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Heart and Blood Vessel Disorders
Symptoms of Heart and Blood Vessel Disorders
Chest Pain
Causes
Evaluation
Treatment
Key Points
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    Chest Pain

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    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, indigestion, 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 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. 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 acute coronary syndromes, are less common:

    • Heart attack or unstable angina
    • A tear in the wall of the aorta (thoracic aortic dissection)
    • A type of collapsed lung in which pressure builds up enough to obstruct blood flow returning to the heart (tension pneumothorax)
    • A tear of the esophagus
    • Blockage of an artery to the lungs by a blood clot (pulmonary embolism)

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

    Evaluation

    People with chest pain should have an evaluation 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, people with new chest pain (within several days), who have a warning sign, or who suspect that a heart attack is occurring (for example because symptoms resemble a previous heart attack) should see a doctor right away. They 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. 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.

    PrintOpen table in new window Open table in new window
    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

    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

    Shock

    Often in people who abuse alcohol or who have gallstones

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

    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

    Esophageal 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, or 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

    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

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

    †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

    CT = computed tomography; ECG = electrocardiography.

    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

    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

    Shock

    Often in people who abuse alcohol or who have gallstones

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

    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

    Esophageal 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, or 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

    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

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

    †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

    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 several ECGs. If these tests do not show an acute coronary syndrome, doctors often then do a stress test (see Diagnosis of Heart and Blood Vessel Disorders: 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, computed tomography (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 ultrasonography 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 acetaminophenSome Trade Names
    TYLENOL
    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 needed to determine a cause.

    Last full review/revision October 2012 by Lyall A. J. Higginson, MD

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    Pronunciations

    acetaminophen

    angina

    aorta

    aortic dissection

    atherosclerosis

    biliary

    computed tomography

    echocardiography

    electrocardiography

    embolism

    endoscopy

    esophageal

    esophagus

    infarction

    lipase

    myocardial

    myocardial infarction

    opioids

    oximetry

    pancreas

    pancreatitis

    pericarditis

    phlegm

    pneumonia

    pneumothorax

    pulmonary embolism

    sclerosis

    tension pneumothorax

    thoracic

    ultrasonography

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