Just for Hearts. . .

Making a difference in Heart Health through Education

The Significance of Symptoms of Chest pain or Chest Discomfort

Written by Joan Stelzner, ARNP

Edited by Hector Fontanet, M.D., FACC

Characterization

In general, any pain that occurs between the neck and abdomen is considered chest pain. The pain can present as sharp, dull, throbbing, stabbing, aching, pressure, crushing, or burning. Pain in the chest does not always mean that there is a problem with the heart. A wide range of ailments, conditions and injuries can cause pain in the chest, including problems with the heart, lungs, gastrointestinal tract, or musculoskeletal system.

Types of Chest Pain       

Chest pain is broken down into two types, cardiac and non-cardiac. Cardiac chest pain refers to pain that occurs when the heart has inadequate blood flow usually from blockages in the coronary arteries. This type of pain is commonly called “angina.” Non cardiac pain is pain that comes from another source other than the heart.

Cardiac chest pain “Angina”

Angina occurs when there is insufficient blood flow to the heart, usually caused by a narrowing of one or more of the coronary arteries that supply blood to the heart. The heart is a muscle and just like any other muscle, if the blood flow is inadequate, a symptom will usually occur to alert the person that there is a problem. Symptoms of angina are usually precipitated by exercise or emotional stress and relieved with rest or nitroglycerin.  The pain associated with angina is frequently characterized as a sense of chest pressure, tightness, squeezing or heaviness.  This symptom usually lasts several minutes in duration and is relieved with rest or nitroglycerin.  Very rarely is anginal plan fleeting or sharp.

Non-cardiac chest pain

Multiple ailments, conditions and injuries can cause non-cardiac chest pain. For instance, lung problems such as asthma or pneumonia can cause chest pain. However, these conditions usually co-exist with other symptoms such as wheezing, fever or cough.  This type of pain also usually resolves upon correcting the problem such as using an inhaler or treating the lung infection.  The gastrointestinal tract can also be a source of non-cardiac chest pain.  A very common condition called GERD (gastroesophageal reflux disease) is a frequent cause of non-cardiac chest pain. 

When the valves (sphincters) within the gastrointestinal tract do not close completely, digestive acid can travel up into the delicate tissues of the esophagus and produce pain in the chest often described as “burning.” Furthermore, if the esophagus gets irritated from the reflux of digestive acids it is prone to spasm which is a very intense sensation of pain in the chest that closely mimics anginal pain.  Finally, the conditions of the musculoskeletal system can also produce chest pain. The chest contains muscles that are prone to injury with strenuous activities.  The ribs have spaces in between them that can become inflamed and produce pain, known as costochrondritis. Certain diseases such as fibromyalgia and rheumatoid arthritis both can produce generalized aches that can occur in the chest. Frequently, the pain caused by a musculoskeletal ailment is described as “ache” and is present constantly, and can often be reproduced by certain movements or a deep breath.

Evaluation of Chest Pain

Usually the first part of the evaluation of chest pain includes obtaining an EKG and a review of the recent history of events prior to the onset of the pain.  If the pain was preceded by a cough and fever and goes away after a round of antibiotics, this probably was not cardiac chest pain.  Likewise, if the pain was preceded by exertion and the patient has multiple risk factors for coronary artery disease, the pain may indeed be coming from the heart.  When there is a fairly obvious source of the pain such as pneumonia, GERD, or muscle pull, then in general, the treatment will be started and the symptoms will be reevaluated upon completion of treatment.  With all chest pain that appears to be non-cardiac, initial treatment will be implemented and re-evaluated upon completion of therapy with the understanding that any worsening of symptoms will be handled as a medical urgency and the patient should seek immediate treatment.

If the chest pain has features characteristic of angina, the evaluation proceeds differently. If the patient has multiple risk factors for coronary artery disease such as hypertension (high blood pressure), diabetes, dyslipidemia (high cholesterol), tobacco use, or a family history of coronary artery disease or stroke, then the evaluation usually involves stress testing.  There are two types of stress test, an exercise treadmill test or a nuclear stress test. The type of stress test ordered depends upon how many risk factors are present, the patient’s age, and whether or not the initial EKG is normal or not.  If the stress test is abnormal, further evaluation is usually recommended with a procedure called cardiac catheterization and coronary angiography. However, often it is difficult to distinguish between cardiac and noncardiac etiology for the symptoms of chest pain. Under these circumstances, a comprehensive evaluation of the chest anatomy and structures may be undertaken utilizing an ultrafast CT scanner with IV contrast enhancement. In rare cases when the patient’s EKG is abnormal and the clinical probability of obstructive coronary artery disease is very high, the patient may proceed directly to cardiac catheterization without first going through stress testing.

Non-cardiac Chest Pain follow up

Usually when the source of chest pain is non-cardiac, there is not a follow up with cardiology.  However, when the patient also has multiple risk factors for coronary artery disease, a follow up appointment may be recommended for preventative purposes.

Cardiac Chest Pain follow up

If the pain has been documented as angina, follow up will occur on a regular basis, usually every three to six months.

Summary

Non-cardiac chest pain usually involves an initial visit with cardiology followed by possibly a second visit that involves some form of testing to better define and understand the cause of the chest pain symptoms. After the testing is complete, the results are explained to the patient and recommendations are made. This is usually the final visit.  Should the tests be normal, and the symptoms resolved, no further follow up is recommended.  Should the results be abnormal, the recommendation is usually a cardiac catheterization. If the cardiac catheterization demonstrates the presence of coronary artery disease then life-long follow up is recommended.  Again, the frequency of follow up depends on the patient’s diagnosis, usually every six to twelve months.