Chest Pain

Deciding the cause of chest pain is sometimes very difficult and may require blood tests, X-rays, CT scans, and other tests.

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 life-threatening, while others are less dangerous.

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
• 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

There may be classic presentations of signs and symptoms for many diseases but they can also present atypically and there may also be significant overlap among the symptoms of each condition. Age, gender, and race can affect presentation and the health care professional must consider many variables before reaching a diagnosis.

Pain can be caused by almost every structure in the chest. Different organs can produce different types of pain; unfortunately, the pain is not specific to each cause.

Many reasons can cause chest pain, for example:

• Broken or bruised ribs
• Pleuritis or pleurisy
• Pneumothorax
• Shingles
• Pneumonia
• Pulmonary embolus
• Angina
• Heart attack (myocardial infarction)
• Pericarditis
• The aorta and aortic dissection
• The esophagus and reflux esophagitis
• Referred abdominal pain

Coronary heart disease

• Smoking
• High blood pressure
• High cholesterol
• Diabetes
• Family history

Pulmonary embolus (blood clot in the lung)

• Prolonged activities such as bed rest and long car or airplane trips
• Recent surgery
• Fractures
• Birth control pill use (particularly if the patient smokes cigarettes)
• Cancer

Aortic dissection

• High blood pressure
• Marfan syndrome
• Ehlers-Danlos syndrome
• Polycystic kidney disease
• Cocaine use
• Pregnancy

Other signs and symptoms that occur with chest pain and chest discomfort include:

• Pressure
• Squeezing
• Heaviness
• Burning
• Sometimes you may feel like you are choking or short of breath

People who have had severe chest pain describe it as discomfort that ranges from sharp to dull, and usually, is located in the jaw, neck, shoulders, upper abdomen, and arms.

Signs like anxiety and other conditions, exertion, eating, exposure to cold, or emotional stress can cause tightness in the chest.

The key to diagnosis is the patient's medical history. Learning about the nature of the pain will give the health care professional direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms, and the patient's risk factors for a specific disease can help the doctor assess the probability of each potential cause and make decisions about what diagnoses should be considered and which ones can be discarded.

Differential diagnosis is a thought process that healthcare professionals use to consider and then eliminate potential causes of an illness. As more information is gathered, from either history, physical examination, or testing, the potential diagnosis list is narrowed until the final answer is achieved. Moreover, the patient's response to therapeutic interventions can expand or narrow the differential diagnosis list. In patients with chest pain, many possible conditions may be present, and the healthcare professional will want to first consider those that are life-threatening. Using laboratory and X-ray tests may not be necessary to exclude potentially lethal diseases like heart attack, pulmonary embolus, or aortic dissection when clinical skills and judgment are employed.

The patient may be asked a variety of questions to help the healthcare professional understand the quality and quantity of the pain. Patients use different words to describe pain, and the healthcare professional must get an accurate impression of the situation. The questions may also be asked in different ways.
The person may be asked to explain their answer because sometimes words mean something different to other people. If the person says that, “they aren’t having chest pain,” but they neglect to tell the doctor that they are feeling “chest pressure.” People may describe the pain as sharp, but they mean intense, while the doctor may think that sharp equals stabbing. The doctor’s understanding of the quality of pain is an important first step in making the diagnosis.

There is a distinct difference between the qualities of pain. The doctor needs to know the type of pain, and how much pain the person is experiencing.

Questions the doctor may ask about chest pain

1. When did the pain start?
2. What is the quality of the pain?
3. How long does the pain last?
4. Does the pain come and go?
5. What makes the pain better?
6. What makes the pain worse?
7. Does the pain radiate somewhere (move to another area of the body)?
8. Has there been any preceding illness?
9. Has there been any trauma?
10. Have there been similar episodes of pain in the past?
11. Is the pain different from that of a previous condition that has been experienced, or is it similar?

Questions about the associated symptoms

1. Is there shortness of breath?
2. Fever or chills?
3. Cough?
4. Nausea or vomiting?
5. Sweating?

Treatment for chest pain depends on the cause, which may include:

• Broken or bruised ribs treatment
• Pleuritis or pleurisy treatment
• Pneumothorax treatment
• Shingles treatment
• Pneumonia treatment
• Pulmonary embolus treatment
• Angina treatment
• Heart attack (myocardial infarction) treatment
• Pericarditis treatment
• The aorta and aortic dissection treatment
• The esophagus and reflux esophagitis treatment
• Referred abdominal pain treatment

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)
• Because the surrounding muscles go into spasms, there is pain with any movement of the trunk

The doctor will listen to the chest to make certain that there is no associated lung damage. Sometimes, subcutaneous emphysema can be felt with a collapsed lung (pneumothorax), a sensation of feeling Rice Krispies when air leaks into the skin. A chest X-ray may be done to look for pneumothorax or pulmonary contusion (a bruised lung). Special X-rays looking for rib fractures are not needed since the presence or absence of a fracture will not alter the treatment plan or recuperation time. Special attention will be given to the upper abdomen since the ribs protect the spleen and liver, to make certain there are no associated injuries.

The major complication of rib injuries is pneumonia. The lungs work like bellows. Normally, when one takes a breath, the ribs swing out and the diaphragm moves down, sucking air into the lungs. Because it hurts to take a deep breath, this mechanism is altered, and the lung underlying the injury may not fully expand because the patient cannot tolerate the pain. The result is stagnant air and lung tissue that does not fully expand, causing a potential breeding ground for a lung infection (pneumonia).

Rib injury treatment may include:

• Pain control with anti-inflammatory medications like ibuprofen and narcotic pain medications allows deep breaths to occur.
• Application of ice to the affected area and 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.

Occasionally, 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 a 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 of 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.

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
• Complications of surgery

The physical exam may be relatively unremarkable, but a friction rub may be heard over the site of pleural inflammation. If a significant amount of fluid leaks from the inflammation, the space between the lung and the chest wall (the pleural space) can fill with fluid, known as an effusion. When listening with a stethoscope, there may be decreased air entry into the lungs. Also, percussion, in which the health care professional taps on the chest wall like a drum, may reveal the dullness of one side compared to the other.

Often a chest X-ray is done to assess the lung tissue and the presence or absence of fluid in the pleural cavity.

Pleurisy is usually treated with anti-inflammatory medication. This will often treat an effusion as well. If the effusion is large and is causing shortness of breath, thoracentesis (thora=chest + centesis=withdrawing fluid) may be done. For thoracentesis, a needle is placed in the pleural space and the fluid is withdrawn. Aside from making the patient feel better, the fluid may be sent for laboratory analysis to help with diagnosis. Ultrasound may be ordered, depending on the patient's situation.

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 an 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 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 the placement of a chest tube to relieve tension, it can be fatal.

Shingles are 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 quite severe. Some patients may develop postherpetic neuralgia, or chronic pain from the inflamed nerve, which may persist long after the infection has cleared. Varieties of pain control strategies are available from medication to pain stimulators to surgery.

Pneumonia is an infection of the lung. In pneumonia, inflammation can cause fluid buildup within a segment of the lung tissue, decreasing its ability to transfer oxygen from air to the bloodstream.

Typical symptoms of infectious pneumonia include:

• Fever
• Chills
• Malaise

Other signs and symptoms include:

• Cough
• Shortness of breath
• Sputum production (coughing up mucus)

The most common causes of lung infections are caused by Streptococcal pneumoniae or pneumococcus bacteria. The classic presentation of a lung infection caused by the bacteria Streptococcal pneumoniae or pneumococcus is the acute onset of shaking chills, fever, and a cough that produces rusty brown sputum.

The doctor will check the patient's vital signs (for abnormalities consistent with an infection), pulse and respiratory rate, and fever, and listen to chest sounds. To diagnose infectious pneumonia procedures and tests may include, a chest X-ray, blood tests, or increased lactic acid (lactate). Treatment usually is with antibiotics.

A blood clot in 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 activities like a long trip in a car or airplane
• Recent surgery or fracture
• Birth control pills (especially associated with smoking)
• Cancer
• Pregnancy

Thrombophilia (thrombo = clot + philia = attraction) comprises a host of blood clotting disorders, which places patients at risk for pulmonary embolism.

The pulmonary embolus begins in veins elsewhere in the body, usually the legs, though it can occur in the pelvis, arms, or the major veins in the abdomen. When a thrombus or blood clot forms, it has the potential to break free (now called an embolus) and float downstream, returning to the heart. The embolus can continue its journey through the heart and then may be pumped into the pulmonary circulation system, eventually becoming lodged in one of the branches of the pulmonary artery and cutting off blood supply to part of the lung. This decreased blood flow doesn't allow enough blood to pick up oxygen in the lungs, and the patient can become markedly short of breath.

As mentioned previously, the common complaints include:

• Pleuritic chest pain from the inflamed lung
• Bloody sputum
• Shortness of breath

The patient can also have anxiety and sweat profusely. Depending upon the size of the clot, the initial presentation may be fainting (syncope) or shock in which the patient collapses, with decreased blood pressure and altered mental function.

Depending on the severity of the embolus and the amount of lung tissue at risk, the patient may present critically ill (in extremis) with markedly abnormal vital signs or may appear rather normal. Physical examination may not be helpful, and the diagnostic studies are done upon clinical suspicion based on history and risk factors.

The diagnosis may be made directly with imaging of the lungs or indirectly by finding a clot elsewhere in the body. The strategy used to make a diagnosis will depend upon each patient's situation, but there are some general tools available, for example, D-Dimer, CT scans, ultrasound, angiography, and medications.

The concern for most patients and healthcare 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, dizziness, 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, 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.

Treatment of angina

The purpose of making the diagnosis of angina is to restore normal blood supply to the heart muscle before a heart attack occurs and permanent muscle damage results. Aside from minimizing risk factors by controlling blood pressure, cholesterol, and diabetes, and stopping smoking, medications can be used to make the heart beat more efficiently (for example, beta-blockers), dilate blood vessels (for example, nitroglycerin), and make blood less likely to clot (aspirin).

Treatment of heart attack

An acute heart attack (myocardial infarction) is a true emergency since a complete blockage of the blood supply will cause part of the heart muscle to die and be replaced by scar tissue. This lessens the ability of the heart to pump blood to meet the body's needs. As well, the injured heart muscle is irritable and can cause electrical disturbances like ventricular fibrillation, a condition in which the heart jiggles like Jell-O and cannot beat in a coordinated fashion. This is the cause of sudden death in a heart attack. The cause of an acute heart attack is the rupture of cholesterol plaque in a coronary artery. This causes a blood clot to form and occlude the artery.

The treatment for heart attack is an emergent restoration of blood supply. Two options include the use of a drug like TPA or TNK to dissolve the blood clot (thrombolytic therapy) or emergency heart catheterization, using a balloon to open up the blocked area (angioplasty), and keeping it open with a mesh cage called a stent. Emergent angioplasty is preferred if the patient lives close to a hospital with that capability but many people do not. Staged treatment with initial thrombolytic therapy followed by angioplasty is also reasonable.

Coronary artery bypass surgery is considered when there is diffuse artery disease that is not amenable to angioplasty and stenting.

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 and potentially cause blood to accumulate in the thin pericardial sac.

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 helps make the diagnosis, look for a recent viral illness, and ask 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. An echocardiogram is helpful if there is fluid in the pericardial sac associated with the inflammation.

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 using the triad of (Beck's triad):

• Low blood pressure
• Distention of neck veins
• Muffled heart tones

Treatment requires placing a needle into the pericardium to withdraw fluid and/or surgery to open a window in the pericardium to prevent future fluid buildup.

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
• A late post-operative complication of open-heart surgery

The pain from aortic dissection occurs suddenly and often is described as intense, stabbing, or ripping. It may be constant, or the pain may be pleuritic (worse with a deep breath). Often it radiates to the back. Often, if the dissection occurs in the chest, it may be confused with the pain of heart attack, esophagitis, or pericarditis. If the aortic dissection is located near or below the diaphragm, it can mimic renal colic (pain from a kidney stone).

Diagnosis is based on history, review of the risk factors, physical examination, and clinical suspicion. Physical examination may reveal loss or delay of pulses in the wrist or leg when comparing one side to the other. A new heart murmur may be detected if the dissection involves the aortic valve that connects the aorta with the heart. If blood vessels exiting the aorta are involved in the area of dissection, the organs that they supply may be at risk. Stroke and paralysis can be seen in dissection. Blood supply can be lost to kidneys and bowel and/or to arms and legs.

The diagnosis of aortic dissection is confirmed by imaging, most commonly by CT angiography of the aorta. Echocardiography or ultrasound may also be used to image the aorta.

Type A dissections of the ascending aorta are treated by surgery in which the damaged piece of the aorta is removed and replaced with an artificial graft. Sometimes the aortic valve needs to be repaired or replaced if it is damaged.

Type B dissections are initially treated with medications to control blood pressure and maintain it in a normal range. Beta-blockers and calcium channel blocker medications are commonly used. If medical therapy fails, surgery may be necessary.

If the dissection tears completely through all three layers of the aortic wall, then the aorta ruptures. This is a catastrophe, and more than 50% of affected patients die before reaching a hospital. The overall mortality of aortic rupture is greater than 80%.

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 a 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 Barrett's esophagus (precancerous changes affecting 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 gastrography 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 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.

The complications of acid reflux depend upon its severity and its duration. Chronic reflux can cause changes in the lining of the esophagus (Barrett's esophagus) which may lead to cancer. Reflux may also bring acid contents into the back of the mouth into the larynx (voice box) and cause hoarseness or recurrent cough. Aspiration pneumonia can be caused by acid and food particles inhaled into the lungs. For more, please read the GERD article.

Conditions in the abdomen can present as pain referred to the chest, especially if there is inflammation along with 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.