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Chest pain – Symptoms and causes

July 13, 2021
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Chest pain is the one of the major causes of Emergency room visits, although it is a major symptom of a cardiac problem but there are many possible causes of this complaint some of them are serious while others are considered not harmful conditions.

Worldwide, chest pain affects 20-40 percent of the general population.

Causes of chest pain:

Cardiac causes:

Acute coronary syndromes: [Heart Attack] (acute MI, NSTEMI, Unstable angina)

In these conditions chest pain is oppressive coming with exertion relieved by rest lasting more than one minute except if acute MI it will be persistent and associated by :

  • Pain in the jaw , neck or back
  • Light headedness
  • Arm or shoulder pain
  • Shortness of breath
  • Women may also experience sudden tiredness, nausea or vomiting

If anyone suspects that he is experiencing a heart attack he should seek emergency medical help, the quicker the treatment the better the chance for survival and the less the severity of damage to the heart.

Pericarditis:

It is an inflammation of the sac around the heart, it results in sharp stabbing chest pain increased by lying down and deep breathing and partially relieved by leaning forward.

Myocarditis:

Myocarditis is an inflammation of the heart muscle resulting in symptoms similar to heart attack such as:

  • Chest pain
  • Fever
  • Difficulty of breathing
  • Fatigue
  • Racing of the heart

Mitral valve Prolapse:

When the mitral valve is unable to close fully it is a structural heart condition that may cause symptoms of chest pain , palpitation , dizziness in mild cases it may cause no obvious symptoms.

Aortic stenosis:

aortic stenosis may be congenital , rheumatic, age related (calcified), usually symptomatic aortic stenosis pain is angina pain which is induced by exertion and relieved by rest may be associated in severe cases by syncope or progressive heart failure.

Hypertrophic cardiomyopathy:

It is a genetic condition resulting in increased thickening of the heart muscle preventing the blood from flowing properly out of the heart usually it is associated by shortness of breath , dizziness and fainting attacks or may present with sudden cardiac death.

Coronary artery dissection:

Sudden intense chest pain appears as tearing across the chest , neck, back or abdomen it is a rare but serious condition.

Aortic causes:

Aortic dissection:

Aortic dissection is a separation of the inner layers of the aortic wall leading the blood will go through the aortic wall causing it’s rupture, it is a life threatening condition requiring immediate medical care.

Pulmonary causes:

Pulmonary embolism:

When a blood clot get trapped in the pulmonary artery feeding blood to the lungs, it causes severe chest pain, difficulty of breathing, coughing and sudden syncope if it is massive pulmonary embolism , it is a life threatening condition if not treated immediately.

Pleurisy:

Pleurisy is an inflammation of the membrane that covers the lungs, it causes sharp stabbing chest pain on deep breathing.

Pulmonary hypertension:

High blood pressure in the pulmonary arteries can sometimes result in chest pain.

Collapsed lung:

when air accumulates in the space between the lung and thoracic cage a lung will collapse causing sudden chest pain with breathing with shortness of breath and rapid heart rate.

Pneumonia:

Infection in the lungs can cause sharp stabbing pain usually associated by other symptoms like fever, chills, coughing and expectoration of phlegm.

Asthma:

Asthma is a recurrent common breathing disorder characterized by recurrent inflammation in the airways causing chest pain, shortness of breath wheezing and coughing.

Gastrointestinal causes:

Esophageal spasm, reflux or esophagitis:

It is a muscular contraction in the tube that connects the mouth to the Stomach, it is in the form of severe pain that lasts few minutes to hours increase with swallowing of food or liquids it can cause burning feeling in the chest and sour taste in the mouth if associated reflux of acid content in the esophagus.

Esophageal rupture:

If the esophagus bursts after intense vomiting or during holding of severe vomiting act or after operation involving the esophagus.

Peptic ulcers:

These are sores in the stomach lining causing intense pain however they may cause chest discomfort and may be confused with coronary syndromes.

Hiatal hernia:

When part of the stomach pushes in the chest the pain is usually related to food intake and may be associated by symptoms like heart burn and chest pain specially with meals and on lying down.

Pancreatitis:

It is a rare condition of inflammation of the pancreas the pain in the upper abdomen and lower chest it worsens by lying down.

Chest wall causes:

Muscle strain:

Inflammation of the muscles and tendons around the ribs can result in persistent chest pain which worsen with activity or carrying heavy weights

Injured ribs:

Ribs bruises and fracture can cause chest pain specially after a history of trauma and the victim may hear a crack followed by extreme pain.

Costochondritis:

It is an inflammation of the cartilage of the ribs, the pain of costochondritis can worsen when sitting or lying in certain positions as well as when the person performs physical activity.

Neurologic causes:

Cervical spondylosis and other compression neuropathy:

It is a spinal cord compression in the neck region it occurs with aging above the age of 50 it is associated by a wide variety of symptoms like weakness and numbness in the hands and arms loss of balance and associated pain radiating to the chest it occurs due to nerve compression.

Herpes:

Herpes Zoster is a viral infection that affects the thoracic dermatome it starts as pain in the affected dermatome for few days followed by vesicular eruption.

Psychological causes:

  • Panic disorder
  • Anxiety
  • Depression
  • Hysteria

Associated with other symptoms like nausea, rapid shallow breathing, excessive sweating, palpitation, sense of fear, shouting and crying.

How to deal with chest pain?

It is always advised to contact a doctor when dealing with chest pain especially if the pain comes suddenly and not relieved if the patient is experiencing difficulty of breathing or if he has manifestations that may threaten his lifelike:

  • A crushing sensation on the breastbone.
  • A chest pain that spreads to the jaw, left arm, or back
  • Change in the level of alertness palpitation or rapid breathing

In the Emergency Department (ED)

  1. Rapid evaluation: to identify life threatening illness is important by TRIAGE of the patients
  2. For suspected acute Coronary Syndrome patients the aim of ED is to reduce myocardial damage by short term observation with specific investigation to identify the source of  pain.
  3. Assessment of  pain in ED involves rapid history taking, physical examination, 12 lead ECG , an initial 92% to 98% of acute MI and approximately 90% of unstable angina cases can be identified.
  4. Further evaluation by cardiac biomarkers like Troponin I for undiagnosed cases of pain.
  5. Chest X ray can diagnose other acute conditions like aortic dissection, lung collapse, pneumonia, fracture rib.
  6. Echocardiography is very important diagnostic tool for other cardiac conditions like Hypertrophic COM, Aortic valve disease, myocarditis, pulmonary embolism and pulmonary hypertension and Mitral valve prolapse.
  7. Stress ECG test is an important tool to diagnose intermittent classic angina pain with negative ECG or cardiac biomarkers.

Treatment of pain is usually directed to treatment of the cause of the chest pain

 

Dr. Bahgat Farag

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