One of the most important symptoms for cardiac diseases is central chest pain.

So, any kind of central chest pain

should be evaluated. But all central chest pain aren’t due to cardiac causes!

So, its very important for anyone to differentiate central chest pain between cardiac and non cardiac causes!

What are the non cardiac causes of chest pain?

Diseases of respiratory system , gastro intestinal system and musculo skeletal system can cause it!

In respiratory system –
Pluritis,
Empyma thorasis,
Pneumonia,
Lung abscess can cause both central and peripheral chest pain.

In gastro intestinal system-

Oesophagitis,
Gastritis,
Gastric reflux diseasis,
Gastric erosion,
Oesophagial malignancy,
Oesophagial injury by foreign bodies or suicidal attempt by strong acid can cause it.

In musculo endocrine system-

Costochondritis,
Any locat pathology in the central chest muscle can cause it!

How to differentiate?

Nature of pain

While cardiac pain is of heaviness, tightness or squeezing in nature, there usually respiratory pain is stabbing in
nature. Burning pain usually goes with oesophageal pain!

Diffuse or fixed

Cardiac pains are more diffuse in nature while pain by other system is more fixed in site!

Migration of pain

Cardiac pain shifts to neck, jaw or left arm. Respiratory pain usually don’t migrate. Oesophageal pain may cause
retro sternal shifting , may migrate to back as well!

Aggravating & Reliving factors

Usually cardiac pains are aggravated by emotional status or after heavy meal or by cold weather! Relived by
sublingual nitrates!

Respiratory pain may aggravate by cough, even movement! Usually relived by anti inflammatory drugs or
oxygen.

Oesophageal pain aggravated by meal, specially spicy meal or by NSAID group of drugs. And usually relived by
peptic ulcer healing drug like proton pump inhibitors!
Cardiac Chest Pain vs Non-Cardiac Chest Pain

The presence of chest pain, especially if it is severe, often raises the concern about cardiac conditions like a heart
attack (myocardial infarction). However this is not the only cause of severe chest pain and a number of factors
have to be taken into consideration in order to discern cardiac chest pain from non-cardiac chest pain.

Cardiac Chest Pain

Cardiac chest pain in this context is considered as any pain attributed to ischemia – oxygen deprivation to the
heart muscle. This must be taken very seriously as it can progress to an infarct (death of heart muscle tissue)
without prompt and appropriate treatment. Example : heart attack (myocardial infarction).

Non-cardiac Chest Pain

Non-cardiac chest pain refers to pain due to other structures within the thoracic cavity. However, it must be
remembered that certain conditions affecting the heart may not always result in ischemia and may therefore not
present in a manner resembling ischemic cardiac pain. Example : GERD (heartburn), pleuritis or even pericarditis
(inflammation of the lining around the heart).

Distinguishing between Cardiac and Non-Cardiac Chest Pain

There is no conclusive way to differentiate between cardiac and non-cardiac chest pain in the home environment.
There are many cases where severe heartburn causes chest pain that resembles cardiac disease and only the use of
nitrates may allow a person to differentiate between cardiac and non-cardiac chest pain in this instance. Severe
chest pain should always be taken seriously and a trip to the emergency room is often warranted to exclude more
serious underlying disorders. This can only be done under the supervision of a medical professional in
conjunction with the relevant tests and investigations.

Nature

• Cardiac
o Pain is dull, constricting, choking and/or crushing.
o Other terms to describe ischemic cardiac chest pain includes squeezing, burning or heavy.
o Sometimes it may just feel like discomfort which is why the character of cardiac chest pain can be
so misleading.
o A common but inconclusive presentation in cardiac chest pain is a patient clutching the chest
(picture below).

• Non-Cardiac
o The pain may vary from burning to sharp,
stabbing and prickling.
o Chest pain due to anxiety may also result in
pain that is similar to cardiac chest pain.

Location
 • Cardiac
o The pain is usually central (towards the center of the chest) and fanning outwards (diffuse).

• Non-Cardiac
o Pain may be away from the center of the chest where a patient can clearly identify it as a right-
sided or left-sided chest pain.
o Pain is usually localized – located at only one spot which can be clearly pinpointed by the patient.

Radiation

• Cardiac
o Pain to the jaw, neck, shoulder, arms (either one or even both) or back.
o Sometimes there pain may be radiated to the upper abdomen.

• Non-Cardiac
o There may not often be any radiation of the pain or it may radiate to other sites apart from those
mentioned above.
o Gastritis with accompanying GERD may cause a burning chest pain as well as upper abdominal
pain and this may be confused for radiation.

Precipitating Factors

• Cardiac
o Triggered or exacerbated by exertion or emotion.
o At times a large meal or even extremes of temperature, particularly cold, can trigger or exacerbate
the pain.
o Unstable angina may not be triggered by any specific factors.

• Non-Cardiac
o Spontaneous although it may be exacerbated by exertion (usually after rather than during activity).
o Changes in posture, deep or rapid breathing or pressure may also exacerbate the pain.

Relieving Factors

• Cardiac
o Pain is relieved by rest and responds quickly to nitrates.

• Non-Cardiac
o Not relieved significantly by rest, if at all.
o Does not respond to nitrates or there may be a slow response.
o Pain relived by antacids may be related to gastrointestinal disorders. Pain that improves upon
leaning forward may be related to the pericarditis (inflammation of the lining around the heart).

Concomitant/Associated Signs and Symptoms

• Cardiac
o Severe shortness of breath – patient may report a feeling of suffocation.
o Dizziness
o Fainting spells (‘blackouts’)

• Non-Cardiac
o Other signs and symptom may be present that is helpful in identifying the cause of the pain.
o Gastrointestinal – bloating, belching, nausea, vomiting and/or regurgitation. Refer to Gastric
Chest Pain.
o Respiratory – shallow breathing, persistent cough, abnormal breathing sounds, difficulty breathing
when lying flat, expectorating mucus or coughing up blood. Refer to Lung Chest Pain.
o Musculoskeletal – limited range of motion, cannot tolerate pressure on the affected area. Refer to
Muscle Chest Pain and Bone Chest Pain.
o Psychological – weepy, depressed, excited, agitated, fearful. Refer to Nerve Chest Pain.