Chest Pain
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
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Disorders of the ribs, rib cartilage, chest muscles (musculoskeletal chest wall pain), or nerves in the chest
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Inflammation of the membrane that covers the lungs (pleuritis)
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Inflammation of the membrane that covers the heart (pericarditis)
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Digestive disorders (such as esophageal reflux or spasm, ulcer disease, or gallstones)
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Heart attack or angina (acute coronary syndromes and stable angina)
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Undiagnosed causes that go away on their own
Acute coronary syndromes (heart attack or unstable angina) 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 heart attack or unstable angina, are less common:
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Heart attack or unstable angina
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A tear in the wall of the aorta (thoracic aortic dissection)
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A type of collapsed lung in which pressure builds up enough to obstruct blood flow returning to the heart (tension pneumothorax)
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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 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
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:
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 outpatient doctor as soon as possible 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
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Causes |
Common Features* |
Tests† |
Heart disorders |
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Heart attack (myocardial infarction) or unstable angina |
Immediately life threatening Sudden, crushing pain that 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, often CT of heart arteries or a stress test If ECG or cardiac marker levels are abnormal, heart catheterization |
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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) |
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Pericarditis (inflammation of the membrane around the heart) |
Potentially life threatening Sharp pain that An abnormal heart sound, heard through a stethoscope |
ECG Echocardiography Blood tests to measure substances that indicate heart damage (cardiac markers) MRI |
Digestive tract disorders |
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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) |
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Pancreatitis (inflammation of the pancreas) |
Potentially life threatening Severe, constant pain that 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 |
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Recurring, vague discomfort that Often in people who smoke, drink alcohol, or do both No warning signs‡ |
A doctor's examination Sometimes endoscopy |
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Gastroesophageal reflux (GERD)§ |
Recurring, burning pain that |
A doctor's examination Sometimes endoscopy |
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Gallbladder and bile duct disorders (biliary tract disease)§ |
Recurring discomfort that |
Ultrasonography of the gallbladder Sometimes hepatobiliary scan (HIDA) |
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Swallowing disorders in which there is abnormal movement (propulsion) of food through the esophagus |
Pain that Usually difficulty swallowing |
Sometimes x-rays of the upper digestive tract after barium is given by mouth (barium swallow) A test to determine whether contractions in the digestive tract are normal (esophageal manometry) |
Lung disorders |
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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 A blood test to detect blood clots (D-dimer test) |
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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 |
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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 |
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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 |
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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 |
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Pain in the chest wall,§ including the muscles, ligaments, nerves, and ribs (musculoskeletal chest wall pain) |
Pain that Tenderness in one spot on the chest No warning signs‡ |
Only a doctor's examination |
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Pain that is |
Only a doctor's examination |
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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 |
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Cancers of the chest or chest wall |
Sometimes pain that is worse when breathing in Sometimes chronic cough, smoking history, weight loss, swelling of lymph nodes in the neck |
Chest x-ray Chest CT Sometimes a bone scan |
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* Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. |
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† 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. |
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‡ Warning signs include |
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§ Unless otherwise described, causes are usually not dangerous, although they are uncomfortable. |
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CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging. |
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Testing
For adults with sudden chest pain, tests are done to rule out dangerous causes. For most people, initial tests include
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 or CT angiography before people go home or within a few days. However, if a newer cardiac marker, called high sensitivity troponin, is used and that test does not show evidence of heart damage, further testing may not be required. 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 or increase blood flow through the coronary arteries (such as dipyridamole).
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
Key Points
Drugs Mentioned In This Article
| Generic Name | Select Brand Names |
|---|---|
acetaminophen |
TYLENOL |
dipyridamole |
PERSANTINE |
