Chest pain

Various medical conditions can cause chest pain, including gastrointestinal and cardiovascular diseases. Pain from esophageal diseases can simulate angina.

Approximately 50% of patients undergoing esophageal evaluation for chest pain are diagnosed with gastroesophageal reflux disease (GERD). Other esophageal disorders associated 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 may be caused by increased neuroreceptor sensitivity of the esophagus (visceral hypersensitivity) or increased normal afferent impulses (allodynia) of the spinal cord or CNS.

Chest pain assessment

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

Anamnesis

Chest pain of esophageal or cardiac origin can be very similar. In both cases, chest pain can be quite severe and associated with physical exertion. Episodes of pain can last from a few minutes to several hours and recur over several days.

Burning pain in the heart region is considered as a retrosternal burning ascending pain that can radiate to the neck, throat or face. It usually occurs after eating or when bending over. Burning in the heart region can be combined with regurgitation of stomach contents into the mouth and the resulting heartburn. Heartburn occurs if the lower esophagus is irritated by acid. Typical burning in the heart region suggests gastroesophageal reflux; however, some patients regard "burning pain in the heart" as an unimportant discomfort behind the breastbone and may doubt the significance of the symptom.

Pain when swallowing is a painful symptom that occurs when hot or cold food or drinks pass through the esophagus, and suggests primarily a disease of the esophagus. It occurs with or without dysphagia. The pain is described as a burning sensation or squeezing chest pain.

Dysphagia is a feeling of difficulty in 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 symptoms characterize chest pain as a consequence of esophageal diseases.

Survey

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

Gastrointestinal evaluation should begin with endoscopic or radiographic examination. Outpatient pH monitoring (to exclude GERD) and esophageal manometry may help identify esophageal motility disorders. Balloon barostat threshold sensitivity testing, used in some centers, may help identify visceral hypersensitivity. If hypersensitivity is detected, psychosocial status and prognosis of psychiatric disorders (eg, panic disorder, depression) may be helpful.

Causes of chest pain

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Neurogenic chest pain

In many ways, similar principles of clinical diagnostics are applicable to the so-called neurogenic thoracalgias (and cardialgias). They, like abdominalgias, can be classified 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; disc herniation; spinal stenosis; facet syndrome; osteoporosis; osteomalacia; muscle-tonic and myofascial syndromes in the area of the scalene, major and minor pectoral muscles; discopathy; pathology of the sternocartilaginous joint (Tietze syndrome); injuries to the muscles and ligaments of the chest (including postoperative); rheumatic polymyalgia.
2. Neurological causes: thoracic disc herniation, radiculopathy; extradural (metastatic and primary) and intradural tumors, vascular malformations, epidermoid and dermoid cysts, lipomas, ependymomas; herpetic ganglionitis; syringomyelia; multiple sclerosis; transverse myelitis; subacute combined degeneration of the spinal cord; radiation myelopathy; paraneoplastic myelopathy; intercostal neuropathy.
3. Psychogenic thoracic pain: in the picture of hyperventilation syndrome (cardiophobic syndrome), panic attack, masked depression, conversion disorders.
4. Thoracalgia caused by diseases of visceral organs (pathology of the heart and large vessels; diseases of the chest and mediastinum organs). This type of thoracalgia occurs 9 times less frequently than the first three.

As in the case of neurogenic abdominalgia, neurogenic thoracic pain requires differential diagnosis with visceral sources of chest pain. The latter include: pain in the heart area; pain in the stomach area; duodenal pain; pain in pancreatitis, pain in the bladder area, in appendicitis, in the genital area, in aortic dissection.

Finally, chest pain may be associated with drug abuse.

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Treatment chest pains

If the etiology of chest pain is unknown, symptomatic treatment includes calcium channel blockers in case of esophageal dysmotility, H2 _blockers or proton pump inhibitors in case of possible GERD. Psychotherapeutic treatment (eg, relaxation techniques, hypnosis, cognitive behavioral therapy) may be effective in cases where anxiety is an etiologic factor. Finally, if symptoms become more frequent or disabling, low-dose antidepressants may be effective, even if the mechanism of chest pain symptoms is unclear.

A doctor's tactics when a patient comes to him with chest pain:

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

Other studies: echocardiography; transesophageal electrocardiography (TEC); gastrointestinal tract studies; fibrogastroduodenoscopy (FGDS); psychological tests.

Diagnostic algorithm: assess the severity and acuteness of pain; focus on the most obvious diagnoses; perform a targeted assessment of the medical history, examination, studies with subsequent clarification of the diagnosis; consider the possibility of empirical therapy.

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

Errors

Misdiagnosis: One of the most common and serious mistakes doctors make when treating patients with chest pain is misdiagnosis of acute angina.

When a misdiagnosis occurs, there are three main scenarios that can occur.

In the first case, the physician recognizes that the patient's chest pain is caused by coronary artery disease, but nevertheless does not prescribe appropriate treatment. For example, a patient with new or worsening angina symptoms may be prescribed anti-angina medications, when the correct course of action should be referral to the hospital.

In the second case, in a patient with typical angina symptoms, the physician rules out coronary artery disease based on the results of a resting electrocardiogram. As discussed earlier, the electrocardiogram often does not show diagnosable abnormalities even in patients with obvious ischemia or developing infarction.

The third type involves patients with atypical chest pain in whom the physician does not consider coronary ischemia as a possible cause of chest pain. Such patients usually present with complaints that are more similar to symptoms of dyspepsia or pulmonary disease, and the physician focuses on these diagnoses without considering the possibility of heart disease.

Undertreatment. Often, physicians fail to prescribe appropriate medications to patients at risk of coronary artery disease. This problem particularly applies to patients with persistent coronary artery disease, a history of myocardial infarction, who are recommended to take beta blockers and aspirin to prevent further coronary attacks. Several studies have shown that primary care physicians (internists and family doctors) do not prescribe these medications to many of these patients.

Studies have shown that women with coronary artery disease are treated less intensively than men with the same clinical complaints. This tendency toward undertreatment may be one reason why outcomes of acute coronary events are worse in women than in men.

Failure to manage the patient's emotional response. Many patients and physicians respond to chest pain out of fear and uncertainty. Failure to recognize and treat chest pain can have unintended consequences. Patients with chest pain fear that they have a life-threatening illness, and when physicians diagnose a non-life-threatening illness, they must explain the cause of the symptoms and reassure the patient that the diagnosis is correct. Physicians who fail to do so leave patients with unresolved questions that can cause emotional distress and lead to unnecessary use of medical resources, as patients often continue to seek answers from other specialists.