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Chest Pain

by Lyall A. J. Higginson, MD

Chest pain is a very common complaint. Pain may be sharp or dull, although some people with a chest disorder describe their sensation as discomfort, tightness, pressure, gas, burning, or aching. Sometimes people also have pain in the back, neck, jaw, upper part of the abdomen, or arm. Other symptoms, such as nausea, cough, or difficulty breathing, may be present depending on the cause of the chest pain.

Many people are well aware that chest pain is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other people, including many with serious disease, minimize or ignore its warnings.

Causes

Many disorders cause chest pain or discomfort. Not all of these disorders involve the heart. Chest pain may also be caused by disorders of the digestive system, lungs, muscles, nerves, or bones.

Common causes

Overall, the most common causes of chest pain are

  • Disorders of the ribs, rib cartilage, chest muscles (musculoskeletal chest wall pain), or nerves in the chest

  • Inflammation of the membrane that covers the lungs (pleuritis)

  • Inflammation of the membrane that covers the heart (pericarditis)

  • Digestive disorders (such as esophageal reflux or spasm, ulcer disease, or gallstones)

  • Heart attack or angina (acute coronary syndromes and stable angina)

  • Undiagnosed causes that go away on their own

Acute coronary syndromes (heart attack or unstable angina—see Acute Coronary Syndromes (Heart Attack) involve a sudden blockage of an artery in the heart (coronary artery) that cuts off the blood supply to an area of the heart muscle. If some of the heart muscle dies because it does not get enough blood, that effect is termed a heart attack (myocardial infarction). In stable angina, long-term narrowing of a coronary artery (for example by atherosclerosis) limits blood flow through that artery (see Angina). This limited blood flow causes chest pain when people exert themselves.


Life-threatening causes

Some causes of chest pain are immediately life threatening but, except for heart attack or unstable angina, are less common:

  • Heart attack or unstable angina

  • A tear in the wall of the aorta (thoracic aortic dissection—see Aortic Dissection)

  • A type of collapsed lung in which pressure builds up enough to obstruct blood flow returning to the heart (tension pneumothorax—see Tension Pneumothorax)

  • A tear of the esophagus (see Mediastinitis : Symptoms)

  • Blockage of an artery to the lungs by a blood clot (pulmonary embolism—see Pulmonary Embolism)

Other causes range from serious, potential threats to disorders that are simply uncomfortable.


Evaluation

People with chest pain should be evaluated by a doctor. The following information can help people decide when evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with chest pain or discomfort, certain symptoms and characteristics are cause for concern. They include

  • Crushing or squeezing pain

  • Shortness of breath

  • Sweating

  • Nausea or vomiting

  • Pain in the back, neck, jaw, upper abdomen, or one of the shoulders or arms

  • Light-headedness or fainting

  • Sensation of rapid or irregular heartbeat


When to see a doctor

Although not all causes of chest pain are serious, because some causes are life threatening, the following people should see a doctor right away:

  • Those with new chest pain (within several days)

  • Those who have a warning sign

  • Those who suspect that a heart attack is occurring (for example, because symptoms resemble a previous heart attack)

These people should call emergency services (911) or be taken to an emergency department as quickly as possible. People should not try to drive themselves to the hospital.

Chest pain that lasts for seconds (less than 30 seconds) is rarely caused by a heart disorder. People with very brief chest pain need to see a doctor, but emergency services are usually not needed.

People who have had chest pain for a longer time (a week or more) should see a doctor within several days unless they develop warning signs or the pain has steadily been getting worse or coming more often, in which case they should go to the hospital right away.


What the doctor does

Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What they find during the history and physical examination often suggests a cause of the chest pain and the tests that may need to be done. However, symptoms due to dangerous and not dangerous chest disorders overlap and vary greatly. For example, although a typical heart attack causes dull, crushing chest pain, some people with a heart attack have only mild chest discomfort or complain only of indigestion or arm or shoulder pain (referred pain—see Figure: What Is Referred Pain?). On the other hand, people with indigestion may simply have an upset stomach, and those with shoulder pain may have only sore muscles. Similarly, although the chest is tender when touched in people with musculoskeletal chest wall pain, the chest can also be tender in people who are having a heart attack. Thus, doctors usually do tests on people with chest pain.

Some Causes and Features of Chest Pain

Causes

Common Features*

Tests

Heart disorders

Heart attack (myocardial infarction) or unstable angina, which are acute coronary syndromes

Immediately life threatening

Sudden, crushing pain that

  • Spreads to the jaw or arm

  • May be constant or come and go

Sometimes shortness of breath or nausea

Pain that occurs during exertion and is relieved by rest (angina pectoris)

Certain abnormal heart sounds, heard through a stethoscope

Often warning signs

ECG, done several times over a period of time

Blood tests to measure substances that indicate heart damage (cardiac markers)

If ECG and cardiac marker levels are normal, CT of heart arteries or a stress test

If ECG or cardiac marker levels are abnormal, heart catheterization

Thoracic aortic dissection (a tear in the wall of the part of aorta in the chest)

Immediately life threatening

Sudden, tearing pain that spreads to or starts in the middle of the back

Sometimes light-headedness, stroke, or pain, coldness, or numbness in a leg (indicating inadequate blood flow to the leg)

Sometimes a pulse or blood pressure in one limb that differs from that in the other limb

Usually in people who are over 55 and have a history of high blood pressure

Warning signs

Chest x-ray

CT of the aorta

Transesophageal echocardiography (ultrasonography of the heart with the ultrasound device passed down the throat)

Pericarditis (inflammation of the membrane around the heart)

Potentially life threatening

Sharp pain that

  • Is constant or comes and goes

  • Is often worsened by breathing, swallowing food, or lying on the back

  • Is relieved by leaning forward

An abnormal heart sound, heard through a stethoscope

ECG

Echocardiography

Blood tests to measure substances that indicate heart damage (cardiac markers)

Digestive tract disorders

Esophageal rupture

Immediately life threatening

Sudden, severe pain immediately after vomiting or after a medical procedure involving the esophagus (such as endoscopy of the esophagus and stomach or transesophageal echocardiography)

Several warning signs

Chest x-ray

X-rays of the esophagus taken after the person swallows water-soluble contrast (esophagography)

Pancreatitis

Potentially life threatening

Severe, constant pain that

  • Occurs in the upper middle of the abdomen or in the lower chest

  • Is often worse when lying flat

  • Is relieved by leaning forward

Vomiting

Upper abdominal tenderness

Sometimes shock

Often in people who abuse alcohol or who have gallstones

Blood tests to measure an enzyme (lipase) produced by the pancreas

Sometimes CT of the abdomen

Peptic ulcer §

Recurring, vague discomfort that

  • Occurs in the upper middle of the abdomen or lower chest

  • Is relieved by food, antacids, or both

Often in people who smoke, drink alcohol, or do both

No warning signs

A doctor's examination

Sometimes endoscopy

Gastroesophageal reflux (GERD) §

Recurring, burning pain that

  • Spreads from the upper middle of the abdomen to the throat

  • Is worsened by bending over or lying down

  • Is relieved by antacids

A doctor's examination

Sometimes endoscopy

Gallbladder and bile duct disorders (biliary tract disease) §

Recurring discomfort that

  • Occurs in the upper right of the abdomen or the lower middle of the chest

  • Occurs after meals (but not after exertion)

Ultrasonography of the gallbladder

Swallowing disorders in which there is abnormal movement (propulsion) of food through the esophagus

Pain that

  • Has developed gradually over a long period of time

  • May or may not occur during swallowing

Usually difficulty swallowing

Sometimes x-rays of the upper digestive tract after barium is given by mouth (barium swallow)

Lung disorders

Pulmonary embolism (blockage of an artery in the lungs by a blood clot)

Immediately life threatening

Often sharp pain when breathing in, shortness of breath, rapid breathing, and a rapid heart rate

Sometimes mild fever, coughing up blood, or shock

More likely in people with risk factors for pulmonary embolism (such as previous blood clots, recent surgery especially surgery on the legs, prolonged bed rest, a cast or splint on a leg, older age, smoking, or cancer)

CT or nuclear scanning of the lungs

Sometimes a blood test to detect blood clots ( d -dimer test)

Tension pneumothorax (a collapsed lung with a high-pressure buildup of air in the chest)

Immediately life threatening

Significant shortness of breath

Low blood pressure, swollen neck veins, and weak breath sounds on one side, heard through a stethoscope

Typically occurs only after a severe chest injury

Usually only a doctor's examination

Sometimes chest x-ray

Pneumonia

Potentially life threatening

Fever, chills, cough, and usually yellow or green phlegm

Often shortness of breath

Sometimes pain when breathing in

A rapid heart rate and congested lungs, detected during the examination

Chest x-ray

Pneumothorax (a collapsed lung)

Potentially life threatening

Sudden, sharp pain, usually on one side of the chest

Sometimes shortness of breath

Sometimes weak breath sounds on one side, heard through a stethoscope

Chest x-ray

Pleuritis (inflammation of the membrane around the lung) §

Sharp pain when breathing

Usually in people who have recently had pneumonia or a viral respiratory infection

Sometimes cough

No warning signs

Usually only a doctor's examination

Other disorders

Pain in the chest wall, § including the muscles, ligaments, nerves, and ribs (musculoskeletal chest wall pain)

Pain that

  • Is typically persistent (lasting days or longer)

  • Is worsened by movement and/or breathing

  • May have no apparent cause or may result from coughing or overuse

Tenderness in one spot on the chest

No warning signs

Only a doctor's examination

Fibromyalgia

Pain that is

  • Nearly constant

  • Affects widespread areas of the body

  • Is usually accompanied by fatigue and poor sleep quality

Only a doctor's examination

Herpes zoster infection §

Sharp pain in a band around the middle of the chest but only on one side

A rash of many small blisters. sometimes filled with pus, in the painful area and sometimes appearing only after the pain

Only a doctor's examination

*Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

For most people with chest pain, the oxygen level in blood is measured with a sensor placed on a finger (pulse oximetry), ECG is done, and a chest x-ray is taken.

Warning signs include

  • Abnormal vital signs (an abnormally slow or fast heart rate, rapid breathing, and abnormally low blood pressure)

  • Signs of decreased blood flow (such as confusion, pale or gray skin color, and excessive sweating)

  • Shortness of breath

  • Abnormal breath sounds or pulses

  • New heart murmurs

§ Unless otherwise described, causes are usually not dangerous, although they are uncomfortable.

CT = computed tomography; ECG = electrocardiography.


Testing

For adults with sudden chest pain, tests are done to rule out dangerous causes. For most people, initial tests include

  • Measurement of oxygen levels with a sensor placed on a finger (pulse oximetry)

  • Electrocardiography (ECG)

  • Chest x-ray

If symptoms suggest an acute coronary syndrome or if no other cause is clear (particularly in people who are at high risk), doctors usually measure levels of substances that indicate heart damage (cardiac markers) in the blood (at least two separate times over a few hours) and do repeated ECGs. If these tests do not show an acute coronary syndrome, doctors often then do a stress test (see Stress Testing) before people go home or within a few days. For a stress test, ECG or an imaging test (such as echocardiography) is done during exercise (often on a treadmill) or after a drug is given to make the heart beat fast.

If pulmonary embolism is suspected, (CT) of the lungs or a lung scan is done. If pulmonary embolism is considered only somewhat possible, a blood test to detect clots ( d -dimer test) is often done. If this test is negative, pulmonary embolism is unlikely, but if the test is positive, other tests, such as of the legs or CT of the chest, are often done.

In people who have had chest pain for a long time, immediate threats to life are unlikely. Most doctors initially do only a chest x-ray and then do other tests based on the person's symptoms and examination findings.


Treatment

Specific identified disorders are treated. If the cause is not clearly benign, people are usually admitted to the hospital or an observation unit for heart monitoring and more extensive evaluation. Symptoms are treated with acetaminophen or opioids as needed until a diagnosis is made.

Key Points

  • Chest pain may be caused by serious life-threatening disorders, so people with new chest pain (within a few days) should get immediate medical attention.

  • The symptoms of life-threatening and non–life-threatening disorders overlap, so testing is usually needed to determine a cause.

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