What is Chest Pain?
Chest pain is a common problem that could indicate a range of different issues, including some that could be life-threatening. It’s crucial for doctors to rule out these serious issues first when figuring out the cause of the chest pain. Only after they’ve confirmed that it isn’t due to anything potentially deadly, can doctors consider less severe causes.
What Causes Chest Pain?
Sometimes, understanding the different types of pain a patient feels can be useful. One of these types is called visceral pain, which is often hard to pinpoint. This is the type of pain people feel in organs like the stomach, lungs, or heart. When patients are asked to indicate where they feel this type of pain, they tend to point out a large, general area rather than a specific spot. Descriptions of visceral pain are often words like dull, deep, or like a squeezing pressure.
This type of pain can sometimes cause discomfort in other parts of the body due to how nerves are connected. This is often referred to as ‘referred pain.’ For instance, a heart problem might cause pain in the shoulders, jaw, or left arm. Nausea and vomiting can also be signs of visceral pain. Irritation of the diaphragm, a muscle located underneath the lungs, can cause pain to be felt in the shoulders as well.
Another type of pain is somatic pain, which comes from the muscles, skin, and bones. This pain is more specific, and patients can usually point to exactly where it hurts. Somatic pain is often described as sharp, stabbing, or poking. And unlike visceral pain, somatic pain doesn’t usually cause discomfort in other parts of the body.
Risk Factors and Frequency for Chest Pain
Chest pain is the second most common reason why people go to the emergency department, accounting for about 5% of all such visits. Doctors who examine patients for chest pain must always keep in mind the life-threatening conditions that chest pain might signal. These conditions, along with the percentage of chest pain patients in the emergency department who have each one, based on a study by Fruerfaard and colleagues, are:
- Acute coronary syndrome (heart issue), which affects 31% of these patients
- Pulmonary embolism (lung blood clot), affecting 2%
- Pneumothorax (collapsed lung), occurrence rate not reported
- Pericardial tamponade (heart compression), occurrence rate not reported (though the similar condition pericarditis affects 4%)
- Aortic dissection (a tear in the big blood vessel), which affects 1% of these patients
- Esophageal perforation (hole in the food pipe), occurrence rate not reported
There are also other regular reasons for chest pain in patients who come to the emergency department, along with the percentage of these patients who have each one:
- Gastrointestinal reflux disease (stomach acid issue), which affects 30% of these patients
- Musculoskeletal causes (related to muscles or skeleton), affecting 28%
- Pneumonia/pleuritis (lung inflammation), affecting 2%
- Herpes zoster (viral infection), which affects 0.5% of these patients
- Pericarditis (heart lining inflammation), occurrence rate not reported
Signs and Symptoms of Chest Pain
Evaluating chest pain begins with gathering a detailed history from the patient. Understanding the details of their pain and other symptoms is crucial. Here are some things to find out:
- Onset: When did the pain begin, and what was the patient doing at the time? Is there a connection with physical activity or rest?
- Location: Can the patient pinpoint the pain, or is it widespread?
- Duration: How long does the pain last?
- Character: Ask the patient to describe the pain in their own words.
- Aggravation and alleviating factors: Find out what worsens or eases the pain. For example, does it relate to physical exertion, eating, breathing, or particular positions? Ask about new physical activities or medications.
- Radiation: Pain that spreads out may indicate visceral (organ) pain.
- Timing: How often does the pain occur, and how long does it ease up for?
- Additional symptoms: Ask about symptoms such as shortness of breath, nausea, vomiting, fever, sweating, cough, indigestion, swelling, or recent illness.
Consider these potential risk factors:
- ACS risks: Previous heart attack, family history of heart disease, smoking, high blood pressure, high cholesterol, and diabetes
- Pulmonary embolism (PE) risks: A history of deep vein thrombosis (DVT) or PE, hormone use (as with birth control pills), recent surgery, cancer, or periods of immobility
- Previous gastrointestinal procedures
- Substance abuse (cocaine and methamphetamine use)
Also, delve into the patient’s medical history for heart-related conditions, blood clotting disorders, and kidney disease. Ask about their family and social histories, especially regarding heart disease, drug, and tobacco use.
With life-threatening causes ruled out, explore other possibilities like pneumonia (particularly in patients with a persistent cough and/or recent upper respiratory infection). Gastroesophageal reflux disease (GERD) is a common cause of chest pain—look for indications of any reflux symptoms. The onset of new physical activities or recent trauma could suggest a musculoskeletal cause.
The physical exam should encompass:
- A full set of vitals, including blood pressure measurements in both arms
- Observation of general appearance, noting any sweating and distress
- Examination of the skin for the presence of lesions (like shingles)
- Neck exam for jugular venous distension (JVD), especially with inspiration (Kussmaul sign)
- Chest exam, including checking for pain and crepitus (a crackling feeling under the skin)
- Heart assessment
- Lung examination
- Abdominal examination
- Examination of extremities for signs of swelling, calf pain, edema (swelling caused by trapped fluid), and for equal, symmetrical pulse strength
Testing for Chest Pain
When you come to the hospital with chest pain, there are certain tests and procedures the doctor should order to better understand what’s causing your discomfort:
1. The Electrocardiogram (ECG): This test records the electrical signal from your heart to check for different heart conditions. The doctor will try to perform this test within the first 10 minutes of your arrival, and may do it a few times to monitor any changes.
2. Chest X-ray: A chest X-ray uses a small amount of radiation to take pictures of your heart, lungs, and blood vessels.
3. Blood tests: The doctor may ask for a complete blood count (CBC), basic metabolic panel (BMP), troponin level, and lipase. The CBC and BMP give general information about your blood and body’s chemistry. Troponin is a type of protein the heart releases when it’s damaged, so elevated levels might indicate a heart attack. Lipase is an enzyme that, if found in the blood, could signal a problem with the pancreas.
4. Computed Tomography Pulmonary Angiography (CTPA) or ventilation-perfusion (VQ) scan: The doctor may ask for these tests if they suspect you might have a pulmonary embolism (PE), which is a blood clot in the lungs. The CTPA uses X-rays to get more detailed images of your lungs, while the VQ scan uses a small amount of radioactive material to examine airflow and blood flow in your lungs.
5. Bedside ultrasound: This test uses sound waves to create images of the heart. The doctor might order this test if they suspect that fluids are building up around your heart, a condition known as pericardial tamponade.
Remember, your health is the doctor’s main priority, and these tests are instrumental in helping create a more precise diagnosis and treatment plan.
Treatment Options for Chest Pain
Acute Chest Pain: Quick Guide to Some Potential Causes
One common cause of chest pain is acute coronary syndrome (ACS), a term for conditions where blood supply to the heart is suddenly blocked. If you’re diagnosed with ACS, medical professionals will place you on a cardiac monitor and set up intravenous (IV) access to deliver medications. You may be given chewable aspirin or other medications, and they will work to control your pain. Nitroglycerin may also be used to lower your blood pressure if it’s too high.
If the doctors see a specific pattern (ST elevation) on your heart monitor, it’s a sign that part of your heart muscle is not getting enough blood. You will then receive immediate treatment to restore blood flow, usually through a procedure called percutaneous coronary intervention (PCI) that opens up blocked heart arteries. If PCI is not available or appropriate for you, medications called thrombolytics that can help to break up blood clots might be used instead.
Another possible cause is a pulmonary embolism (PE), which is a blood clot that has travelled to your lungs. A CT scan can confirm the diagnosis, and treatment can include medications to dissolve the clot or prevent new clots from forming.
A pneumothorax (PTX), or collapsed lung, is another potential reason for chest pain. If you have a pneumothorax, doctors will use a chest tube to remove air from the space around your lungs to allow them to expand again.
Pericardial tamponade is a serious condition where fluid builds up around the heart, restricting its ability to pump blood. Doctors use an ultrasound to diagnose this condition, and treatment may include removing the fluid using a needle or through a surgical procedure.
An aortic dissection is a tear in the wall of the aorta, the main artery carrying blood from your heart to the rest of your body. This situation often requires immediate surgery. Doctors will try to lower your blood pressure quickly to reduce strain on the aorta and may use medications such as beta-blockers.
Esophageal perforation, or a hole in your esophagus (the tube that carries food from your mouth to your stomach), is another possible cause. This is a medical emergency, and a surgical consultation will be needed promptly.
Finally, heartburn, often caused by gastroesophageal reflux disease (GERD), can also result in severe chest pain. A special concoction of medications may provide relief, but it’s essential to rule out heart conditions first. In the long run, heartburn or GERD is managed using medications that reduce stomach acid.
What else can Chest Pain be?
When a doctor is trying to identify the cause of certain symptoms, they could potentially be dealing with a range of conditions. Here are some of the possibilities:
- Acute Coronary Syndrome
- Aortic Dissection
- Embolism
- Gastroesophageal Reflux
- Muscle or Skeletal Pain
- Esophageal Rupture
- Pericarditis
- Pneumonia Shingles
- Pneumothorax
- Pulmonary Embolism
- Cervical Radiculopathy
- Esophageal Spasm