Chest pain

Chest discomfort or pain is a very common symptom and can be caused by cardiac and non cardiac problems. It is important that every episode is taken seriously and investigated promptly especially to exclude potentially serious cardiac problems.

Cardiac Causes of Chest Discomfort / Pain
The most common cardiac cause of chest discomfort is coronary artery disease (CAD). This is a condition where fatty deposits result in narrowings in the coronary arteries in turn limiting the flow of blood to the heart. CAD is more common in smokers and individuals who suffer from diabetes, high blood pressure (hypertension) or high cholesterol levels. There is also an important genetic component to CAD. As a result it tends to occur more frequently in families or certain races. For example, it is more common in Asian and Caucasian and less common in Afro-Caribbean races.

Although not the only cause of chest pain, these heart problems are common causes:

Stable_angina

Angina is the most common presentation of CAD. Patients describe angina as a “heavy” or “tight” sensation in the chest, which is usually triggered by physical activity, and relived by rest. The discomfort can spread to the arms, jaw, or the back. Patients with angina also often have breathlessness, sweating, or nausea and can feel unusually tired.

Stable angina only occurs during physical activity when the heart has a greater demand for blood. However, this increased demand is not adequately met as narrowed coronary arteries prevent normal blood flow to the heart. At rest the “supply and demand” for blood in the heart is matched and thus lack of symptoms.

Patients with suspected angina should undergo comprehensive cardiac evaluation. Screening tests such an ECG (heart trace), echocardiogram (ultrasound scan of the heart) and a stress test (which can be done using medication of exercise on a treadmill) are preformed first. If preliminary tests are positive then most patients will need to undergo a coronary angiogram to confirm the diagnosis. The treatment options for angina include tablets, angioplasty or bypass surgery (see procedures section for more detail).

Unstable_angina_/_myocardial_infarction_(heart_attack)

Unstable angina and myocardial infarction are a part of spectrum of conditions which occur when a clot in a critically narrowed coronary artery suddenly blocks the flow of blood to the heart. As a result chest discomfort or pain occurs unpredictably usually at rest without any provocation.

Patients with unstable angina often experience chest “tightness” or “heaviness”. The discomfort usually lasts no more than a few minutes and settles of its own accord, but can recur on many occasions in succession. The stuttering nature of the symptoms occurs because the blood clot in a diseased coronary dissolves of its own accord. Unstable angina often heralds a myocardial infarction (heart attack).

Patients with unstable angina need to seek urgent treatment and often require admission to hospital. Blood tests, ECG and echocardiogram are used in making the diagnosis. Initial treatment involves stabilisation of the heart with intra-venous blood thinning medication such as Heparin and Aspirin. Almost all patients will need to undergo a coronary angiogram to identify the pattern of disease in the coronary arteries. The definitive treatment for unstable angina is to overcome the narrowing by angioplasty or bypass surgery.

The symptoms of a myocardial infarction are much more severe than unstable angina. A mild chest discomfort rapidly progresses to a severe chest pain that is unremitting. Patients often feel very unwell and frightened. Breathlessness, sweating and vomiting are also common. In contrast to patients with unstable angina, the blood clot in a myocardial infarction is permanent, and does not dissolve spontaneously.

Myocardial infarction is a cardiac emergency and must be treated immediately. A simple ECG is often diagnostic and no more tests are required in the acute period. In most urban centres patients are transferred to a regional “heart attack centre” where they undergo emergency angioplasty to unblock the culprit artery. Without emergency treatment the heart muscle will sustain significant damage resulting in heart failure. With modern angioplasty techniques the outlook for patients suffering a myocardial infarction is good as long as treatment is delivered in a timely fashion.

Pericarditis

Pericarditis is the term given to inflammation of the outermost lining of the heart (the pericardium). The most common cause for pericarditis is a viral infection that is picked up in a similar fashion to a common cold. There are also other causes of pericarditis, such as when there is a problem with the body’s immune system or in response to trauma, but these are causes are rare.

The main symptom of pericarditis is chest pain felt behind the breast bone. It is often sudden in onset and has a “sharp” or “stabbing” nature to it. The pain is often worse when lying down or breathing in and better when sitting up. Pericarditis is diagnosed with an ECG. An echocardiogram is also helpful to ensure that inflammation has not led to a collection of fluid around the heart.

The vast majority of pericarditis cases are not serious. It is usually treated on an out-patient basis with rest and simple over-the-counter anti-inflammatory pain killers such as Ibuprofen.

In a small group of patients the symptoms may become recurrent. These patients will require more prolonged treatment which may include a course of steroids.

Myocarditis.

In addition to chest pain, this heart muscle inflammation may cause fever, fatigue, and trouble breathing. Although no blockage exists, myocarditis symptoms can resemble those of a heart attack.

Hypertrophic_cardiomyopathy.

Heart failure occurs when the heart muscle becomes thickened. This makes the heart work harder to pump blood. Along with chest pain, this type of cardiomyopathy may cause dizziness, lightheadedness, shortness of breath, and other symptoms.

Mitral_valve_prolapse.

Mitral valve prolapse is a condition in which a valve in the heart fails to close properly. A variety of symptoms have been associated with mitral valve prolapse, including chest pain, palpitations, and dizziness, although it can also have no symptoms, especially if the prolapse is mild.

Coronary_artery_dissection.

A variety of factors can cause this rare condition, which results when a tear develops in the coronary artery. It may cause a sudden severe pain with a tearing or ripping sensation that goes up into the neck, back, or abdomen.

Non-Cardiac Causes of Chest pain

There are multiple non-cardiac causes of chest discomfort which arise from the other organs present in the chest such as the oesophagus (gullet) (gastro-oesophageal reflux disease – GORD), lungs (chest infection), or muscles and joints (costochondritis).

Commonly encountered symptoms include:

Gastro-oesophageal_reflux_disease(GORD)_(heart

This is a very common condition where acid from the stomach leaks out of the stomach and up into the oesophagus (gullet).

Symptom of GORD are variable and include heart burn (a burning sensation or discomfort behind the breast bone which can last for many hours) or acid reflux (a burning sensation or discomfort in the throat often accompanied by a bad taste in the mouth). Patients with severe GORD may have pain (odynophagia) and difficulty (dysphagia) on swallowing.
The first step in treating GORD involves simple measures such as changes to diet (avoiding alcohol, caffeine and fatty or acidic food) and smoke cessation. If these measures are not effective in controlling symptoms then medication such as antacids (for example Gaviscon) or drugs which switch off acid production in the stomach (for example proton pump inhibitors) can be used.

If symptoms are recurrent then an endoscopy (a procedure where a flexible camera is swallowed to look inside the stomach) may be of value.

Chest_Infection

A chest infection arises because of an infection in the lungs. This can be because of a viral (often called bronchitis) or bacterial (often called pneumonia) infection.

Patients with a chest infection have a multiple symptoms including a cough which may accompany a thick yellow or green phlegm (mucus), breathlessness, fever, and occasionally chest discomfort. The chest discomfort is normally a sharp pain that occurs during coughing or movement.

The treatment for a chest infection involves antibiotics. Depending of the severity of teh infection some patients may need to be admitted to hospital.

Costochondritis


Costochondritis arises when there is inflammation of the cartilage in the joints that join your ribs to the breastbone. Costochondritis can occur as a result of an infection, injury, or some time “wear and tear” in the joints.
This results in a sharp chest pain that is worse with movement (such as deep breathing or cough) and posture (such as lying down). Often the pain is confined to a single spot which is also tender to touch.

It can be difficult to tell the difference between the chest pain associated with costochondritis and pain caused by more serious conditions, such as a heart attack.

However, a heart attack usually causes more widespread pain and additional symptoms, such as breathlessness, nausea and sweating.

If you, or someone you are with, experiences sudden chest pain and you think there is a possibility it could be a heart attack, dial 999 immediately and ask for an ambulance.

If you have had chest pain for a while, don’t ignore it. Make an appointment to see your GP so they can investigate the cause.

Inflammation is the body’s natural response to infection, irritation or injury. It is not known exactly why the costochondral joint becomes inflamed, but in some cases it has been linked to:

  • severe coughing, which strains your chest area
  • an injury to your chest
  • physical strain from repeated exercise or sudden exertion that you are not accustomed to, such as moving furniture
  • an infection – including respiritory tract infections and wound infections
  • wear and tear – your chest moves in and out 20 to 30 times a minute, and this motion can, over time, lead to discomfort in these joints

Costochondritis tends to be more common in adults over 40 years of age, whereas Tietze’s syndrome usually affect young adults under 40.


If you have symptoms of costochondritis, your GP will carry out a physical examination by looking at and touching the upper chest area around your costochondral joint. They will ask you when and where your pain occurs, and look at your recent medical history.
Before a diagnosis can be confirmed, some tests may need to be carried out to rule out other possible causes of your chest pain. These may include:

  • an electrocardiogram (ECG), which records the rhythms and electrical activity of your heart
  • a blood test to check for signs of underlying inflammation
  • a chest X ray

If no other condition is suspected or found, a diagnosis of costochondritis may be made. Tietze’s syndrome may be diagnosed if you have swelling in your chest, in addition to your other symptoms.


Costochondritis often gets better after a few weeks, but self-help measures and medication can manage the symptoms.
Self-help
Costochondritis can be aggravated by any activity that places stress on your chest area, such as strenuous exercise, or even simple movements like reaching up to a high cupboard.
Any activity that makes the pain in your chest area worse should be avoided until the inflammation in your ribs and cartilage has improved.
You may also find it soothing to regularly apply heat to the painful area – for example, using a cloth or flannel that has been warmed with hot water.
Painkillers
Painkillers, such as paracetamol can be used to ease mild to moderate pain.
Taking a type of medication called a non-steroidal anti-inflammatory drug (NSAID) – such as ibuprofen and naproxen – two or three times a day can also help control the pain and swelling. Aspirin, another type of NSAID, is also a suitable alternative.
These medications are available from pharmacies without a prescription, but you should make sure you carefully read the instructions that come with them before use.
NSAIDs are not suitable for people with certain health conditions, including asthma, stomach ulcers, high blood pressure, or kidney or heart problems. Children under 16 should not take aspirin.
Contact your GP if your symptoms get worse despite resting and taking painkillers, as you may benefit from treatment with corticosteroids.
Corticosteroid injections
Corticosteroids are powerful medicines that can help to reduce pain and swelling. They can be injected into and around your costochondral joint to help relieve the symptoms of costochondritis.
Corticosteroid injections may be recommended if your pain is severe, or if NSAIDs are unsuitable or ineffective. They may be given by your GP, or you may need to be referred to a specialist called a rheumatologist.
Having too many corticosteroid injections can damage your costochondral joint, so you may only be able to have this type of treatment once every few months if you continue to experience pain.

Costochondritis can improve on its own after a few weeks, although it sometimes last for several months or more.
The condition is not life-threatening and does not lead to any permanent problems.
In cases of Tietze’s syndrome, you may still have some swelling after the pain and tenderness have gone.

Text