Chest pain of non-traumatic cause is one of the most frequent reasons for consultation in emergency departments with an estimated 6% of the total number of cases seen in these medical units. It refers to pain felt in any area of the chest from the level of the shoulders to the lower part of the ribs. It can often be very difficult for emergency and primary care physicians to diagnose without some tests and investigations.
In certain cases the intensity of the pain does not correlate with the severity of the disease present. When a patient comes to the emergency department for chest pain, it is important to take into account some characteristics of the affected individual, such as age, risk factors for heart disease, and signs and symptoms suggestive of a cardiac cause.
Most causes of chest pain are not related to a cardiovascular disorder. The most common causes of chest pain include:
Gastroesophageal Reflux. This is a very common condition characterized by some of the acidic contents of the stomach moving up into the esophagus and pharynx, which can cause chest pain. The most common symptoms of gastroesophageal reflux include:
1. Heartburn, which is discomfort characterized by a burning sensation in the chest.
2. An unpleasant taste in the mouth caused by heartburn.
Osteo-muscular disorders. Chest pain may be caused by muscle strain or inflammation of the bony structures of the chest. The main characteristic of this type of pain is its sudden onset and great intensity, in addition to an increase in sensitivity when pressure is exerted on the thorax, unlike cardiac pain which appears gradually and progressively.
Anxiety and panic attacks. Anxiety and panic attacks may manifest as chest pain, accompanied by palpitations, sweating, shortness of breath (dyspnea) and dizziness.
Pulmonary diseases. Chest pain may be caused by some lung diseases such as pneumonia, and inflammation of the pleura (pleuritis), which are mostly caused by infectious processes.
Angina pectoris. Angina is a pain of cardiac origin. It is usually caused by decreased or blocked blood flow in the coronary arteries, which supply blood to the heart muscle. At first, the blood supply may be adequate while the person is at rest. However, when engaged in some type of physical activity, the heart requires more blood and oxygen, and if blood cannot flow adequately through the coronary arteries, the heart muscle responds with the onset of pain. Angina can manifest as a tightness in the center of the chest; it can also be caused by spasm of the coronary arteries (usually occurs in heavy smokers, cocaine users and extreme cold). Difficulty breathing or dyspnea is usually the only symptom of angina in patients older than 85 years.
Myocardial infarction. Triggers severe chest pain, almost always while the person is at rest. It is caused by narrowing, decrease or blockage of blood flow in the coronary arteries. Unless the obstruction to coronary blood flow is removed quickly, the heart muscle may necrose (tissue death) and endanger the patient’s life.
Other causes of chest pain include:
1. Pericarditis (inflammation of the membrane covering the heart).
2. Disorders of the pancreas.
3. Gallbladder diseases.
4. Neuromuscular disorders.
5. Peptic ulcer.
6. Pulmonary embolism.
7. Herpes Zoster.
8. Pneumothorax (air trapped between a lung and the chest wall).
Undiagnosed Chest Pain of Cardiac Cause
There are certain situations in which chest pain of cardiac origin caused by ischemia (decreased blood flow in the coronary arteries) goes undiagnosed or is overlooked in emergency rooms, the most important being:
1. Young patient.
2. Presence of atypical symptoms.
3. Female sex.
4. Non-white race.
5. Inexperience of the physician.
6. Failure to detect ischemia in the normal electrocardiogram (misinterpretation by medical staff, or non-specific results).
7. Failure to obtain an electrocardiogram (due to damage or unavailability of the device).
Signs and Symptoms
Chest pain is usually accompanied by other discomforts that will vary according to the disease causing it. For example, if the chest pain is related to an infection, fever and general malaise may appear. The pain may also move from the neck, back and belly area to the chest.
Ischemic type pain (angina, infarction). This type of chest pain is usually described by the patient as oppressive, penetrating, burning, cramping, or as a feeling of weight pressing on the chest. It tends to spread to the upper limbs (particularly the left arm), neck and lower jaw; occasionally it extends to the back. The fist held over the sternal area (Levine’s sign) is indicative of pain of ischemic origin.
Aortic dissection. It is a very severe pain, of sudden onset as a sensation of something tearing and very often located between both scapulae. It may extend to the neck, back, abdomen and lower limbs.
Pulmonary embolism. The pain produced by pulmonary embolism is very similar to ischemic pain, it can also present as pleuritic pain (pain on breathing, stabbing, located on one side of the chest) and is accompanied by severe respiratory difficulty (intense dyspnea), increased respiratory frequency, bluish color of the face, lips and skin (cyanosis), anxiety and agitation.
Spontaneous pneumothorax. When presented with chest pain, it is of pleuritic type, on one side of the chest, with abrupt onset, accompanied by severe dyspnea.
Herpes zoster. Before the eruptive lesions appear, a band-like pain may appear in one or more specific regions of the skin (dermatome) of the thorax. On physical examination, on palpation of the skin, there is increased sensitivity of the involved area, and in 4-5 days later, the characteristic eruptive lesions of this disease appear.
Peptic ulcer disease and biliary colic. Ischemic pain of the lower wall of the heart can be confused with peptic ulcer disease and gallbladder stone colic. In addition to pain, other complaints such as repeated vomiting, decreased appetite, difficulty swallowing, weight loss, vomiting blood (hematemesis), dark stools (melena), anemia, fever, and yellowing of the skin and conjunctivae (jaundice) may occur.
Pericarditis. It is a stabbing and penetrating pain that is relieved when the patient sits up or when the trunk is tilted forward. Deep breathing in may increase the pain. It may spread to the shoulders, neck and back.
Pleuritis. It presents as a stabbing pain that changes with respiratory movements. It is usually accompanied by cough.
Alarm symptoms of chest pain
Signs and symptoms that reveal the presence of extremely severe chest pain and require urgent medical attention include:
1. Systolic blood pressure < 90 mm Hg.
2. Heart rate > 100 beats per minute.
3. Altered level of consciousness or presence of neurological damage (paralysis of a body part).
4. Absence of pulses in the extremities.
5. Intense shortness of breath.
6. Bluish coloration of the skin, face or lips (cyanosis).
Diagnosis involves questioning the patient’s family members and the patient himself if he is conscious, and also a thorough physical examination for signs and symptoms that indicate whether the disease is serious. As for complementary studies these include:
-Electrocardiogram. It is useful to detect angina or myocardial infarction.
-Blood tests. It allows measuring the levels of some chemical substances such as troponin, which, if elevated, confirms the presence of an infarction. Other tests include D-dimer, which detects the presence of blood clots, which could be a cause of coronary artery clogging. A positive D-dimer value may indicate the presence of deep vein thrombosis or pulmonary embolism.
-Chest X-ray. It may reveal the presence of pneumonia, pneumothorax or other chest wall conditions (fractures or fissures of the bony structure).
Other scans and images include:
2. Computed tomography or coronary angiography by tomography.
3. Coronary angiography, which is the study of the arteries supplying the heart muscle.
4. Coronary perfusion scan, which is often performed to help confirm the diagnosis of anginal chest pain.
5. Endoscopy. Endoscopy allows exploration of the esophagus and stomach in search of a digestive cause of chest pain (peptic ulcer, gastroesophageal reflux).
Treatment will depend on the cause of the chest pain. Including cardiac causes of chest pain, medications used may include:
Coronary vasodilators. These include nitroglycerin, which is usually used sublingually, to allow blood to flow through narrowed coronary arteries. Some drugs used in the treatment of arterial hypertension also relax and widen the blood vessels.
Aspirin. This medication is widely used in cardiovascular diseases in both primary and secondary prevention.
Anticoagulants. They are used to prevent the formation of blood clots.
Antacid medications. They help in the relief of heartburn.
Analgesics. They are used to relieve pain and depending on the severity of the pain they are used orally or parenterally (intramuscular or intravenous).
Antidepressants and sedatives. They may be prescribed in patients suffering from anxiety or panic attacks. Psychological or behavioral therapy is also useful in these cases.
Chest pain, especially that of cardiac origin can be prevented if the risk factors that contribute to the onset of cardiovascular disease are controlled. These measures include:
1. Avoidance or cessation of smoking and alcohol consumption.
2. Adequate control of diseases such as diabetes and high blood pressure.
3. Practicing some type of physical activity; if the patient suffers from a cardiovascular disorder, this should be under medical supervision.
4. Do not consume saturated fats (red meat, lamb and beef), fried foods, and bakery and pastry products.
5. Control cholesterol and triglyceride levels.
6. Do not eat sausages and pickled products (due to their high salt content).
7. Increase the consumption of fruits and vegetables, since they can help to maintain normal cholesterol levels.
- Asociación Colombiana de Medicina Interna. MEDICINA INTERNA EN URGENCIAS. Segunda edición. EDITORIAL MÉDICA CELSUS. 2013