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What are the causes of chest pain?

Chest pain is a common reason why patients seek medical attention. Approximately eight million people visit the ER in the US complaining of chest pain, making it the second most common complaint. About 2-5% of heart attacks are missed and sent home from the ER. It’s important to know the common and uncommon ways heart attack can present. Chest pain can occur from heart related causes or from other structures inside the chest and abdomen. Seek immediate medical help for any new or worsening chest pain.

What are the life threatening causes for chest pain?

  • Heart attack also known as myocardial infarction
  • Aortic dissection
  • Pulmonary embolism
  • Pneumothorax
  • Cardiac tamponade
  • Esophageal rupture
  • Stomach ulcer

Other causes include

  • Pneumonia
  • Pericarditis
  • Costochondritis
  • Pleuritis
  • GERD
  • Mitral valve prolapse
  • Fibromyalgia
  • Back pain radiating to chest

Chest pain from a Heart attack has certain characteristics that make it more likely. Chest pain from heart disease or heart attack is more likely to be pressure like, feel like heaviness often described as a elephant sitting on the chest, tight, constricting. It can be in the center of the chest or left and usually starts with increased activity and gets better with rest. It’s more commonly described as a discomfort rather than pain.

Other descriptions for chest discomfort from heart attack have included knot in the center of chest, lump in the throat, chest tightness, ache, band like feeling, strangling, constricting, squeezing, jaw, neck and arm pain.

Pain from heart disease can occur after eating since the blood pools in the gut after eating and this decreases blood supply to the heart. When blood flow to the heart is decreased, it’s known as ischemia. Anything that decreases blood flow to the heart can cause ischemia. Increase in physical activity like exercise, increased stress or sex can cause decrease blood flow to the heart and cause a heart attack in a person with heart disease. Blood pressure tends to increase in the early morning and heart attacks occur more commonly in the morning. The platelets are also more active at night due to increased release of thromboxane. Thromboxane a2 increases platelet count and causes them stick together. This is one of the reason why cholesterol lowering medications are prescribed at night.

Aortic dissection is an uncommon but serious cause of chest pain. Aorta is the largest blood vessel in the body and in an aortic dissection a tear forms inside the blood vessel. This creates a tunnel where the blood “dissects” through the wall of the artery. If not corrected, the results can be fatal. High blood pressure is the most important factor which leads to the development of aortic dissection.

Pulmonary embolism is another potentially fatal diagnosis where blockage occurs in the pulmonary artery. The blockage can be from any material but most commonly a blood clot, which travels from the leg veins and into the pulmonary artery. Other substances which can cause blockage include, tumor, fat, air, amniotic fluid etc. If the doctor is suspicious then he or she may order some blood tests and imaging test like a CT scan to diagnose a pulmonary embolism. The death rate (mortality) from a PE that’s untreated is close to 30% and 2-11% in those treated with blood thinners.

Pneumothorax is a collapsed lung, which is caused by air entry between the lungs and chest wall. It can occur spontaneously without any risk factors. It’s more common in young, tall, thin men and smokers. It usually happens when a bleb or bubble on the lung surface ruptures. It causes a sudden difficulty breathing and chest pain when taking a deep breath. Depending on the severity, treatment may include oxygen, needle aspiration of air or chest tube.

Cardiac tamponade occurs when fluid collects outside the heart causing pressure on the heart and impairing its pump function. Under pressure, the heart is unable to pump blood effectively which drops the blood pressure and can lead to shock. Symptoms include chest pain, shortness of breath, and fast heart rate. It usually occurs after some type of trauma or cardiac procedure. The doctor may order a EKG, chest xray and echocardiogram to help with diagnosis. The main treatment is removing the fluid around the heart by a catheter or surgery.

Esophageal rupture also called Boerhaave syndrome occurs with sudden increase of pressure in the esophagus from straining or vomiting. Other causes of increased pressure include seizures, giving birth, coughing and weightlifting. The ruptured esophagus can spill its contents into the chest cavity causing inflammation and bacterial infection. Symptoms include severe pain in the chest, neck or upper abdomen after any activity which increases the esophageal pressures. Treatment may involve IV fluids, nutrition, antibiotics, endoscopy or surgery. If left untreated the infection can causes sepsis and organ failure.

Stomach ulcers might not cause any symptoms. When symptoms are present, it can cause pain at the top of the stomach, feeling of fullness, discomfort, and nausea. Symptoms may get worst after eating. If left untreated, stomach ulcers can cause bleeding, swelling and obstruction of the stomach outlet and perforation. Perforation is a medical emergency and the treatment is surgical. Prevention involves stopping all NSAID’s (ex. Ibuprofen, naproxen), treating H. pylori if present, using medications to control stomach acids with PPI (omeprazole) or H2 blockers (ranitidine) and in some patient’s surgery. The importance of diet, exercise and stress management are also vital for prevention.

Pneumonia is a lung inflammation caused by a bacteria or virus. It can also occur with medications, chemicals, and gastric fluid aspiration. Most common bacterial cause is Streptococcus pneumoniae. Diagnosis usually requires chest xray in combination with physical exam and symptoms. Symptoms of pneumonia may include fever, cough, chest pain, shortness of breath and sputum production. Due to the overuse of antibiotics, resistance against the antibiotics is on the rise. The choice of antibiotic depends on the patient’s age, their medical history, any recent use of antibiotics, any history of drug resistance and whether they live in the community or hospital. For uncomplicated pneumonias, antibiotics are usually given for five days.

Pericarditis is inflammation of the sac around the heart. The cause is unknown most of the time but usually involves viruses. Other causes include bacterial infections, cancer, tuberculosis and autoimmune diseases. Main symptoms include chest pain that’s worst with deep breathing, a friction rub heard by stethoscope, changes on the EKG and sometimes fluid around the heart. If patient is deemed to be low risk, it can be managed with NSAIDs like ibuprofen, naproxen or glucocorticoids like prednisone. Colchicine, which is a gout medication has also been used together with aspirin to treat pericarditis.

Costochondritis is pain and inflammation of the ribs. It’s a common cause of chest pain after more serious causes has be eliminated. It can occur after any strenuous activity and it’s worst with pressing directly on the chest wall. The doctor will usually press on the chest wall to help make the diagnosis of costochondritis together with other symptoms. There is usually no redness, warmth or swelling of the skin. Treatment may involve avoiding heavy lifting, stretching, taking NSAIDs, using ice or heat. Use caution when using heating pads since skin burns can happen with prolonged use. Ice is usually recommended after a recent injury since it helps with swelling. Heat can be added later to increase blood supply to the tissue and for muscle spasms.

Pleuritis is inflammation of the tissue surrounding the lungs. Autoimmune diseases, medications and viruses can cause it. It mainly presents with chest pain that’s worst when taking a deep breath. The symptoms can last for weeks to months and are treated with NSAIDs. It’s usually a benign disorder if its not associated with another medical condition.

GERD or gastroesophageal reflux disease affects 10-20% of people in the US. It occurs when stomach fluid refluxes up into the esophagus. The fluid causes esophageal irritation, inflammation and over years can lead to cancer formation. The danger signs to look for include difficulty swallowing, pain with swallowing, onset after age 60, any signs of bleeding or anemia, weight loss, decreased appetite, or vomiting. The doctor may prescribe a proton pump inhibitor like omeprazole, pantoprazole or others along with diet and exercise. Even a ten-pound weight loss by proper diet and exercise can decrease the symptoms of GERD significantly.

Mitral valve prolapse occurs when the mitral valve bulges into the left atrium of the heart. The mitral valve is located between the left atrium and left ventricle. It’s also known as a click murmur or floppy valve syndrome. It’s slightly more common in females and leaner individuals. The click of mitral valve prolapse can be heard with the stethoscope. There may also be mitral regurgitation which is blood flowing backwards up into the left atrium. Echocardiogram is needed to make the diagnosis definitive. If not associated with other heart conditions, mitral valve prolapse by itself is usually benign. A healthy lifestyle involving aerobic exercise, avoiding alcohol, stress and caffeine reduction are recommended.

Fibromyalgia causes pain and fatigue throughout the body. It’s also associated with psychological, emotional and cognitive impairments. Patients usually have tender spots in many areas of the body. There are usually no signs on joint inflammation like redness and swelling on exam. There are no laboratory tests that can definitively diagnose fibromyalgia. Some tests that may be ordered are CBC, ESR, CRP to look for any other inflammatory disease. Thyroid disorder or other autoimmune diseases may be tested. Treatment involves drug therapy with medications like Neurontin or Lyrica, anti-inflammatory drugs, and anti-depressants. Alternative therapies like tai chi, yoga, meditation and acupuncture may also help.

Back pain from a pinched nerve can sometimes cause chest pain. This occurs since the nerves that come from the spinal cord run along the lower portion of the ribs and chest wall. Any nerve compression or irritation can cause the pain to be referred to the chest.

Chest pain can be from many different causes ranging from serious to benign. A thorough examination by a doctor is necessary for accurate diagnosis. Always inform your doctor of any chest pain especially if it comes suddenly and not getting better with anti-inflammatory medications.

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