Chest pain

Definition

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.Chest pain can come on suddenly at any time. 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 (ER)?

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 for evaluation.

Symptoms

Chest pain related to cardiac problems A wide range of health problems can cause chest pain. In many cases, the underlying cause has nothing to do with your heart — though there's no easy way to tell without seeing a doctor.

In general, chest pain related to a heart attack or another heart problem is associated with one or more of the following:

• Pressure, fullness or tightness in your chest
• Crushing or searing pain that radiates to your back, neck, jaw, shoulders and arms, especially your left arm
• Pain that lasts more than a few minutes, goes away and comes back or varies in intensity
• Shortness of breath, sweating, dizziness or nausea

Chest pain related to noncardiac problems
Chest pain that isn't related to a heart problem is more often associated with:

• A burning sensation behind your breastbone (sternum)
• A sour taste or a sensation of food re-entering your mouth
• Trouble swallowing
• Pain that gets better or worse when you change your body position
• Pain that intensifies when you breathe deeply or cough
• Tenderness when you push on your chest

When to see a doctor
If you have new or unexplained chest pain or suspect you're having a heart attack, call for emergency medical help immediately. Don't waste time trying to diagnose heart attack symptoms yourself.

Every minute is crucial if you're having a heart attack. A trip to the emergency room could save your life — or bring you peace of mind if nothing is seriously wrong with your health.

Don't drive yourself to the hospital, unless you have no other option. Driving yourself puts you and others at risk if your condition suddenly worsens.

Causes

Chest pain has many possible causes, all of which deserve medical attention.

Chest pain

Cardiac causes

• Heart attack. A heart attack is a result of a blood clot that's blocking blood flow to your heart muscle.
• Angina. Hard, thick, cholesterol-containing plaques can gradually build up on the inner walls of the arteries that carry blood to your heart. These plaques temporarily narrow the arteries and restrict the heart's blood supply, particularly during exertion. Restricted blood flow to your heart can cause recurrent episodes of chest pain — angina pectoris, or angina (pronounced an-JI-nuh or AN-juh-nuh).
• Aortic dissection. This life-threatening condition 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. In coronary spasm, which is sometimes called Prinzmetal's angina, arteries that supply blood to the heart go into spasm, temporarily stopping blood flow. It occurs at rest and may coexist with coronary artery disease — a buildup of plaques in the coronary arteries.
• Pericarditis. This condition, an inflammation of the sac surrounding your heart, is short-lived and often related to a viral infection.
• Other heart-related conditions. Other heart problems — such as myocarditis, an inflammation of the heart that often is caused by viral infection — can cause chest pain. Certain types of heart muscle disorders, such as hypertrophic cardiomyopathy, also may cause chest pain.

Digestive causes

• Heartburn. Stomach acid that washes up from your stomach into the tube (esophagus) that runs from your throat to your stomach can cause heartburn — a painful, burning sensation behind your breastbone (sternum).
• Esophageal spasm. Disorders of the esophagus, the tube that runs from your throat 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.
• Hiatal hernia. In this condition, part of the stomach slides up above the diaphragm into the chest. This can cause chest pressure or pain, particularly after eating, as well as heartburn
• Achalasia (ak-uh-LA-zhuh). In this swallowing disorder, 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.
• Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder (cholecystitis) or pancreas can cause acute abdominal pain that radiates to your chest.

Musculoskeletal causes

• Costochondritis. In this condition — also known as Tietze syndrome — the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed. The result is chest pain, often worsened when you push on your sternum or on the ribs near your sternum.
• Sore muscles. 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.

Respiratory causes

• Pulmonary embolism. This cause of chest pain occurs when a blood clot becomes lodged in a lung (pulmonary) artery, blocking blood flow to lung tissue. It's rare for this life-threatening condition to occur without preceding risk factors, such as recent surgery or immobilization.
• Pleurisy. This sharp, localized chest pain that's made worse when you inhale or cough 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.
• 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.

Other causes

• 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.
• Shingles. This infection of the nerves caused by the chickenpox virus can produce pain and a band of blisters from your back around to your chest wall.
• Cancer. Rarely, cancer involving the chest or cancer that has spread from another part of the body can cause chest pain.

Preparing for your appointment

Have a family member or friend come with you, if possible. Someone who accompanies you can help soak up all the information provided during your evaluation.Call 911 or emergency medical help or have someone drive you to an emergency room if you experience new or unexplained chest pain or pressure that lasts for more than a few moments. Don't waste any time for fear of embarrassment if it's not a heart attack. Even if there's another cause for your chest pain, you need to be seen right away.

Share this information on the way to the hospital:

• Any symptoms you're experiencing, and for how long.
• Your personal and family medical history, including other health problems that you or your close relatives have had and the names of any prescription and over-the-counter medications you're taking. In particular, it will help your doctor to know whether you have diabetes, high cholesterol or a family history of heart attacks.
• Any recent trauma to your chest that may have caused an internal injury, such as a broken rib or pinched nerve.
• Your key personal information, including any major stresses or recent life changes.

Once you're at the hospital, it's likely that your medical evaluation will move ahead rapidly. Based on results from an electrocardiogram (ECG) and blood tests, your doctor may be able to quickly determine if you are having a heart attack — or give you another explanation for your symptoms. You'll probably have a number of questions at this point. If you haven't received the following information, you may want to ask:

• What is likely causing my symptoms or condition?
• Are there other possible causes for my symptoms or condition?
• What kinds of tests do I need?
• Do I need to be hospitalized?
• What treatments do I need right now?
• Are there any risks associated with these treatments?
• What are the next steps in my diagnosis and treatment?
• Do I need to follow any restrictions after returning home?
• Should I see a specialist?

Don't hesitate to ask any additional questions that occur to you during your medical evaluation.

What to expect from the doctor
A doctor who sees you for chest pain may ask:

• What are your symptoms?
• When did you first begin experiencing symptoms?
• Have your symptoms gotten worse over time?
• Where does your pain seem to start?
• Does your pain radiate to any other parts of your body?
• What words would you use to describe your pain?
• Are you having any trouble breathing?
• Do your symptoms include nausea or vomiting?
• Do your symptoms include dizziness or lightheadedness?
• Does exercise or physical exertion make your symptoms worse?
• Does anything else seem to make your pain worse?
• Does anything seem to make your pain better?
• Are you aware of any history of heart problems in your family?
• Are you being treated or have you recently been treated for any other health conditions?
• What medications are you currently taking, including vitamins and supplements?
• Do you or did you smoke? How much?
• Do you use alcohol or caffeine? How much?

Tests and diagnosis

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 an aortic dissection or life-threatening lung conditions — such as pulmonary embolism or a collapsed lung (pneumothorax) — that can cause chest pain.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 a number of questions about your 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 electrical 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.
• 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 and to look for lung problems that can cause chest pain, such as pneumonia or pneumothorax.
• 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).
• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart. This image can help doctors identify heart problems.
• 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.
• Computerized tomography (including CT scan, CT coronary calcification scan or CT coronary angiogram). Different types of CT scans can be used to check your heart arteries for signs of calcium, which indicate that atherosclerotic plaques may be accumulating and blocking arteries supplying your heart. CT scans can also be done with dye to look directly at your heart arteries.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses magnetic fields and radio waves to create cross-sectional images of your body. MRI of the heart is sometimes done to look for evidence of heart damage or inflammation (myocarditis).
• 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.

Treatments and drugs

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

• 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.
• Thrombolytics. These drugs, also called clotbusters, help dissolve a blood clot that's blocking blood flow to your heart. These drugs are most effective when taken within an hour after symptoms of a heart attack begin.
• 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.
• 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 sometimes use heart medications such as calcium channel blockers to relax the coronary arteries and prevent spasm.

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

• Angioplasty and stenting. During an angioplasty — also called a percutaneous coronary intervention (PCI) — doctors insert a catheter with a special balloon into a blocked coronary artery. The balloon is inflated to open up the artery and restore blood flow to your heart. Then, a small wire mesh coil (stent) is usually inserted to keep the artery open. Many people will go straight from the emergency room to the catheterization laboratory to have angioplasty performed as quickly as possible.
• Coronary bypass surgery. This procedure creates an alternative route for blood to go around a blocked coronary artery.

Angina treatment
Doctors usually first treat angina with medication. You'll likely start receiving medication in the emergency room, including aspirin, nitroglycerin, beta blockers and blood thinners.

If you have unstable angina — chest pain while you're at rest — you may need immediate coronary catheterization followed by angioplasty and stenting. In some cases, you may need coronary bypass surgery.

Treatment for other cardiovascular conditions
Other heart and lung conditions can be treated initially in the emergency room. If it's clear you're experiencing a pulmonary embolism, you'll likely be treated with emergency blood-thinning medications, sometimes including clotbusting medications (thrombolytics).

Aortic dissection often requires emergency surgery.

Noncardiac causes
If emergency room doctors determine you're out of immediate danger, you may be referred to your own physician or a specialist for further evaluation. 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.

  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 time in the ER having your chest pain evaluated can bring you peace of mind, and may even save your life.