| What Is Chest Pain? |
It's the middle of the night or maybe the beginning of a busy workday when you suddenly feel pain in your chest. You may try to ignore it at first, but the pain has you scared and worried. Could you be having a heart attack? Should you go to the emergency room?
Chest pain is one of the most common reasons people call for emergency medical help. Every year emergency room doctors see nearly 5 million Americans for this symptom.
Chest pain doesn't always signal a heart attack. Often it's unrelated to any heart problem. But even if the chest pain you experience has nothing to do with your cardiovascular system, the problem may still be important — and worth the time spent in an emergency room to have it evaluated.
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| Causes |
Chest pain has many possible causes, all of which deserve medical attention. The causes of chest pain fall into two major categories — cardiac and noncardiac causes.
Cardiac causes
- Heart attack. A heart attack — a blood clot that's blocking blood flow to your heart muscle
— can cause pressure, fullness, or a squeezing or crushing pain in your chest that lasts more than a
few minutes. The pain may radiate to your back, neck, jaw, shoulders and arms, especially your left
arm. Other signs and symptoms may include shortness of breath, sweating, dizziness and nausea. All,
some or none of these may accompany your chest pain.
- Angina. Fatty deposits can build up in the arteries that carry blood to your heart,
narrowing them and temporarily restricting blood flow to your heart, especially during times of
exertion. Restricted blood flow to your heart can cause recurrent episodes of chest pain — angina
pectoris, or angina. Angina (an-JI-nuh or AN-juh-nuh) is often described as a pressure or tightness in
the chest. It's usually brought on by physical or emotional stress. The pain usually goes away within
minutes after you stop the stressful activity.
- Other cardiac causes. Other problems that can cause chest pain include inflammation of the sac surrounding your heart (pericarditis), a short-lived condition often related to a viral infection. Pericarditis causes sharp, piercing and centralized chest pain. You may also have a fever and feel sick. A rare, life-threatening cause of chest pain called aortic dissection involves the main artery leading from your heart — your aorta. If the inner layers of this blood vessel separate, forcing blood flow between them, the result is sudden and tearing chest and back pain. Aortic dissection can result from a sharp blow to your chest or develop as a complication of uncontrolled high blood pressure. Coronary spasm, also known as Prinzmetal's angina, Syndrome X or endothelial dysfunction, also can cause varying degrees of chest discomfort. In coronary spasm, coronary arteries — arteries that supply blood to the heart — go into spasm, temporarily limiting blood flow to the heart. Spasms of the coronary arteries may occur spontaneously or be triggered by a stimulant, such as nicotine or caffeine. Coronary artery spasms, which tend to cause episodes of chest pain, can occur with activity or at rest. The spasms may even wake you from sleep. The condition may coexist with coronary artery disease — the buildup of fatty deposits in the coronary arteries.
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Noncardiac causes
Many conditions unrelated to your heart can cause chest pain. These include:
- Heartburn. Stomach acid that washes up from your stomach into the tube that runs from your
mouth to your stomach (esophagus) can cause heartburn — a painful, burning sensation behind your
breastbone (sternum). Often this feeling is accompanied by a sour taste and the sensation of food
re-entering your mouth (regurgitation). Heartburn-related chest pain usually follows a meal and may
last for hours. Signs and symptoms occur more frequently when you bend forward at the waist or lie
down.
- Panic attack. If you experience discrete periods of intense fear, accompanied by chest
pain, rapid heartbeat, rapid breathing (hyperventilation), profuse sweating and shortness of breath,
you may be experiencing a panic attack — a form of anxiety.
- Pleurisy. Sharp, localized chest pain that's made worse when you inhale or cough may point
to pleurisy as a cause. This condition occurs when the membrane that lines your chest cavity and
covers your lungs becomes inflamed. Pleurisy may result from a wide variety of underlying conditions,
including pneumonia and, rarely, autoimmune conditions such as lupus. An autoimmune disease is one in
which your body's immune system attacks healthy tissue.
- Costochondritis. In this condition — also known as Tietze's syndrome — the cartilage of
your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed.
The pain from costochondritis (kos-toe-KHON-dri-tis) may occur suddenly and be intense, leading you to
assume you're having a heart attack. Yet the location of the pain is different. Costochondritis causes
your chest to hurt when you push on your sternum or on the ribs near your sternum. Heart attack pain
is usually more widespread, and the chest wall usually isn't tender.
- Pulmonary embolism. This condition occurs when a blood clot becomes lodged in a lung
artery, blocking blood flow to lung tissue. Symptoms of this life-threatening condition can include
sudden, sharp chest pain that begins or worsens with a deep breath or cough. Other signs and symptoms
can include shortness of breath, rapid heartbeat, anxiety and faintness. It's rare for pulmonary
embolism to occur without preceding risk factors, such as recent surgery or immobilization.
- Other lung conditions. A collapsed lung (pneumothorax), high blood pressure in the arteries
carrying blood to the lungs (pulmonary hypertension) and severe asthma can also produce chest pain.
- Sore muscles. Muscle-related chest pain tends to come on when you twist side to side or
when you raise your arms. Chronic pain syndromes, such as fibromyalgia, can produce persistent
muscle-related chest pain.
- Injured ribs or pinched nerves. A bruised or broken rib, as well as a pinched nerve, can
cause chest pain that tends to be localized and sharp.
- Swallowing disorders. Several disorders of the esophagus, the tube that runs from your
mouth to your stomach, can make swallowing difficult and even painful. One type is esophageal spasm, a
condition that affects a small group of people with chest pain. When people with this condition
swallow, the muscles that normally move food down the esophagus are uncoordinated. This results in
painful muscle spasms. Because esophageal spasms can be calmed with the medication nitroglycerine —
which also rapidly relieves some heart-related pain — this condition is sometimes mistaken for a heart
problem. Another swallowing disorder, which also affects a small group of people with chest pain, is
achalasia (ak-uh-LA-zhuh). In this condition, the valve in the lower esophagus doesn't open properly
to allow food to enter your stomach. Instead food backs up into the esophagus, causing pain. Pain with
swallowing also can accompany heartburn.
- Shingles. This infection of nerves caused by the chickenpox virus can produce pain and a
band of blisters on your back around to your chest wall. This sharp, burning pain may begin several
hours to a day or so before blisters appear.
- Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder
(cholecystitis) or pancreas can cause acute abdominal pain that radiates to your chest.
- Cancer. Rarely, cancer involving the chest or cancer that has spread from another part of the body can cause chest pain.
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| When to Seek Medical Advice |
Pain in your chest can be severe. It can be difficult to interpret. The pain could be caused by something as simple as heartburn or as serious as a heart attack.
If you experience unexplained and persistent chest pain — particularly if it's accompanied by other signs and symptoms, such as shortness of breath or pain that radiates beyond your chest to one or both of your arms or your neck — seek emergency medical care. A trip to the emergency room could save your life — or bring you peace of mind if nothing is seriously wrong with your health.
| Screening and Diagnosis |
At the emergency room or chest pain center — some large hospitals designate areas just for the evaluation of chest pain — you'll probably have your blood pressure, pulse and temperature checked right away. In addition, the doctor will ask you questions about your chest pain: Where is the pain located? How would you describe the pain? Do you have other signs and symptoms along with the pain?
Chest pain doesn't always signal a heart attack. But that's what emergency room doctors will test for first because it's potentially the most immediate threat to your life. They may also check for life-threatening lung conditions, such as pulmonary embolism or a collapsed lung (pneumothorax), that can cause chest pain.
Tests you may have to determine the cause of your chest pain include:
- Electrocardiogram (ECG). This test can help doctors diagnose a heart attack as well as
other heart problems. It records the electrical activity of your heart through electrodes attached to
your skin. Impulses are recorded as waves displayed on a monitor or printed on paper. Because injured
heart muscle doesn't conduct electrical impulses normally, the ECG may show that a heart attack has
occurred or is in progress.
- Stress tests. These measure how your heart and blood vessels respond to exertion, which may
indicate if your pain is related to your heart. There are many kinds of stress tests. You may be asked
to walk on a treadmill or pedal a stationary bike while hooked to an ECG. Or you may be given a drug
intravenously to stimulate your heart in a way similar to exercise. Stress tests may be combined with
imaging scans of the heart.
- Blood tests. Your doctor may order blood tests to check for increased levels of certain
enzymes normally found in heart muscle. Damage to heart cells from a heart attack may allow these
enzymes to leak, over a period of hours, into your blood.
- Chest X-ray. An X-ray of your chest allows doctors to check the condition of your lungs and
the size and shape of your heart and major blood vessels. Doctors also can use a chest X-ray to check
for tumors in the chest.
- Nuclear scan. This test helps doctors diagnose cardiac causes of chest pain, such as a
narrowed heart artery. Trace amounts of radioactive material, such as thallium, are injected into your
bloodstream. Special cameras can detect the radioactive material as it flows through your heart and
lungs.
- Coronary catheterization (angiogram). This test helps doctors identify individual arteries
to your heart that are narrowed or blocked. A liquid dye is injected into the arteries of your heart
through a catheter — a long, thin tube that's fed through an artery, usually in your leg, to arteries
in your heart. As the dye fills your arteries, they become visible on X-ray and video.
- Electron beam computerized tomography (EBCT). This procedure, also called an ultrafast CT
scan, scans your arteries for signs of calcium, which indicates that fatty deposits along with calcium
may be accumulating and blocking arteries supplying your heart.
- Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart.
This image can help doctors identify heart problems.
- Endoscopy. In this test a thin, flexible instrument attached to a camera is passed down your throat, allowing doctors to view your esophagus and stomach and check for gastroesophageal problems that can cause chest pain.
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| Treatment |
Cardiac causes
If it appears that heart problems are the cause of your chest pain, your doctor may give you medications such as:
- Aspirin. Aspirin inhibits blood clotting, helping to maintain blood flow through narrowed
heart arteries. When taken during a heart attack, aspirin can decrease death rates by 25 percent. You
may be asked to chew the aspirin to hasten its absorption.
- Nitroglycerine. This medication for treating angina temporarily opens narrowed blood
vessels, improving blood flow to and from your heart.
- Beta blockers. These drugs help relax your heart muscle, slow your heart rate and decrease
your blood pressure.
- Angiotensin-converting enzyme (ACE) inhibitors. These drugs allow blood to flow from your
heart more easily. Your doctor may prescribe ACE inhibitors if you've had a moderate to severe heart
attack that has reduced your heart's pumping capacity.
- Calcium channel blockers. When treating coronary artery spasms, doctors use heart medications such as calcium channel blockers to relax the coronary arteries and prevent the spasms.
If it's clear you're experiencing a pulmonary embolism, you will likely be treated with emergency blood-thinning medications. Aortic dissection, also an emergency, may require surgery. Other heart and lung conditions can be treated initially in the emergency room. Cancer involving the chest requires treatment and referral to an oncologist, or doctor who specializes in cancer treatment.
Doctors usually treat angina — chest pain caused by restricted blood flow to the heart —with medication, angioplasty or coronary bypass surgery. For people who don't respond to or who aren’t candidates for these standard treatments, doctors at some major medical centers are evaluating an alternative treatment called enhanced external counterpulsation (EECP). During EECP therapy, a person lies on a bed wearing three inflatable pressure cuffs on the calves, the upper and lower thighs, and buttocks. Timed with the beating of the heart, the cuffs — which resemble blood pressure cuffs — are sequentially inflated and then simultaneously deflated. This sequential squeezing of the legs is repeated continually for an hour and sets up a pressure wave that forces blood from the legs to the heart. For some people, sessions of EECP help decrease episodes of chronic angina.
Most of the time, chest pain isn't related to emergency heart or lung problems. If doctors determine you're out of immediate danger, evaluation and treatment may shift to an outpatient setting. You may be referred to your own physician or a specialist for further evaluation.
Noncardiac causes
Treatments for noncardiac causes of chest pain depend on the type of problem. These problems and their treatments include:
- Heartburn. If your symptoms suggest heartburn, you'll likely need to take an
over-the-counter or prescription-strength (stomach) acid blocker or antacid in the emergency room.
Most episodes of heartburn are isolated events caused by overeating. However, if you experience
frequent heartburn (at least one episode a week), your doctor or a gastroenterologist, a doctor who
specializes in stomach and intestinal problems, may ask you to undergo more tests. Left untreated,
chronic, frequent heartburn can occasionally lead to scarring and narrowing of your esophagus.
Treatment for chronic heartburn may include dietary modifications, prescription medications and, in
some cases, surgery.
- Panic attack. This anxiety-related cause of chest pain can be treated with prescription
anti-anxiety medications, relaxation techniques and counseling to find out what may be triggering your
attacks. Panic attacks are often mistaken for heart attacks, and many people are seen in emergency
rooms for this problem. But once your condition is diagnosed, you can be referred for treatment to
help you gain control over these attacks.
- Pleurisy. This inflammation of the pleura, the membrane that lines your chest cavity and
covers your lungs, may result from a variety of conditions, including pneumonia and, rarely,
autoimmune conditions such as lupus. Your doctor will want to identify and treat the underlying
disease that caused pleurisy. Over-the-counter pain relievers can help minimize the pain until the
inflammation subsides.
- Costochondritis. Treatment for this inflammation of the cartilage of your rib cage is
generally rest, heat and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin,
others).
- Sore muscles, injured ribs or pinched nerves. Chest pain from injured ribs, pinched nerves
and sore chest muscles improves with time and self-care measures recommended by your doctor.
- Swallowing disorders. These disorders have many causes, which can usually be treated with
minor surgery, medications or endoscopic techniques. You will probably be referred to a
gastroenterologist for evaluation and treatment.
- Shingles. If identified within 3 days of the rash outbreak, shingles can be treated with
medications to reduce pain and risk of future complications.
- Gallbladder or pancreas problems. Surgery may be necessary to treat an inflamed gallbladder or pancreas that's causing pain to radiate from your abdomen into your chest.
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— April 12, 2002 —