Chest Pain

Chest pain is very common, but also a very insidious symptom that is one of the most usual reason of an internist examination. Chest pain has many causes ranging from utterly trivial to life threatening conditions. This text does not cover all causes, but it is sufficient to inform you about most important and significant ones.

Causes

Angina pectoris

This pain is caused by a reduced oxygen supply to heart muscle. Coronary arteries’ atherosclerosis is the typical reason. Coronary arteries supply heart with blood. If they are narrowed by atherosclerotic process, blood doesn’t flow enough by physical exertion. Heart muscle suffers from the lack of oxygen and hurts because of ischemia. The pain classically occurs during exertion and stops when the affected person relaxes. It lasts only a short time, mostly several minutes. If the whole process is untreated, symptoms continue to deteriorate (pain begins to occur with less exertion or even at rest). At any stage of this process an atherosclerotic plate rupture can create a blood clot and completely close the affected coronary vessel resulting in acute myocardial infarction.

 

Chest pain resulting from physical activity and rapidly subsiding at rest is definitely a reason to visit a doctor!

Myocardial infarction (heart attack)

Myocardial infarction occurs by sudden closure of a coronary artery by a blood clot that can occur at sites affected by atherosclerosis. It may be preceded by a long-term uncontrolled angina pectoris with chest pain by physical activities, but it can also occur without any previous symptoms. Myocardial infarction differs from angina pectoris by fact that there is present heart muscle necrosis (cell death) of some extent due to lack of oxygen. A big heart attack can kill a man on the spot, because the heart can suddenly cease to function as a pump. Damaged heart cells are prone to emergence of severe arrhythmias like fatal ventricular fibrillation.

 

Pain in a heart attack is extremely strong, is located behind the breastbone, it often burns, it may radiate to the left upper hand, sometimes it radiates to the abdomen and it is often associated with nausea and vomiting. It can occur at rest or during physical activity, but unlike pain in angina pectoris, it does not fade away. The victim is often very frightened and sweaty. Larger heart attacks, resulting in deterioration of cardiac function, are often associated with shortness of breath.

Pericarditis

Pericarditis is inflammation of the pericardium. Pericardium is a membrane that surrounds the heart and pain occurs by its inflammation. There are many reasons of such inflammation (viral infections, lupus erythematosus, rheumatic fever, systemic body reactions to a cancer disease and many others). The pain is usually not severe as by myocardial infarction, but it is overall not always easy to distinguish pericarditis from a heart attack. An ECG or echocardiography can help a bit, but proper diagnosis is quite a challenging issue.

Pleurisy

Inflammation of pleura (a membrane lining chest cavity and lungs) may also manifest as chest pain. Pleural pain is quite is quite distinguishable, because it is related to breathing and gets worse by inspiration.

Myocarditis

Inflammation of heart muscle by any cause (see the relevant article) can cause chest pain. In addition, abnormal heart rhythms and symptoms of heart failure may be present as well.

Heartburn (gastroesophageal reflux disease)

Reflux disease is a condition when stomach fluid including aggressive acid returns into the esophagus. Normally, esophagus is separated from stomach by a sphincter muscle, which allows food to pass from esophagus to stomach, but not backwards. If this sphincter does not work properly, the acidic stomach contents return back into esophagus damaging its wall. This may be associated with sudden chest pain. The pain often occurs after meals and antacids (alkaline substances reducing gastric acidity) bring a quick relief. Pain is sometimes "just" uncomfortable, but other times it can be so violent that it reminds a heart attack. In case of a suspected heart attack it is however a good idea to call medical help immediately to eliminate risk of a myocardial infarction. In addition, people with reflux disease often have episodes of unpleasant nocturnal dry cough. It is because during sleep in horizontal position it is easier for stomach content to flow into esophagus, pharynx and into airways that become irritated.

Pulmonary embolism

This is a condition when a venous blood clot occurs in the body (typically in veins of lower extremities as so-called deep vein thrombosis). This blood clot can break as a so-called embolus flow in bloodstream into the lungs, where it blocks pulmonary blood vessels to a variable extent. Large sudden obstruction of pulmonary vessels can cause sudden death. Pulmonary arteries obstruction of lower extent may present with chest pain associated with a dry cough and shortness of breath. If a patient has symptoms of deep vein thrombosis and suddenly complains about chest pain the suspicion of pulmonary embolism is very strong.

Respiratory infections

Infections of respiratory tract may cause chest pain. It is especially common in pneumonias. There is not only chest pain, but usually also high fever and cough (dry or with expectoration of phlegm). The diagnosis is confirmed by chest X-ray or computed tomography. Blood tests show us presence of an infectious process (elevated sedimentation and CRP).

Musculoskeletal pain

Thoracic spine adjacent nerves and muscles are probably the most common cause of chest pain. This pain is often described as “stinging” and it often shoots from the back to the front of the chest. It is usually not dangerous, but also not too comfortable for the patient. Pain may worsen during inspiration and mimics pleurisy.

Pneumothorax

Pneumothorax is a condition when air enters the pleural cavity. Pleural cavity is a pair area; both lungs have one of those. These cavities are lined with a membrane called the pleura and they are filled with vacuum. The vacuum allows dilation of the lungs during inspiration. Relatively common is the so-called spontaneous pneumothorax. It typically occurs in otherwise completely healthy young men. Their lung ruptures in some area and air from the affected lung flows into its pleural cavity. This condition is often associated with acute chest pain. By a large pneumothorax, significant shortness of breath usually emerges. The status can be recognized while listening by a stethoscope as there is no apparent breathing sounds on side of affected lung. A chest X-ray helps to confirm the diagnosis. Smaller pneumothoraces can be only monitored as they tend to absorb and disappear. By larger pneumothoraces it is necessary to puncture the affected pleural cavity and administer negative-pressure drainage to get air out.

Aortic dissection

This is a rupture of thoracic aorta caused by the power of blood flow. It is a condition associated with extremely severe chest pain that is practically impossible to distinguish from a heart attack. Clear signs of myocardial infarction on ECG or in blood tests are, however, not present. It is one of the most insidious conditions in internal medicine because it is difficult to properly diagnose it and incorrect diagnose often has fatal consequences.

Transmitted abdominal pain

Some painful abdominal diseases can radiate pain into chest. It is for example, acute pancreatitis or biliary colic.

Shingles

This is an infectious disease caused by the varicella-zoster virus. It attacks sensation nerves leading from the skin and subcutaneous tissues. The infestation may appear virtually in any part of the body including chest, head or face. By chest affection there is often chest pain present than can be easily mistaken with a heart attack. Few days after the onset of pain skin blisters occur in affected area. When it happens, the diagnosis is not too difficult anymore. The pain may persist even months after the rash disappears.