving the arms
• Muscle sprains: These are common and occur after excessive strain.
• Disease involving vertebral discs: Compression of the spinal cord or nerve roots in the chest area can present with shooting pain and numbness.

5. Skin

• Herpes Zoster: This is an infective disorder caused by reactivation of the chickenpox virus where it causes vesicles on the skin. There is a pain in the region affected starting prior to the appearance of lesions and may often last even after their disappearance.

Symptoms Experienced 

The character of the chest pain is determined by the underlying cause. Below are some of the common symptoms associated with the different causes

• Cardiac chest pain (Anginal chest pain)
  • Pain is often related to exertion
  • Squeezing or pressure like pain
  • Localised to the central or left side of the chest with radiation to the neck and arms
  • Associated with Sweating, breathlessness
  • Resolution with rest or intake of nitroglycerin

In case of a heart attack, these symptoms occur at rest as well

• Other forms of chest pain
  • Sharp stabbing pain may be experienced in diseases of the lungs
  • Pain on movement is seen with musculoskeletal causes
  • Burning pain is seen with reflux disease
  • Colicky pain is associated with gall stones

Evaluation of Chest Pain

Due to the danger of missing out on a life threatening cause for the chest pain, most patients presenting to the emergency department or to a doctor’s clinic are generally evaluated thoroughly.

• History and Physical Examination: a complete history of the duration and nature of symptoms is helpful to determine the cause. A thorough examination of the chest in addition to checking the pulse and blood pressure is done.
• Chest X ray: This can identify any pathology in the lungs like pneumonia or pneumothorax.
• Electrocardiogram (ECG): This measures the electric activity in the heart and can identify if there is a heart attack. Different patterns can also suggest other conditions. The ECG can be done while walking on a treadmill to pick up any changes during exercise.
• Echocardiogram: This is an ultrasound based test to look at the heart chambers. An area of reduced blood supply can show as an area of reduced movement.
• Angiography or cardiac cath: This test is used to visualise the coronary blood vessels to locate a block.
• CT arteriography: This is a CT scan after inserting contrast dye in the blood to visualise the aorta. This is done if a dissection of the aorta is suspected.
• Measurement of cardiac enzymes: This is done using a blood test to look for the levels of substances released by the heart muscle upon damage. These are cardiac troponins, creatinine kinase and Lactate dehydrogenase (LDH).
• Upper GI endoscopy: this can be performed if reflux or peptic ulcer disease is suspected to be the cause for the chest pain.

Management of Chest Pain

The cause of the chest pain needs to be determined first which is followed by a specific therapy. The initial treatment of some of the common causes of chest pain is given below

• Anginal Chest pain: Drugs such as nitroglycerin can help relieve symptoms. For long term management, beta-blockers and calcium channel blockers are helpful. Aspirin is recommended to prevent the formation of clots. Angiography with stent placement is effective for opening up any blocked vessels
• Heart Attack: In an emergency setting, the patient is provided with oxygen and medications to control the pain and prevent the worsening of the vessel blockage. Angiography with stent placement, clot destruction, and bypass surgery are treatment options.
• Acid reflux and peptic ulcer disease: Acid suppressing medications like pantoprazole or ranitidine are recommended
• Pneumonia: Antibiotics are prescribed by a physician if diagnosed with the infection.

References

1. David A. Morrow, Chest Discomfort, Harrison’s Principles of Internal Med1cine, 19^th Edition (2015)
2. Hollander JE, et al. Evaluation of the adult with chest pain in the emergency department. https://uptodate.com/contents/search. Accessed Aug. 7, 2018