Causes of pain behind the sternum

The main causes of pain behind the sternum:

• diseases of the musculoskeletal system: rib chondritis, rib fracture;
• cardiovascular diseases: ischemia of the heart caused by atherosclerosis of the heart vessels; unstable / stable angina; cardiac ischemia caused by coronary vasospasm (angina pectoris); mitral valve prolapse syndrome; cardiac arrhythmia; pericarditis.
• gastrointestinal diseases: gastroesophageal reflux, spasm of the esophagus, stomach and duodenum ulcer, gallbladder disease;
• anxiety states: undefined anxiety or "stress," panic disorder;
• pulmonary diseases: pleurodynia (pleuralgia), acute bronchitis, pneumonia;
• neurological diseases;
• uncharacteristic definite or atypical pain behind the sternum.

The chest pain is not limited to a certain age group, but is more common in adults than in children. The highest percentage is observed among adults over 65 years, and in second place - male patients aged 45 to 65 years.

The frequency of diagnosis, by age and sex

Floor	Age group (years)	The most common diagnoses
Men's	18-24	1. Gastroesophageal reflux
		2. Muscular pain of the chest wall
	25-44	1. Gastroesophageal reflux
		2. Muscular pain of the chest wall
		3. Costal chondritis
	45-64	1. Angina pectoris, unstable angina, myocardial infarction
		2. Muscular pain of the chest wall
		3. "Atypical" pain behind the sternum
	65 and more	1. Muscular pain of the chest wall
		2. "Atypical" chest pain or coronary artery disease
Women	18-24	1. Costal chondritis
		2. Anxiety / stress
	25-44	1. Muscular pain of the chest wall
		2. Costal chondritis
		3. "Atypical" pain behind the sternum
		4. Gastroesophageal reflux
	45-64	1. Angina pectoris, unstable angina, myocardial infarction
		2. "Atypical" pain behind the sternum
		3. Muscle pain of the chest wall
	65 and more	1. Angina pectoris, unstable angina, myocardial infarction
		2. Muscular pain of the chest wall
		3. "Atypical" pain behind the sternum or costal chondritis

Equally difficult is the position of the doctor in the initial treatment of pain, when he tries to connect it with the pathology of one or another organ. Observability of the clinicians of the last century helped them to formulate assumptions about the pathogenesis of pain - if the attack of pain occurs without a cause and stops on its own, then probably the pain is of a functional nature. Works devoted to a detailed analysis of chest pain are not numerous; The groups of pains offered in them are far from perfect. These shortcomings are due to the objective difficulties in analyzing the patient's feelings.

The complexity of the interpretation of pain in the chest is also due to the fact that the detectable pathology of one or another organ of the thorax or of the musculoskeletal formation does not yet mean that it is the source of pain; in other words, the detection of a disease does not mean that the cause of pain is precisely defined.

When assessing patients with chest pain, the physician should weigh all the relevant variants of the potential causes of pain, determine when an intervention is necessary, and make a choice among an almost limitless number of diagnostic and therapeutic strategies. All this must be done while reacting to the distress experienced by patients who are concerned about the presence of a life-threatening disease. The complexity of diagnosis is further complicated by the fact that chest pain often represents a complex interaction of psychological, pathological and psychosocial factors. This makes it the most common problem in primary care.

When considering pain behind the sternum, the following five elements must be considered (at least): predisposing factors; characterization of the attack of pain; duration of painful episodes; characteristic of the actual pain; factors that relieve pain.

With all the variety of causes that cause pain in the chest, pain syndromes can be grouped.

Approaches to groupings can be different, but mostly they are built on a nosological or organ principle.

Conditionally it is possible to distinguish 6 following groups of the reasons of a pain behind a breast:

1. Pain caused by heart disease (so-called heart pain). These painful sensations can be the result of defeat or dysfunction of the coronary arteries - coronary pain. In the origin of non-coronary pains, the "coronary component" does not participate. In the future, we will use the terms "heart pain syndrome," "heart pain," understanding their relationship to a particular pathology of the heart.
2. Pain caused by the pathology of large vessels (aorta, pulmonary artery and its branching).
3. Pain caused by the pathology of the bronchopulmonary apparatus and the pleura.
4. Pain related to the pathology of the spine, anterior thoracic wall and muscles of the shoulder girdle.
5. Pain caused by the pathology of the mediastinum.
6. Pain associated with diseases of the abdominal cavity and the pathology of the diaphragm.

Pain in the chest area is also subdivided into acute and long-lasting, with obvious cause and for no apparent reason, "non-dangerous" and pain, which serve as a manifestation of life-threatening conditions. Naturally, first of all it is necessary to establish whether the pain is dangerous or not. The "dangerous" pains include all varieties of anginal (coronary) pain, pain with pulmonary embolism (PE), exfoliating aortic aneurysm, spontaneous pneumothorax. To "non-dangerous" - pain in the pathology of the intercostal muscles, nerves, bone-cartilaginous formations of the thorax. "Dangerous" pains are accompanied by a suddenly developed severe condition or severe disorders of heart or respiratory function, which immediately makes it possible to narrow down the range of possible diseases (acute myocardial infarction, PE, exfoliating aortic aneurysm, spontaneous pneumothorax).

The main causes of acute pain behind the sternum, representing a danger to life:

• cardiac: acute or unstable angina, myocardial infarction, exfoliating aortic aneurysm;
• pulmonary: pulmonary embolism; intense pneumothorax.

It should be noted that the correct interpretation of pain behind the sternum is quite possible in the usual physical examination of the patient with the use of a minimum number of instrumental methods (conventional electrocardiographic and roentgenological examination). The erroneous initial presentation of the source of pain, in addition to increasing the time of examination of the patient, often leads to severe consequences.

Anamnesis and physical examination data to determine the cause of chest pain

Data of anamnesis	Diagnostic category
	Cardiac	Gastrointestinal	Musculoskeletal
Predisposing factors	Male. Smoking. High blood pressure. Hyperlipidemia. Myocardial infarction in a family history	Smoking. Alcohol consumption	Physical activity. A new type of activity. Abuse. Duplicate actions
Characteristic of an attack of pain	With a high level of stress or emotional stress	After eating and / or on an empty stomach	With or after activity
Duration of pain	Minutes	From min. Before hours	From hours to days
Characteristics of pain	Pressure or "burning"	Pressure or drilling »pain	Sharp, local, caused by movements
Factors, Taking Pain	Recreation. Nitro drugs under the tongue	Eating. Antacids. Antihistamines	Recreation. Analgesics. Nonsteroidal anti-inflammatory drugs
Confirmation data	At attacks of a stenocardia disturbances of a rhythm or noise are possible or probable	Pain in the epigastric region	Pain at palpation in the paravertebral points, at the points of intercostal nerves, morbidity of the periosteum

Cardialgia (non-angiogenic pain). Cardialgia caused by these or other heart diseases are very common. According to its origin, significance and place in the structure of the incidence of the population, this group of pains is extremely heterogeneous. The causes of such pain and pathogenesis are very diverse. Diseases or conditions in which cardialgias are observed are as follows:

1. Primary or secondary cardiovascular functional disorders are the so-called cardiovascular syndrome of the neurotic type or neurocirculatory dystonia.
2. Diseases of the pericardium.
3. Inflammatory diseases of the myocardium.
4. Cardiac muscle dystrophy (anemia, progressive muscular dystrophy, alcoholism, vitamin deficiency or starvation, hyperthyroidism, hypothyroidism, catecholamine effects).

As a rule, non-angiogenic pains are of good quality, since they are not accompanied by coronary insufficiency and do not lead to the development of ischemia or necrosis of the myocardium. However, in patients with functional disorders that lead to an increase (usually a short-term) in the level of biologically active substances (catecholamines), the probability of developing ischemia still exists.

Pain behind the breastbone of neurotic origin. We are talking about pain in the heart, as one of the manifestations of neurosis or neurocirculatory dystonia (vegetative-vascular dystonia). Usually, these are aching or piercing pains of varying intensity, sometimes prolonged (hours, days) or, conversely, very brief, instantaneous, piercing. The localization of these pains is very different, not always constant, almost never overloading. Pain can increase with physical activity, but usually with psychoemotional stress, fatigue, without a clear effect of nitroglycerin, do not decrease at rest, but, on the contrary, patients feel better on movement. The diagnosis takes into account the presence of signs of a neurotic condition, autonomic dysfunction (sweating, dermographism, subfebrile, pulse and blood pressure fluctuations), as well as young or middle age of patients, mostly female. These patients have increased fatigue, decreased exercise tolerance, anxiety, depression, phobias, fluctuations in heart rate, blood pressure. In contrast to the severity of subjective disorders, objective research, including the use of various additional methods, does not reveal a particular pathology.

Sometimes among these symptoms of neurotic origin the so-called hyperventilation syndrome is revealed. This syndrome is manifested by voluntary or involuntary increase and deepening of respiratory movements, tachycardia, arising in connection with adverse psycho-emotional effects. In this case, pain behind the sternum, as well as paresthesia and muscle twitching in the limbs due to the emerging respiratory alkalosis, may occur. There are observations (incompletely confirmed), indicating that hyperventilation can lead to a decrease in myocardial oxygen consumption and provoke coronarospasm with pain and ECG changes. It is possible that hyperventilation can be the cause of the appearance of pain in the heart area when carrying out a sample with physical exertion in people with vegetative-vascular dystonia.

To diagnose this syndrome, a provocative test with induced hyperventilation is performed. The patient is asked to breathe more deeply - 30-40 times a minute for 3-5 minutes or until the appearance of normal symptoms for the patient (pain behind the sternum, headaches, dizziness, shortness of breath, sometimes half-unconscious). The appearance of these symptoms during the performance of the sample or 3-8 minutes after its termination, with the exclusion of other causes of pain, has a very definite diagnostic value.

Hyperventilation in some patients may be accompanied by aerophagia with the appearance of pain or a feeling of heaviness in the upper part of the epigastric region due to stretching of the stomach. These pains can spread upwards, behind the breast bone, into the neck and the left shoulder region, simulating angina. Such pains increase with pressure on the epigastric region, in the supine position, with deep breathing, decrease with belching by air. With percussion, an expansion of the Traube area is found, including tympanitis over the area of absolute stupidity of the heart, with fluoroscopy - an enlarged gastric bladder. Similar pain can occur when stretching with the left-corner gas of the large intestine. In this case, the pains are often associated with constipation and are relieved after defecation. Careful anamnesis usually allows you to determine the true nature of pain.

The pathogenesis of cardiac pain in neurocirculatory dystonia is unclear, due to the impossibility of their experimental reproduction and confirmation in the clinic and experiment, in contrast to anginal pain. Perhaps in connection with this circumstance a number of researchers in general question the presence of pain in the heart with neurocirculatory dystonia. Such trends are most common among representatives of the psychosomatic area in medicine. According to their views, it is a question of transforming psychoemotional disorders into a painful sensation.

The origin of the pain in the heart with neurotic states finds an explanation from the standpoint of the cortico-visceral theory, according to which the pathological dominant in the central nervous system arises when the vegetative instruments of the heart are irritated with the formation of a vicious circle. There is reason to believe that pain in the heart with neurocirculatory dystonia occurs due to a violation of myocardial metabolism against the background of excessive adrenal stimulation. In this case, a decrease in the content of intracellular potassium, activation of dehydrogenation processes, an increase in the level of lactic acid, and an increase in the demand for myocardium in oxygen are observed. Hyperlactatemia is a well-proven fact in neurocirculatory dystonia.

Clinical observations, indicating a close connection of pain in the heart and emotional effects, confirm the role of catecholamines as a triggering mechanism for the onset of pain. In favor of this position is evidenced by the fact that with intravenous administration of isadrine, patients with neurocirculatory dystonia have pains in the heart region of the type of cardialgia. Obviously, catecholamine stimulation can also explain the provocation of cardialgia by a breakdown with hyperventilation, as well as its occurrence at the height of respiratory disorders with neurocirculatory dystonia. A confirmation of this mechanism can also serve as positive results of cardialgia treatment by respiratory exercises aimed at eliminating hyperventilation. A certain role in the formation and maintenance of painful cardiac syndrome in neurocirculatory dystonia is played by the flow of pathological impulses coming from the zones of hyperalgesia in the area of the muscles of the anterior thoracic wall into the corresponding segments of the spinal cord, where, according to the "portal" theory, the summation phenomenon arises. In this case, there is a reverse flow of impulses, which causes irritation of the thoracic sympathetic ganglia. Of course, the low threshold of pain sensitivity in vegetative-vascular dystonia is also important.

In the emergence of pain, such factors, as yet insufficiently studied factors, such as a disturbance of microcirculation, changes in the rheological properties of the blood, an increase in the activity of the kinin kallikrein system may play a role. It is possible that with prolonged existence of severe vegetative-vascular dystonia, it is possible to transition to coronary artery disease with unchanged coronary arteries, in which pain is caused by spasm of the coronary arteries. In a focused study of a group of patients with proven coronary artery disease with unchanged coronary arteries, it was found that all of them had a severe neurocirculatory dystonia in the past.

In addition to vegetative-vascular dystonia, cardialgia are also observed in other diseases, but the pain is less pronounced and usually never appears in the clinical picture of the disease to the fore.

The origin of pain with pericardial damage is quite understandable, since there are sensitive nerve endings in the pericardium. Moreover, it has been shown that irritation of those or other pericardial zones gives different localization of pain. For example, irritation of the pericardium on the right causes pain sensations along the right median-clavicular line, and irritation of the pericardium in the left ventricle is accompanied by pain that spreads along the inner surface of the left shoulder.

Pain in myocarditis of various origin is a very common symptom. Their intensity is usually small, but in 20% of cases they have to differentiate with the pain caused by coronary artery disease. Pain in myocarditis is probably associated with irritation of nerve endings located in the epicardium, as well as with inflammatory myocardial edema (in the acute phase of the disease).

Even more uncertain is the origin of pain in myocardiodystrophies of different origin. Probably, the pain syndrome is caused by the disturbance of myocardial metabolism, the concept of local tissue hormones, convincingly presented by N.R. Paleev et al. (1982), can shed light on the causes of pain. In some myocardial dystrophies (due to anemia or chronic carbon monoxide poisoning), pain can be of mixed origin, in particular an ischemic (coronary) component is of significant importance.

We should dwell on the analysis of the causes of pain in patients with myocardial hypertrophy (due to pulmonary or systemic hypertension, valvular heart disease), as well as in primary cardiomyopathies (hypertrophic and dilated). Formally, these diseases are mentioned in the second category of anginal pain due to the increased demand for myocardium in oxygen with unchanged coronary arteries (the so-called noncoronogenic forms). However, in these pathological conditions, in a number of cases unfavorable hemodynamic factors arise that cause relative myocardial ischemia. It is believed that the pain of the type of angina pectoris observed in aortic insufficiency depends primarily on low diastolic pressure and, consequently, low coronary perfusion (coronary blood flow is realized during diastole).

With aortic stenosis or idiopathic hypertrophy of the myocardium, the appearance of pain is associated with a violation of coronary circulation in the subendocardial regions due to a significant increase in intramyocardial pressure. All pain sensations in these diseases can be designated as metabolic or hemodynamically caused anginal pain. Despite the fact that they are not formally related to IHD, one should keep in mind the possibility of developing small-focal necrosis. However, the characterization of these pains often does not correspond to classical angina, although typical seizures are also possible. In the latter case, the differential diagnosis with ischemic heart disease is especially complicated.

In all cases of detection of non-coronary causes of the origin of chest pain, it is taken into account that their presence does not at all contradict the simultaneous existence of IHD and, accordingly, requires the examination of the patient for the purpose of exclusion or confirmation.

Pain behind the breastbone, caused by the pathology of the bronchopulmonary apparatus and the pleura. Pain quite often accompanies a diverse pulmonary pathology, occurring in both acute and chronic diseases. However, it is usually not a leading clinical syndrome and is easily differentiated.

The source of pain is the parietal pleura. From the pain receptors located in the parietal pleura, the afferent fibers go in the intercostal nerves, so the pain is clearly localized on the affected half of the chest. Another source of pain is the mucous membrane of the large bronchi (which is well proven in bronchoscopy) - afferent fibers from the large bronchi and trachea are part of the vagus nerve. The mucous membrane of small bronchi and pulmonary parenchyma probably does not contain pain receptors, therefore pain sensations in the primary lesion of these formations appear only when the pathological process (pneumonia or swelling) reaches the parietal pleura or spreads to the large bronchi. The most severe pains are noted in the destruction of lung tissue, sometimes acquiring a high intensity.

The nature of the pain sensations depends to some extent on their origin. Pain with lesions of the parietal pleura usually stitching, clearly associated with a cough and deep breathing. Dull pain is associated with the stretching of the mediastinal pleura. Strong constant pain, which increases with breathing, movement of the arms and shoulder girdle, may indicate the germination of the tumor in the chest.

The most common causes of pulmonary-pleural pain are pneumonia, lung abscess, bronchial and pleural tumors, pleurisy. For pain associated with pneumonia, dry or exudative pleurisy, wheezing in the lungs and noise of friction of the pleura can be detected during auscultation.

Severe pneumonia in adults has the following clinical signs:

• moderate or severe oppression of respiratory function;
• temperature 39.5 ° C or higher;
• confusion of consciousness;
• frequency of breathing - 30 per min or more;
• pulse 120 beats per minute or more;
• systolic blood pressure below 90 mm Hg. P.
• diastolic blood pressure is below 60 mm Hg. P.
• cyanosis;
• over 60 years - features: the drainage pneumonia, proceeds more heavily with accompanying serious diseases (diabetes, heart failure, epilepsy).

NB! All patients with signs of severe pneumonia should be immediately referred for inpatient treatment! Referral to hospital:

• severe pneumonia;
• patients with pneumonia from socially and economically disadvantaged segments of the population, or who are unlikely to fulfill the prescription of a doctor at home; who live very far from a medical facility;
• pneumonia in combination with other diseases;
• suspected atypical pneumonia;
• patients who do not have a positive reaction to treatment.

Pneumonia in children is described as follows:

• retraction of the intercostal spaces of the chest, cyanosis and inability to drink in young children (from 2 months to 5 years) also serves as a sign of a severe form of pneumonia, which requires an urgent referral to the hospital;
• it is necessary to distinguish pneumonia from bronchitis: the most valuable sign in the case of pneumonia is tachypnea.

Painful sensations in pleural lesions almost do not differ from those in acute intercostal myositis or intercostal muscle injury. With spontaneous pneumothorax, there is acute unbearable pain behind the sternum, associated with the defeat of the bronchopulmonary apparatus.

Pain behind the sternum, difficult to interpret due to its uncertainty and isolation, is observed in the initial stages of bronchogenic lung cancer. The most painful pain is characteristic of the apical localization of lung cancer, when the defeat of the common CVII and ThI trunk of nerves and brachial plexus is almost inevitable and rapid. The pain is localized mainly in the brachial plexus and irradiates along the external surface of the arm. On the side of defeat often develops Gorner's syndrome (narrowing of the pupil, ptosis, enophthalmus).

Pain syndromes also occur with mediastinal localization of the cancer, when compression of the nerve trunks and plexuses causes acute neuralgic pain in the foreleg, upper limb, thorax. This pain gives rise to erroneous diagnosis of angina pectoris, myocardial infarction, neuralgia, plexitis.

The need for differential diagnosis of pain due to pleural injury and bronchopulmonary apparatus, with IHD occurs in cases where the picture of the underlying disease is unclear and pain comes to the fore. In addition, such differentiation (especially in acute unbearable pains) should also be carried out with diseases caused by pathological processes in large vessels - PE, which breaks down the aneurysm of various parts of the aorta. The difficulty of detecting pneumothorax as a cause of acute pain is due to the fact that in many cases the clinical picture of this acute situation is erased.

The pain behind the breastbone associated with the pathology of the mediastinal organs is due to diseases of the esophagus (spasm, reflux esophagitis, diverticula), mediastinum tumors and mediastinitis.

Pain in diseases of the esophagus usually have a burning nature, localize behind the fudina, arise after eating, intensify in a horizontal position. Such common symptoms as heartburn, belching, swallowing, may be absent or not clearly expressed, and the chest pains often appear during physical exertion and inferior to the action of nitroglycerin. Similarity of these pains with angina is complemented by the fact that they can irradiate to the left half of the thorax, shoulders, hands. In more detailed inquiry, however, it appears that the pain is more often associated with food, especially abundant, and not with physical exertion, usually arise in the prone position and pass or are facilitated when going to sitting or standing position, walking, after taking antacids, such as soda, which is not characteristic of IHD. Often, palpation of the epigastric region intensifies these pains.

Vaginal pains are also suspicious for gastroesophageal reflux and esophagitis. To confirm the presence of which are important 3 types of tests: endoscopy and biopsy; intrasophageal infusion of 0.1% hydrochloric acid solution; monitoring of the intraepithelial pH. Endoscopy is important for the detection of reflux, esophagitis and for the exclusion of another pathology. X-ray examination of the esophagus with barium reveals anatomical changes, but its diagnostic value is considered relatively low due to the high incidence of false positive signs of reflux. With the perfusion of hydrochloric acid (120 drops per minute through the probe), the appearance of the usual pain for the patient is important. The test is considered highly sensitive (80%), but not specific enough, which, with indistinct results, requires repeated studies.

With unclear results of endoscopy and perfusion of hydrochloric acid, intra-esophageal pH can be monitored using a radiotelemetric capsule placed in the lower part of the esophagus for 24-72 hours. The coincidence in the time of pain occurrence and the decrease in pH is a good diagnostic sign of esophagitis, i.e. Indeed the criterion of the esophageal origin of the pain.

Pain behind the breastbone, similar to angina pectoris, can also be a consequence of increased motor function of the esophagus with achalasia (spasm) of the cardiac department or diffuse spasm. Clinically, in such cases, there are usually signs of dysphagia (especially when taking solid food, cold liquid), which, unlike organic stenosis, has a non-permanent character. Sometimes the chest pains of different duration appear on the foreground. Difficulties in differential diagnosis are also due to the fact that this category of patients sometimes helps nitroglycerin, which relieves spasm and pain.

Radiographically, with achalasia of the esophagus, an expansion of its lower part and a delay in its barium mass are detected. However, X-ray examination of the esophagus in the presence of pain is of little informative, or rather is not convincing: false-positive results were noted in 75% of cases. More effective is the esophagus manometry using a three-lumen probe. The coincidence in the time of the appearance of pain and increase in the intra-esophageal pressure has a high diagnostic value. In such cases, a positive effect of nitroglycerin and calcium antagonists may appear, which reduces the tone of smooth muscle and intra-esophageal pressure. Therefore, these drugs can be used in the treatment of such patients, especially in combination with anticholinergics.

Clinical experience shows that in the pathology of the esophagus, it is often erroneously diagnosed with ischemic heart disease. In order to correctly diagnose a physician should look for other symptoms of a violation of the esophagus in the patient and compare the clinical manifestations and results of various diagnostic tests.

Attempts to develop a complex of instrumental studies that would help distinguish between anginal and esophageal pains have not been successful, since a combination of this pathology with angina often occurs, as evidenced by bicycle ergometry. Thus, despite the application of various instrumental methods, the differentiation of pain sensations presents great difficulties at the present time.

Mediastinitis and mediastinal tumors are infrequent causes of chest pain. Usually, the need for differential diagnosis with IHD occurs at pronounced stages of tumor development, when, however, there are still no significant compression symptoms. The appearance of other signs of the disease greatly facilitates the diagnosis.

Pain behind the breastbone with diseases of the spine. Pain sensations in the chest can also be associated with degenerative changes in the spine. The most common disease of the spine is osteochondrosis (spondylosis) of the cervical and thoracic region, in which there is pain, which is similar sometimes with angina. This pathology is widespread, since after 40 years, changes in the spine are observed frequently. When the cervical and / or upper thoracic spine is affected, the secondary radicular syndrome with the spread of pain in the thoracic region is often observed. These pains are associated with the irrigation of the sensitive nerves by osteophytes and thickened intervertebral discs. Usually, there are bilateral pains in the corresponding intercostal space, but the patients quite often focus their attention on the retrograde or near-cardiac localization, referring them to the heart. Such pains can be similar to angina pectoris by the following signs: they are perceived as a feeling of pressure, severity, sometimes radiating to the left shoulder and arm, neck, can be provoked by physical exertion, accompanied by a feeling of shortness of breath due to the impossibility of deep breathing. Given the elderly patients in these cases, often diagnosed with CHD, with all the ensuing consequences.

However, degenerative changes in the spine and the pain caused by them can be observed in patients with undoubted coronary artery disease, which also requires a clear delineation of the pain syndrome. Probably, in a number of cases, attacks of angina on the background of coronary artery atherosclerosis in patients with spinal cord injury also appear reflexively. The unconditional recognition of this possibility, in turn, transfers the "center of gravity" to the pathology of the spine, reducing the importance of independent lesion of the coronary arteries.

How to avoid a diagnostic error and put the correct diagnosis? Of course, it is important to conduct a radiograph of the spine, but the changes found in this case are not enough for diagnostics, since these changes can only accompany CHD and / or not manifest clinically. Therefore it is very important to find out all the features of pain. As a rule, the pains depend not so much on physical activity as on the change in the position of the body. Pain often increases with coughing, deep breathing, can decrease in some convenient position of the patient, after taking analgesics. These pains differ from angina pectoris by a more gradual onset, longer duration, they do not go away at rest after the application of nitroglycerin. Irradiation of pain in the left arm occurs on the dorsal surface, in the I and II fingers, whereas in angina pectoris, in the IV and V fingers of the left arm. Of particular importance is the detection of local soreness of the spinous processes of the corresponding vertebrae (trigger zone) with pressure or effleurage paravertebrally and along the intercostal space. Pain can also be caused by certain methods: strong pressure on the head towards the back of the neck or pulling one hand with a simultaneous turn of the head to the other side. With veloergometry, pain can occur in the region of the heart, but without characteristic changes in the ECG.

Thus, the diagnosis of radicular pain requires a combination of radiologic signs of osteochondrosis and the characteristic features of chest pain that do not correlate with coronary artery disease.

The frequency of muscular-fasciastic (muscular-dystonic, muscular-dystrophic) syndromes is 7-35% in adults, and in some professional groups it reaches 40-90%. With some of them, heart disease is often mistakenly diagnosed, since the pain syndrome in this pathology has some similarity to pain in cardiac pathology.

There are two stages of the disease of muscular-fascial syndromes (Zaslavsky ES, 1976): functional (reversible) and organic (muscular-dystrophic). In the development of muscular-fascial syndromes there are several etiopathogenetic factors:

1. Injuries of soft tissues with the formation of hemorrhages and gray-fibrinous extravasates. As a result, densification and shortening of muscles or individual muscle bundles, ligaments, a decrease in the elasticity of fascia develops. As a manifestation of the aseptic inflammatory process, connective tissue is often formed in excess.
2. Microtravmatization of soft tissues in certain types of professional activity. Microtrauma disturbs the tissue circulation of the blood, causes muscular-tonic dysfunction with subsequent morphological and functional changes. This etiologic factor is usually combined with others.
3. Pathological impulsation in visceral lesions. This impulse, which occurs when the internal organs are damaged, is the cause of the formation of various sensory, motor and trophic phenomena in the integumentary tissues innervationally associated with the altered internal organ. Pathological interoceptive impulses, switching through the spinal segments, go to the corresponding afflicted internal organ connective tissue and muscle segments. The development of muscular-fascial syndromes accompanying cardiovascular pathology can change the pain syndrome so much that diagnostic difficulties arise.
4. Vertebrogenic factors. When stimulating the receptors of the affected motor segment (receptors of the fibrous ring of the intervertebral disc, posterior longitudinal ligament, joint capsules, autochthonous muscles of the spine), not only local pain and muscle-tonic disorders occur, but also a variety of reflex responses at a distance - in the area of integumentary tissues, innervationally related with affected vertebral segments. But far from all cases there is a parallelism between the severity of x-ray changes in the spine and the clinical symptomatology. Therefore, the radiographic signs of osteochondrosis can not yet serve as an explanation of the cause of the development of muscular-fascial syndromes exclusively by vertebrogenic factors.

As a result of several etiological factors, muscle-tonic reactions develop in the form of hypertonicity of the affected muscle or group of muscles, which is confirmed by electromyographic examination. Muscle spasm is one of the sources of pain. In addition, the violation of microcirculation in the muscle leads to local tissue ischemia of tissue edema, the accumulation of kinins, histamine, heparin. All these factors also cause pain. If the muscular-fascial syndromes are observed for a long time, then there is a fibrous degeneration of the muscle tissue.

The greatest difficulties in the differential diagnosis of muscular-fascial syndromes and pain of cardiac origin are found in the following variants of syndromes: shoulder-scapular periarthritis, scapular-rib syndrome, anterior thoracic wall syndrome, interscapular pain syndrome, small pectoral muscle syndrome, anterior stair muscle syndrome. The syndrome of the anterior thoracic wall is observed in patients after a previous myocardial infarction, as well as with non-coronary heart lesions. It is supposed that after a myocardial infarction transferred, the pathological pulse flow from the heart spreads along the segments of the vegetative chain and leads to dystrophic changes in the corresponding formations. This syndrome in people with a known healthy heart can be caused by traumatic myositis.

The more rare syndromes, accompanied by pain in the anterior chest wall, are: Titze syndrome, xifoidia, manubriosternal syndrome, scalenus syndrome.

The Tietze syndrome is characterized by a sharp pain in the place of sternum connection with cartilages of the II-IV ribs, swelling of the costal-cartilaginous articulations. It is observed mainly in middle-aged people. Etiology and pathogenesis are unclear. There is an assumption about aseptic inflammation of the costal cartilage.

Xifoidia manifests itself by sharp pain for the sternum, which is strengthened by pressing on the xiphoid process, sometimes accompanied by nausea. The cause of pain is unclear, there may be a connection with the pathology of the gallbladder, duodenum, stomach.

When manubriosternal syndrome noted acute pain over the upper part of the sternum or somewhat lateral. The syndrome is observed with rheumatoid arthritis, but it is isolated and then it becomes necessary to differentiate it from angina pectoris.

Scalenius syndrome - compression of the neurovascular bundle of the upper limb between the anterior and middle staircase muscles, as well as the normal I or additional rib. Pain in the anterior chest wall is combined with pain in the neck, shoulder straps, shoulder joints, sometimes a wide irradiation zone is noted. At the same time, vegetative disorders are observed in the form of chills, pallor of the skin. Difficulty in breathing, Raynaud's syndrome is noted.

Summarizing the above, it should be noted that the true incidence of pain of this origin is unknown, so it is not possible to determine their specific gravity in the differential diagnosis of angina pectoris.

Differentiation is necessary in the initial period of the disease (when thinking about angina pectoris first of all) or if the pains caused by the listed syndromes do not combine with other signs that allow correctly to recognize their origin. However, pain of this origin can be combined with true IHD and then the doctor should also understand the structure of this complex pain syndrome. The need for this is obvious, since the correct interpretation will affect both treatment and prognosis.

Pain behind the breastbone, caused by diseases of the abdominal cavity and the pathology of the diaphragm. Diseases of the abdominal organs are often accompanied by pain in the heart area in the form of a syndrome of typical angina or cardialgia. Pain in peptic ulcer of the stomach and duodenum, chronic cholecystitis can sometimes irradiate to the left half of the chest, which causes diagnostic difficulties, especially if the diagnosis of the underlying disease is not yet established. Such irradiation of pain is quite rare, but it should be taken into account when interpreting pain in the heart and behind the breastbone. The occurrence of these pains is explained by reflex effects on the heart with lesions of internal organs, which occur as follows. In the internal organs, interorganic connections have been discovered, through which axon reflexes are performed and, finally, polyvalent receptors in vessels and smooth muscles are revealed. In addition, it is known that along with the main border sympathetic trunks there are also paravertebral plexuses connecting both borderline trunks, as well as sympathetic collaterals located parallel to and along the sides of the main sympathetic trunk. In such conditions, afferent excitation, moving from any organ along the reflex arc, can switch from centripetal to centrifugal pathways and thus be passed on to various organs and systems. At the same time, viscero-visceral reflexes are realized not only by reflex arcs closing at different levels of the central nervous system, but also through vegetative nerve nodes at the periphery.

As for the causes of reflex pain in the heart, it is assumed that a long-term painful focus disrupts the primary afferent pulsations from the organs due to a change in the reactivity of the receptors located in them, and in this way becomes a source of pathological afferentation. Pathologically altered impulses lead to the formation of dominant foci of irritation in the cortex and subcortical region, in particular in the hypothalamic section and in the net formation. Thus, the irradiation of these stimuli is accomplished by means of central mechanisms. Hence, pathological impulses are transmitted by efferent pathways through the underlying parts of the central nervous system and then along the sympathetic fibers reach the vasomotor receptors of the heart.

Causes of chest pain may also be diaphragmatic hernia. The diaphragm is richly innervated organ mainly due to the diaphragmatic nerve. It runs along the front inner edge of the m. Scalenus anticus. In the mediastinum, it goes along with the superior vena cava, then, bypassing the mediastinal pleura, reaches the diaphragm, where it branches. Hernias of the esophageal opening of the diaphragm are more common. Symptoms of diaphragmatic hernias are varied: usually it is dysphagia and pain in the lower parts of the chest, eructation and a feeling of bursting in the epigastrium. When the hernia temporarily penetrates into the chest cavity, there is a sharp pain that can be projected onto the lower left half of the chest extending into the interlobular region. The accompanying spasm of the diaphragm can cause reflected pain due to irritation of the diaphragmatic nerve in the left scapular region and in the left shoulder, which suggests "cardiac" pain. Considering the paroxysmal nature of the pain, its appearance in middle-aged and elderly people (mainly in men), it is necessary to conduct a differential diagnosis with an attack of angina pectoris.

Pain sensations can also be caused by diaphragmatic pleurisy and much less often - sub-diaphragmatic abscess.

In addition, when examining the chest can be found shingles, with palpation can be detected fracture of the rib (local soreness, crepitus).

Thus, to determine the cause of pain behind the sternum and to make the correct diagnosis to the general practitioner, a thorough examination and questioning of the patient should be carried out and the possibility of the existence of all the above conditions should be taken into account.

[1], [2], [3]