Chest pain

A heart, lungs, an esophagus, and large vessels receive the afferent innervations from the same thoracic nerve ganglion. Pain impulses from these organs are perceived most often as chest pain, but since there is a crossing of the afferent nerves in the spinal ganglia, chest pain may be felt anywhere between the epigastric region and the jugular fossa, including arms and shoulders (as referred pain).

Pain impulses from the chest cavity can cause discomfort, described as pressure, bursting, burning, aching, and sometimes sharp pain. Many patients describe these feelings as pain, because they have visceral basis. However, it is better to interpret them as discomfort.

[1], [2],

Chest pain causes

Many diseases are accompanied by a discomfort or the pain in the chest. Some of them (for example, myocardial infarction, and unstable angina, dissection of thoracic part of aorta, tension pneumothorax, esophageal rupture, and pulmonary embolism) have direct threat to life. Some diseases (stable angina, pericarditis, myocarditis, pneumothorax, pneumonia, pancreatitis, various tumors of the chest) have a potential threat to the life of the patient. Other states (such as gastroesophageal reflux disease (GERD), peptic ulcer, dysphagia, low back pain, osteochondrosis, chest trauma, biliary tract disease, and shingles) cause the discomfort, but are usually nonhazardous ones.

Chest pain in children and young people (under 30 years) is rarely caused by myocardial ischemia, however, myocardial infarction may develop in the age of 20. Muscle, skeleton damages, or lung disease occur more often in this age group.

Chest pain is the most common cause of emergency room doctor on call. The main diseases of the cardiovascular system, which are accompanied by expressed pain in the chest, are:

• Stenocardia;
• Myocardial infarction;
• Aortic dissection;
• Pulmonary embolism;
• Pericarditis.

An exertional angina is a classic example of the pain or the discomfort in the chest. Pain or discomforts of crushing or compressing character behind the breastbone appear in case of "classical" exertional angina during physical exercises. In the presence of stenocardia, pain disappears quickly after ending of exercises (after stopping), usually within 2-3 minutes, rarely within 5 minutes. If you just administer nitroglycerin under the tongue, the pain disappears after 1.5-2 minutes. Pain in angina pectoris is caused by myocardial ischemia. During spontaneous stenocardia pain occurs at rest ("rest angina pectoris"), but the character of pain at the typical attacks is the same, as in exertional angina. Also, most patients with the spontaneous angina have accompanied exertional angina. Insulated ("clean") spontaneous stenocardia is extremely rare. In the presence of spontaneous stenocardia in most cases there is a clear effect of nitroglycerin. In the presence of chest pain, occurring at rest, the effect of nitroglycerin is of great diagnostic value that indicates in favor of an ischemic origin of pain.

Unstable angina and myocardial infarction are characterized by more intense pain, accompanied by fear, severe sweating. Myocardial pain is usually not associated with the load. At least, it does not pass at rest after exercise stopping. Duration of the pain in case of infarction can be several hours or even days. In most cases nitroglycerin does not eliminate the pain in the presence of myocardial infarction. The term "acute coronary syndrome" is used before the establishment of an accurate diagnosis with pain in the chest by the character, corresponding to the unstable angina or myocardial infarction.

In case of aortic dissection, pain immediately and generally reaches maximum, and usually irradiates to the back.

Chest pain in case of massive pulmonary embolism is often very similar to the pain in case of heart attack, but at the same time dyspnea (increased respiratory frequency, tachypnea) is almost always marked. In the case of pulmonary infarction, pleural pain appears on the one side of the chest (aggravated at deep breathing and coughing) after 3-4 days. Consideration of risk factors of pulmonary embolism appearance and no signs of a heart attack on the ECG facilitates diagnostics. Precise diagnosis is carried out after hospitalization.

Increased pain with deep breathing, coughing, swallowing, in the supine position is typical for pericarditis. Pain radiates often into trapezius muscles. Pain is reduced when you lean forward or in the prone position.

Pulmonary, gastrointestinal, thoracic, spine and chest diseases belong to major extracardiac diseases, at which chest pains are observed.

Pain occurs usually on one side, in the back parts of the chest, aggravate at breathing, coughing, body movement in the presence of diseases of the lung and pleura. Esophagus and stomach diseases often cause sensation like heartburn, burning, which are connected with the food intake and are often exacerbated in the prone position. In case of emergency pain can be acute ("knife-like"). Diagnosis facilitates the absence of a clinical history of exertional angina, connection identification with food intake, relief of pain in a sitting position after an administration of antacids. Pain caused by damages of the spine and chest is characterized by the appearance or strengthening during body movement, tenderness in the presence of palpations.

Thus, pain in the chest, which is caused by extracardiac diseases, almost always differs markedly from pain during a typical clinical course of diseases of the cardiovascular system.

Many people have "neurotic" character pain in the heart region ("neurocirculatory dystonia"). Neurotic pains are often felt in the left in the apex of the heart (the nipple region). In most cases, you can specify the location of pain by finger. Neurotic pains are observed most often in two types: acute, short-term pain of "piercing" character that does not allow breathing, or long aching pain in the heart for a few hours, or almost constant one. Neurotic pain is often accompanied by pronounced dyspnea and anxiety up to the so-called panic disorders. In these cases, the differential diagnosis with acute coronary syndrome and other emergency conditions can be quite difficult.

Thus, it is quite easy to establish the diagnosis of all emergency cardiac conditions in case of typical manifestations of pain syndrome. Chest pain, caused by extracardiac pathology, always differs noticeably from pain in the presence of cardiovascular system damage in case of typical clinical picture. Difficulties occur in case of atypical or completely atypical manifestations as cardiovascular and non-cardiac diseases.

After hospitalization and examination of the patients with the chest pain 15-70% of patients have acute coronary syndrome and about 1-2% of patients have pulmonary embolism, or other cardiovascular disease. Other patients have extracardiac disease as a reason of the pain.

[3], [4],

Chest pain symptoms

The symptoms that occur in the presence of severe diseases of the chest cavity, are similar very often, however sometimes they can be differentiated.

Unbearable pain that irradiates to the neck or the arm, indicates about acute ischemia or myocardial infarction. Patients often compare myocardial ischemic pain with dyspepsia.

Pain associated with the load, which disappears at rest, is typical for angina.

Excruciating pain which irradiates to the back, shows the dissection of the thoracic aorta.

Burning pain that spreads from the epigastric region into the throat, aggravates in the supine position and decreases in case of antacid administration, is a sign of GERD.

High body temperature, chills and cough testify in favor of pneumonia.

Severe dyspnea occurs in the presence of pulmonary embolism and pneumonia.

The pain may be triggered by breathing, movement or both of these factors, like in case of light and heavy diseases. These provoking factors are not specific.

Short (less than 5 seconds), acute, intermittent pain is rarely a sign of a serious disease.

[5], [6], [7], [8]

Unbiased examination

Symptoms such as tachycardia, bradycardia, tachypnea, arterial hypotension or signs of circulatory disorders (for example, mental confusion, cyanosis, sweating) are non-specific, but their presence increases the possibility of that fact that a patient has a heavy disease.

The absence of respiratory murmurs from one side is a sign of pneumothorax; resonating percussion sound and jugular veins of neck testify in favor of tension pneumothorax. Increased body temperature and crepitations are symptoms of pneumonia. Fever is possible in the presence of pulmonary embolism, pericarditis, acute myocardial infarction, or esophagus rupture. Pericardial rub is another sign of pericarditis. Appearance of IV heart sound (S₄), late systolic murmur, dysfunction of the papillary muscles or both of these features appear in case of myocardial infarction. Local CNS damages, noise of an aortic regurgitation, the asymmetry of the pulse or blood pressure on the hands are the symptoms of thoracic aorta dissection. Swelling and tenderness of the lower extremity indicate about deep vein thrombosis and, thus, about the possible embolism of pulmonary artery. Chest pain during the palpation is found in 15% of patients with the acute myocardial infarction. This symptom is not specific for diseases of the chest wall.

Additional methods of an examination

The minimum amount of patient examination with chest pain includes pulse oximetry, ECG and chest X-ray. Adults are conducted often research on markers of myocardial damage. The results of these tests in conjunction with the data of the clinical history and physical examination allow making a presumptive diagnosis. The study of blood is often not available in case of the initial examination. Separate normal indexes of markers of myocardial damage cannot be a ground for an exclusion of a cardiac damage. In the case if myocardial ischemia is probable, research needs to be repeated several times as well as ECG. Performance of stress ECG and stress echocardiography is also possible.

Diagnostic administration of nitroglycerin tablet under the tongue or liquid antacid does not allow to differentiate authentically myocardial ischemia and GERD or gastritis. Any of these drugs can reduce the symptoms of each disease.

[9], [10], [11], [12], [13], [14], [15], [16], [17], [18]

Chest pain diagnosis 

The clinical history. Refinement of localization, duration, nature and intensity of pain, and also it’s provoking and reducing factors is very important. Preceding heart disease, administration of drugs that can cause spasm of the coronary arteries (for example, cocaine, phosphodiesterase inhibitors), the presence of the risk factors of the coronary artery disease or the pulmonary embolism (for instance, pain in the legs or fractures, preceded immobilization, travels, pregnancy) are also important. The presence or the absence of the risk factors of coronary heart disease (such as hypertension, hypercholesterolemia, smoking, family history) increase the likelihood of coronary artery disease, but do not help to clarify the causes of acute chest pain.

[19], [20], [21], [22], [23]

Chest pain treatment

The treatment of the chest pain is performed in accordance with the diagnosis. The patient must be taken to hospital for cardiac monitoring and more in-depth examination in the case, if cause of chest pain is not fully figured out. Symptomatically, it is possible to prescribe opiates (if it is necessary) before the diagnosis.

[24], [25], [26], [27]