Chest pain

Various conditions can cause chest pain, including gastrointestinal and cardiovascular diseases. Pain in diseases of the esophagus can simulate angina pectoris.

Approximately 50% of patients who undergo esophageal examination for chest pain are diagnosed with gastroesophageal reflux disease (GERD). Other diseases of the esophagus with chest pain include infections (bacterial, viral, or fungal), tumors, and motility disorders (eg, hyperkinetic esophageal motility disorders, achalasia, diffuse esophageal spasm).

Esophageal chest pain can be caused by an increase in the nerve receptor sensitivity of the esophagus (visceral hypersensitivity) or an increase in normal afferent impulses (allodynia) of the spinal cord or central nervous system.

Assessment of chest pain

Because the symptoms are similar, many patients with esophageal disease undergo a cardiac examination (including coronary arteriography) to rule out heart disease; some patients with coronary artery disease undergo a gastrointestinal examination to rule out esophageal disease.

Anamnesis

Chest pain of esophageal or cardiac origin can be very similar. In both cases, chest pain can be severe enough to be associated with exercise. The episodes of pain can last from a few minutes to several hours and can be repeated over several days.

Burning pain in the region of the heart is regarded as a burning upward pain in the chest that may radiate to the neck, throat, or face. It usually appears after eating or bending over. A burning sensation in the region of the heart can be combined with regurgitation of the contents of the stomach into the oral cavity and the resulting heartburn. Heartburn occurs when acid irritation occurs in the lower esophagus. A typical burning sensation in the region of the heart suggests gastroesophageal reflux; however, some patients regard “burning pain in the heart” as an unremarkable discomfort behind the breastbone and may doubt the significance of the symptom.

Pain when swallowing is a painful symptom that appears when passing through the esophagus, most often hot or cold food or drinks and suggests primarily a disease of the esophagus. It manifests itself with or without dysphagia. The pain is described as a burning or constricting chest pain.

Dysphagia is a feeling of difficulty passing food through the esophagus and is usually associated with its pathology. Patients with esophageal motility disorders often complain of both dysphagia and pain when swallowing.

Physical examination

A number of signs characterize chest pain as a consequence of diseases of the esophagus.

Survey

Feeling of discomfort in the chest area requires an emergency ECG, chest fluoroscopy and, depending on the patient's age, symptoms and risk factors, an exercise ECG or instrumental studies with stress tests. If heart disease is excluded, symptomatic treatment is prescribed, followed by further examination.

Examination of the gastrointestinal tract should begin with an endoscopic or radiopaque examination. PH monitoring (to rule out GERD) on an outpatient basis and esophageal manometry can help identify abnormalities in esophageal motility. The balloon barostat threshold score used in some centers helps to identify visceral hypersensitivity. When hypersensitivity is identified, assessment of psychosocial status and prognosis of mental illness (eg, panic disorder, depression) may be helpful.

Causes of chest pain

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Neurogenic chest pain

In many ways, the same principles of clinical diagnosis are applicable to the so-called neurogenic thoracalgias (and cardialgias). They, like abdominalgias, can be categorized into three main categories.

1. Vertebral, vertebrogenic and myofascial syndromes: scoliotic, kyphotic and other spinal deformities (Paget's disease, ankylosing spondylitis, rheumatoid arthritis and others); spondylosis; herniated disc; spinal stenosis; facet syndrome; osteoporosis; osteomalacia; muscle-tonic and myofascial syndromes in the scalene, pectoralis major and minor muscles; discopathy; pathology of the sterno-cartilaginous joint (Tietze syndrome); injuries to muscles and ligaments of the chest (including postoperative); polymyalgia rheumatica.
2. Neurological causes: herniated disc of the thoracic spine, radiculopathy; extradural (metastatic and primary) and intradural tumors, vascular malformations, epidermoid and dermoid cysts, lipomas, ependymomas; herpetic gunlionitis; syringomyelia; multiple sclerosis; transverse myelitis; subacute combined degeneration of the spinal cord; radiation myelopathy; paraneoplastic myelopathy; intercostal neuropathy.
3. Psychogenic thoracalgia: in the picture of hyperventilation syndrome (cardiophobic syndrome), panic attack, masked depression, conversion disorders.
4. Thoracalgia caused by a disease of the visceral organs (pathology of the heart and large vessels; diseases of the chest and mediastinal organs). This variant of thoracalgia occurs 9 times less often than the first three.

As with neurogenic abdominalgias, neurogenic thoracalgias require  differential diagnosis  from visceral sources of chest pain. The latter include: pain in the region of the heart; pain in the stomach; duodenal pain; pain in pancreatitis, pain in the bladder, with appendicitis, in the genital area, with dissection of the aorta.

Finally, chest pain can be associated with drug abuse.

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Treatment of the chest pain

If the etiology of chest pain is unknown, symptomatic treatment includes calcium channel blockers for esophageal motility disorders, H ₂ blockers or proton pump inhibitors for possible GERD. Psychotherapeutic treatment (eg, relaxation techniques, hypnosis, cognitive behavioral therapy) can be effective in cases where anxiety is the causative factor. Finally, if symptoms become more frequent or cause disability, small doses of antidepressants may be effective, even if the mechanism behind the symptoms of chest pain is unclear.

Tactics of the doctor when treating a patient with chest pain:

• main history;
• physical examination;
• additional research;
• electrocardiogram;
• stress tests (bicycle ergometry, step test);
• nitroglycerin test, anaprilin test;
• blood tests (enzymes, CPK, ALT, ACT, cholesterol, prothrombin index).

Other examinations: echocardiography; transesophageal electrocardiography (TEEK); studies of the gastrointestinal tract; fibrogastroduodenoscopy (FGDS); psychological tests.

Diagnostic algorithm:  assess the severity and severity of pain; focus on the most obvious diagnoses; perform a directed assessment of the medical history, examination, research, followed by a more precise diagnosis; consider empirical therapy.

Treatment of chest pain is carried out after completing the necessary set of clinical studies: for pain of angina pectoris, it is necessary to prescribe antianginal drugs (nitrates) to treat ischemia, to prevent the development of acute coronary circulation disorders (angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, etc.).); for pain of neurogenic and vertebrogenic origin - NSAIDs, non-pharmacological methods of treatment; for diseases of the lungs, mediastinal organs, abdominal cavity - appropriate treatment of the revealed pathology.

Errors

Making the wrong diagnosis. One of the most common and serious mistakes that doctors make when working with patients with chest pain is misdiagnosis of acute angina pectoris.

When a misdiagnosis is made, there are three main scenarios for the development of events.

In the first case, the doctor admits that the patient's chest pain is caused by coronary artery disease, but, nevertheless, appropriate treatment is not prescribed. For example, a patient with newly-onset or worsening symptoms of angina pectoris may be prescribed medication for angina pectoris, while referral to the hospital should be the correct course of action.

In the second case, in a patient with typical symptoms of angina pectoris, the doctor excludes the possibility of coronary arterial disease based on the results of an electrocardiogram taken at rest. As mentioned earlier, the electrocardiogram often does not show the presence of diagnosed abnormalities, even in patients with obvious ischemia or developing heart attack.

The third option includes patients with atypical chest pain in whom the doctor does not consider coronary ischemia as a possible cause of chest pain. These patients usually present with complaints that look more like symptoms of dyspepsia or pulmonary disease, and the doctor focuses on these diagnoses without considering the possibility of heart disease.

Insufficient treatment. Often, doctors do not prescribe appropriate medications to patients who are at risk of coronary artery disease. This problem, in particular, applies to patients with persistent coronary artery disease, myocardial infarction in the past, who are recommended to take beta-blockers and aspirin to prevent further coronary attacks. Several studies have shown that primary care physicians (general practitioners and family doctors) do not prescribe these medicines for many of these patients.

Studies have shown that women with coronary artery disease are not treated as intensively as men with the same clinical complaints. This trend towards under-treatment is perhaps one of the reasons why the outcomes of acute coronary attacks are poorer in women than in men.

Failure to cope with the patient's emotional response.  Fear and uncertainty drive many patients and doctors to deal with chest pain. Failure to recognize and treat such diseases can have undesirable consequences. Patients with chest pain fear that they have a life-threatening disease, and when doctors diagnose a non-life-threatening disease, they must explain to the patient the cause of these symptoms and convince them of the correct diagnosis. Doctors who do not do this leave patients alone with unresolved questions, which can lead to emotional distress, and lead to unnecessary use of medical resources, as patients often continue to seek answers to these questions from other specialists.