Chest pain

Introduction
It's the middle of the night or maybe the beginning of a busy workday when you suddenly feel
pain in your chest. You try to ignore it at first, but your chest pain has you scared and worried.
Could you be having a heart attack? Should you go to the emergency room?

Chest pain is one of the most common reasons people call for emergency medical help. Every
year emergency room doctors evaluate and treat millions of people for chest pain.

Fortunately, chest pain doesn't always signal a heart attack. Often chest pain is unrelated to any
heart problem. But even if the chest pain you experience has nothing to do with your
cardiovascular system, the problem may still be important — and worth the time spent in an
emergency room to have your chest pain evaluated.

Causes
Chest pain has many possible causes, all of which deserve medical attention. The causes of
chest pain fall into two major categories — cardiac and noncardiac causes.

Cardiac causes

• Heart attack. A heart attack — a blood clot that's blocking blood flow to your heart
muscle — can cause pressure, fullness or a crushing pain in your chest that lasts more
than a few minutes. The pain may radiate to your back, neck, jaw, shoulders and arms,
especially your left arm. Other signs and symptoms may include shortness of breath,
sweating, dizziness and nausea. All, some or none of these may accompany your chest
pain.

• Angina. Fatty deposits can build up in the arteries that carry blood to your heart,
narrowing them and temporarily restricting blood flow to your heart, especially during
times of exertion. Restricted blood flow to your heart can cause recurrent episodes of
chest pain — angina pectoris, or angina. Angina (an-JI-nuh or AN-juh-nuh) is often
described as a pressure or tightness in the chest. It's usually brought on by physical or
emotional stress. The pain usually goes away within minutes after you stop the stressful
activity.

• Other cardiac causes. Other problems that can cause chest pain include inflammation
of the sac surrounding your heart (pericarditis) , a short-lived condition often related to a
viral infection. Pericarditis causes sharp, piercing and centralized chest pain. You may
also have a fever and feel sick. A rare, life-threatening cause of chest pain called aortic
 dissection involves the main artery leading from your heart — your aorta. If the inner
layers of this blood vessel separate, forcing blood flow between them, the result is
sudden and tearing chest and back pain. Aortic dissection can result from a sharp blow to
your chest or develop as a complication of uncontrolled high blood pressure. Coronary
spasm, also known as Prinzmetal's angina, can cause varying degrees of chest
discomfort. In coronary spasm, coronary arteries — arteries that supply blood to the heart
— go into spasm, temporarily closing down blood flow to the heart. Spasm of the
coronary arteries may occur spontaneously or be triggered by a stimulant, such as
nicotine or caffeine. Coronary artery spasm, which tends to cause episodes of chest pain,
can occur with activity or at rest. A spasm may even wake you from sleep. The condition
may coexist with coronary artery disease — a buildup of fatty deposits in the coronary
arteries. Other possible heart-related conditions that can cause chest pain are metabolic
syndrome and endothelial dysfunction.

Noncardiac causes

Many conditions unrelated to your heart can cause chest pain. These include:

• Heartburn. Stomach acid that washes up from your stomach into the tube (esophagus)
that runs from your mouth to your stomach can cause heartburn — a painful, burning
sensation behind your breastbone (sternum). Often this feeling is accompanied by a sour
taste and the sensation of food re-entering your mouth (regurgitation) . Heartburn-related
chest pain usually follows a meal and may last for hours. Signs and symptoms occur
more frequently when you bend forward at the waist or lie down.

• Panic attack. If you experience periods of intense fear accompanied by chest pain, rapid
heartbeat, rapid breathing (hyperventilation) , profuse sweating and shortness of breath,
you may be experiencing a panic attack — a form of anxiety.

• Pleurisy. Sharp, localized chest pain that's made worse when you inhale or cough may
be caused by pleurisy. This condition occurs when the membrane that lines your chest
cavity and covers your lungs becomes inflamed. Pleurisy may result from a wide variety
of underlying conditions, including pneumonia and, rarely, autoimmune conditions such
as lupus. An autoimmune disease is one in which your body's immune system mistakenly
attacks healthy tissue.

• Costochondritis. In this condition — also known as Tietze's syndrome — the cartilage of

your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes
inflamed. The pain from costochondritis (kos-toe-KHON- dri-tis) may occur suddenly and
 be intense, leading you to assume you're having a heart attack. Yet the location of the
pain is different. Costochondritis causes your chest to hurt when you push on your
sternum or on the ribs near your sternum. Heart attack pain is usually more widespread,
and the chest wall usually isn't tender.

• Pulmonary embolism. This condition occurs when a blood clot becomes lodged in a
lung artery, blocking blood flow to lung tissue. Symptoms of this life-threatening condition
can include sudden, sharp chest pain that begins or worsens with a deep breath or
cough. Other signs and symptoms can include shortness of breath, rapid heartbeat,
anxiety and faintness. It's rare for pulmonary embolism to occur without preceding risk
factors, such as recent surgery or immobilization.

• Other lung conditions. A collapsed lung (pneumothorax) , high blood pressure in the
arteries carrying blood to the lungs (pulmonary hypertension) and asthma also can
produce chest pain.
• Sore muscles. Muscle-related chest pain tends to come on when you twist side to side
or when you raise your arms. Chronic pain syndromes, such as fibromyalgia, can
produce persistent muscle-related chest pain.
• Injured ribs or pinched nerves. A bruised or broken rib, as well as a pinched nerve, can
cause chest pain that tends to be localized and sharp.
• Swallowing disorders. Several disorders of the esophagus, the tube that runs from your
mouth to your stomach, can make swallowing difficult and even painful. One type is
esophageal spasm, a condition that affects a small group of people with chest pain.
When people with this condition swallow, the muscles that normally move food down the
esophagus are uncoordinated. This results in painful muscle spasms. Because
esophageal spasms can be calmed with the medication nitroglycerin — which also
rapidly relieves some heart-related pain — this condition is sometimes mistaken for a
heart problem. Another swallowing disorder, which also affects a small group of people
with chest pain, is achalasia (ak-uh-LA-zhuh) . In this condition, the valve in the lower
esophagus doesn't open properly to allow food to enter your stomach. Instead, food
backs up into the esophagus, causing pain. Pain with swallowing also can accompany
heartburn.
• Shingles. This infection of nerves caused by the chickenpox virus can produce pain and
a band of blisters on your back around to your chest wall. This sharp, burning pain may
begin several hours to a day or so before blisters appear.
• Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder
(cholecystitis) or pancreas can cause acute abdominal pain that radiates to your chest.
• Cancer. Rarely, cancer involving the chest or cancer that has spread from another part of
the body can cause chest pain.

When to seek medical advice

Pain in your chest can be severe. It can be difficult to interpret. The cause of the pain could be
something as simple as heartburn or as serious as a heart attack.

If you experience unexplained and persistent chest pain or a feeling of pressure or tightness in
your chest — particularly if it's accompanied by other signs and symptoms, such as shortness of
breath, sweating, nausea, dizziness or pain that radiates beyond your chest to one or both of your
arms or your neck — seek emergency medical care immediately. A trip to the emergency room
could save your life — or bring you peace of mind if nothing is seriously wrong with your health.

Screening and diagnosis

At the emergency room or chest pain center — some large hospitals designate areas just for the
evaluation of chest pain — you'll probably have your blood pressure, pulse and temperature
checked right away. In addition, the doctor will ask you questions about your chest pain: Where is
the pain located? How would you describe the pain? Do you have other signs and symptoms
along with the pain?

Chest pain doesn't always signal a heart attack. But that's what emergency room doctors will test
for first because it's potentially the most immediate threat to your life. They may also check for
life-threatening lung conditions, such as pulmonary embolism, aortic dissection or a collapsed
lung (pneumothorax) , that can cause chest pain.

Tests you may have to determine the cause of your chest pain include:

• Electrocardiogram (ECG). This test can help doctors diagnose a heart attack as well as
other heart problems. It records the electrical activity of your heart through electrodes
attached to your skin. Heart rate and rhythm and the electric impulses going through your
heart are recorded as waves displayed on a monitor or printed on paper. Because injured
heart muscle doesn't conduct electrical impulses normally, the ECG may show that a
heart attack has occurred or is in progress.
• Stress tests. These measure how your heart and blood vessels respond to exertion,
which may indicate if your pain is related to your heart. There are many kinds of stress
tests. You may be asked to walk on a treadmill or pedal a stationary bike while hooked up
to an ECG. Or you may be given a drug intravenously to stimulate your heart in a way
similar to exercise. Stress tests may be combined with imaging of the heart using
ultrasound (echocardiography) or radioactive material (nuclear scan).
• Blood tests. Your doctor may order blood tests to check for increased levels of certain
enzymes normally found in heart muscle. Damage to heart cells from a heart attack may
allow these enzymes to leak, over a period of hours, into your blood.
• Chest X-ray. An X-ray of your chest allows doctors to check the condition of your lungs
and the size and shape of your heart and major blood vessels. Doctors can also use a
chest X-ray to check for tumors in the chest.
• Nuclear scan. This test helps doctors diagnose cardiac causes of chest pain, such as a
narrowed heart artery. Trace amounts of radioactive material, such as thallium or
sestamibi, are injected into your bloodstream. Special cameras can detect the radioactive
material as it flows through your heart and lungs.
 • Coronary catheterization (angiogram). This test helps doctors identify individual
arteries to your heart that may be narrowed or blocked. A liquid dye is injected into the
arteries of your heart through a catheter — a long, thin tube that's fed through an artery,
usually in your groin, to arteries in your heart. As the dye fills your arteries, they become
visible on X-ray and video.
• Electron beam computerized tomography (EBCT). This procedure, also called an
ultrafast CT scan, scans your arteries for signs of calcium, which indicates that fatty
deposits along with calcium may be accumulating and blocking arteries supplying your
heart.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses magnetic
fields and radio waves to create cross-sectional images of your body.
• Echocardiogram. An echocardiogram uses sound waves to produce a video image of
your heart. This image can help doctors identify heart problems.
• Endoscopy. In this test a thin, flexible instrument attached to a camera is passed down
your throat, allowing doctors to view your esophagus and stomach and check for
gastroesophageal problems that can cause chest pain.

Many types of chest pain may at first seem related to heart problems. But often, after careful
evaluation, doctors can distinguish the symptoms of noncardiac chest pain from the pain caused
by a heart condition.

Treatment
Cardiac causes

If it appears that heart problems are the cause of your chest pain, your doctor may give you
medications such as:

• Aspirin. Aspirin inhibits blood clotting, helping to maintain blood flow through narrowed
heart arteries. When taken during a heart attack, aspirin can significantly decrease death
rates. You may be asked to chew the aspirin to hasten its absorption. Aspirin is
recommended for most people who have had a heart attack.
• Nitroglycerin. This medication for treating angina temporarily widens narrowed blood
vessels, improving blood flow to and from your heart.
• Beta blockers. These drugs help relax your heart muscle, slow your heart rate and
decrease your blood pressure, which decreases the demand on your heart. These
medications help limit the amount of damage during a heart attack and prevent a second
heart attack.
• Angiotensin- converting enzyme (ACE) inhibitors and angiotensin receptor
blockers (ARBs). These drugs allow blood to flow from your heart more easily. Your
doctor may prescribe ACE inhibitors or ARBs if you've had a moderate to severe heart
attack that has reduced your heart's pumping capacity. These drugs also lower blood
pressure and may prevent a second heart attack.
• Calcium channel blockers. When treating coronary artery spasm, doctors use heart
medications such as calcium channel blockers to relax the coronary arteries and prevent
the spasm.
 • Ranolazine (Ranexa). This is a relatively new drug for treating chronic angina. It's used
only when other anti-anginal drugs haven't worked because it can cause a heart problem
known as QT prolongation, which can increase your risk of heart rhythm problems. It
should be used with other angina medications, such as calcium channel blockers, beta
blockers or nitroglycerin.

If it's clear you're having a heart attack, you may be treated with clot-busting drugs or undergo a
surgical procedure such as:

• Angioplasty. In this procedure, doctors insert a catheter with a special balloon tip into a
blocked coronary artery. The balloon is inflated to open up the artery and improve blood
flow to your heart.
• Stenting. A stent is like a scaffold inside the artery to prop it open after it has been
opened with angioplasty.
• Coronary bypass surgery. This procedure creates an alternative route for blood to go
around a blocked coronary artery.

If it's clear you're experiencing a pulmonary embolism, you'll likely be treated with emergency
blood-thinning medications. Aortic dissection, also an emergency, may require surgery. Other
heart and lung conditions can be treated initially in the emergency room. Cancer involving the
chest requires treatment and referral to an oncologist, or doctor who specializes in cancer
treatment.

Doctors usually treat angina — chest pain caused by restricted blood flow to the heart — with
medication, angioplasty or coronary bypass surgery. For people who don't respond to or who
aren't candidates for these standard treatments, an alternative treatment called enhanced
external counterpulsation (EECP) may be available for the treatment of chronic angina.

Most of the time, chest pain isn't related to emergency heart or lung problems. If doctors
determine you're out of immediate danger, evaluation and treatment may shift to an outpatient
setting. You may be referred to your own physician or a specialist for further evaluation.

Noncardiac causes

Treatments for noncardiac causes of chest pain depend on the type of problem. These problems
and their treatments include:

• Heartburn. If your symptoms suggest heartburn, you'll likely need to take an over-the-
counter or prescription- strength stomach acid blocker or antacid in the emergency room.
Most episodes of heartburn are isolated events caused by overeating or by eating fatty
foods. However, if you experience frequent heartburn (at least one episode a week), your
doctor or a doctor who specializes in stomach and intestinal problems (gastroenterologist
), may ask you to undergo more tests. Left untreated, chronic, frequent heartburn can
occasionally lead to scarring and narrowing of your esophagus. Treatment for chronic
 heartburn may include dietary modifications, antacids, acid blockers or other prescription
medications and, in some cases, surgery.
• Panic attack. This anxiety-related cause of chest pain can be treated with prescription
anti-anxiety medications, relaxation techniques and counseling to find out what may be
triggering your attacks. Panic attacks are often mistaken for heart attacks, and many
people are seen in emergency rooms for this problem. But once your condition is
diagnosed, you can be referred for treatment to help you gain control over these attacks.
• Pleurisy. This inflammation of the pleura, the membrane that lines your chest cavity and
covers your lungs, may result from a variety of conditions, including pneumonia and,
rarely, autoimmune conditions such as lupus. Your doctor will want to identify and treat
the underlying disease that caused pleurisy. Over-the-counter pain relievers can help
minimize the pain until the inflammation subsides.
• Costochondritis. Treatment for this inflammation of the cartilage of your rib cage is
generally rest, heat and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil,
Motrin, others).
• Sore muscles, injured ribs or pinched nerves. Chest pain from injured ribs, pinched
nerves and sore chest muscles improves with time and self-care measures
recommended by your doctor.
• Swallowing disorders. These disorders have many causes, which can usually be
treated with medications, minor surgery or endoscopic techniques. You'll probably be
referred to a gastroenterologist for evaluation and treatment.
• Shingles. Treatment with acyclovir (Zovirax) or a similar antiviral medication is best
started as quickly as possible, preferably within 24 hours from the onset of pain or
burning, and before the appearance of blisters. Doctors use other treatments, such as
analgesics and antihistamines, to control symptoms such as pain and itching.
• Gallbladder or pancreas problems. You may need surgery to treat an inflamed
gallbladder or pancreas that's causing pain to radiate from your abdomen into your chest.

Chest pain can be one of the most difficult symptoms to interpret. But spending a few hours in the
ER having your chest pain evaluated can bring you peace of mind, and may even save your life.

saraswati

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