Chest Pain

Various features of chest pain can provide clues to possible underlying cause. Features concerning the chest pain that are important include
site, where exactly do you feel the pain?
nature of the pain; what does the pain feel like, what words can you use to describe it?
radiation; does the pain spread anywhere?
precipitating factors, what triggers the pain, what makes it worse?
relieving factors; what helps or makes the pain go away?
associated factors; what other symptoms do you have?

Note that chest pain can be a very non-specific symptom and may be the result of a variety of causes. A chest pain with classical features may not always be caused by the most usual diseases. For example classical angina (heart pain), i.e. chest pain that is brought on by exercise and relieved by rest, may be caused by problems other than coronary artery disease.

Remember, common things are common. The diagnosis of chest pain rests 95% on the history and often the findings on examination are either normal, unhelpful or irrelevant. So the key here is to provide a good, accurate history. So if a patient tells us that he/she has discomfort across the centre of the chest coming on during exercise that stops on rest and that GTN tablets relieve the pain within 5 minutes he/she is going to have ischaemic heart disease almost without doubt. Temperature, green sputum and knife-like pain in the side upon deep breathing is likely to be infection. Of course, the pain and other symptoms are not always so clear cut. However, often the first thing patients wants to know is whether the pain is coming from the heart and it may be possible to provide reassurance on the basis of the description alone. The following provide some further information about more specific causes of chest pain. This is often a worrying symptom and sometimes there is a serious underlying condition so if you have any doubt about the origin of your chest pain or concerns about your health, do seek further help and advice from your doctor.

Ischaemic heart disease

Angina is the pain that comes from the heart muscle when it is not getting enough oxygen. This is usually due to coronary artery disease. The name is derived from the Greek 'agkone' which means strangling. The mechanism of pain sensation is uncertain: the metabolic products of 'oxygen lack' stimulate pain nerve fibres which run together with nerve fibres supplying body parts from the neck to the upper chest. The pain is thus usually felt across the middle of the chest (and not on the left side).

Causes

Angina pain is usually caused by narrowing of the arteries supplying heart muscle with blood that carries oxygen to enable the muscle to burn sugar for energy. Narrowing of these arteries is called coronary artery disease.

Other causes include, problems with heart valves (the heart has to work harder, so needs more oxygen), anaemia (the blood can carry less oxygen so the heart muscle needs a higher flow rate), problems with heart muscle (cardiomyopathy) where there may be excess heart muscle causing higher demands of oxygen, an overactive thyroid gland driving the heart faster, and sometimes spasm of the muscle in the coronary arteries which temporarily narrows them.
The incidence of angina is is approximately 5 new patients per 1000 people per year in males over the age of 40 years in the UK.

History

Angina pain is usually situated across an area of the central chest. It is very unlikely that the patient will be able to point to the precise area of the pain and the description may be not of pain, but rather of discomfort. This may spread to the neck, jaw, the arms (either, but more commonly the left, and usually the inside of the arms) or the top of the stomach area. It is possible for the pain to spread to the back. The hallmark of angina is that the discomfort occurs when the heart is stressed. For example, increasing cardiac work load during exercise, after emotional upset or after meals. Of these by far the most common presentation is of exercise induced chest discomfort. Bear in mind that in Indo-Asian patients the presentation may be atypical (and indeed these patients are particularly prone to ischaemic heart disease. Heavy, crushing, tight, band-like or like a clenched fist are descriptions that would be consistent with angina. It is not uncommon for the discomfort to have been attributed to indigestion by the patient (and sometimes the doctor!). Angina pain stops when the patient rests, usually after a few minutes only. The exception may be angina that was precipitated by emotional upset since the patient may brood or reflect on the cause of the upset for a considerable period of time. Pain commencing or persisting at rest may well be a heart attack where the blood supply is interrupted sufficiently long and severely enough for some heart muscle fibres to start dying. This is an indication for urgent assessment. The pain of a heart attack is similar to that of angina but may be more severe and may be accompanied by other feelings of unwellness such as sweating or anxiety. It will typically last longer and will not respond to nitrate tablets or spray (e.g. GTN under the tongue).

Clinical findings

There are no diagnostic clues for angina per se in the examination although clues pertaining to the cause may be found. For example, high blood pressure, signs of high cholesterol such as xanthelasma (chalky deposits of cholesterol in the skin around the eyes), tobacco stains on fingers (although let’s face it you will already know that smoking causes heart disease—won’t you?), murmurs of heart valve disease heard with the stethoscope, and abnormalities in heart rate and rhythm may provide clues for the doctor. Clearly, if the patient is unwell, has a low blood pressure and has persistent pain we will be referring up to the hospital physician to rule out/in either a heart attack or unstable angina.

Investigations

The resting heart tracing (ECG) is great for diagnosing acute or recent heart attacks but usually not relevant for angina per se when it may perfectly normal or show some non-specific changes. That is not to say that useful information cannot be had. If the ECG is abnormal the information may be highly useful. Is the rhythm normal, is there evidence that the heart has been under strain or is more muscular than expected?. If there is doubt regarding the diagnosis of angina then the exercise ECG will help. Here the patient walks on a treadmill gradually increasing speed and gradient whilst a continuous ECG monitors the tracing looking for tell tale signs of lack of oxygen in the heart muscle. A negative treadmill test when the patient has reached maximum effort and predicted heart rate makes angina unlikely (although there is always syndrome X—ischaemic heart disease in the absence of evidence on treadmill testing—a small proportion of these patients will have a heart attack in the following 2 years). Exercise ECG testing or exercise radionucleotide scanning using thallium may reveal that the heart muscle has an inadequate supply of oxygen. The exercise ECG is abnormal in 85% of patients with angina.

If ischaemic heart disease is confirmed it would be necessary to check for risk factors including cholesterol, blood sugar, blood pressure, body mass index for obesity, smoking, alcohol and lifestyle (e.g. exercise).

Initial management

Four main classes of anti-anginal drugs are in common use: nitrates; calcium antagonists; potassium channel blockers (that tend to work by dilating blood vessels making it easier for the heart to pump blood around), and beta-blockers that act principally by slowing heart rate and making the heart work less hard. Low dose, daily aspirin has been shown to be of benefit and concomitant treatment of high blood pressure and cholesterol lowering will be necessary. Various drugs may be more suitable than others for individual patients. Nitrates may cause headaches initially, verapamil (a calcium antagonist) may cause constipation, other calcium antagonists (especially nifedipine) may cause ankle swelling and facial flushing, beta blockers may cause tiredness and impotence and should not be used in patients with obstructive airways disease (e.g. asthma) or poor circulation in the legs since they may make it worse.

Angina will usually require assessment by a cardiologist, principally to identify those patients who will benefit from dilatation of coronary artery narrowing or who require surgery to bypass the narrowing in the coronary arteries.

Follow up management

Heart disease is a killer. This is dependent on the number of affected vessels, the severity of the narrowing and the possibility of correcting the problem with surgery or angioplasty (opening up the narrowing using a tiny balloon temporarily pumped up inside the blood vessel).
Patients and relatives may be frightened when they discover that they have ischaemic heart disease and for the first time may be confronted with thoughts about their mortality. The presence of heart disease may have significant effects on their ability to continue with their present employment. Successful rehabilitation will take these worries and concerns into account.

Musculo-skeletal pain

Pain coming from the muscles, ribs or cartilage of the rib cage is common. Musculo-skeletal pain presents as atypical chest pain that is reproducible by springing the chest, movement of the chest wall during deep respirations, movement of the limbs or by direct pressure. The causes are many but consider trauma, injury due to coughing and Tietze’s syndrome. Tietze's syndrome is an inflammation of the cartilage that joins the ribs to the breast bone. The patient has pain that is often well localized just next to the breast bone. The syndrome usually affects the second rib from the top. The pain is made worse by motion, coughing, or sneezing. There is localized tenderness. Treatment is with pain relief e.g. ibuprofen or paracetamol and usuall clears up in a week or so.

Oesophageal pain

Your oesophagus (the gullet) is the tube that joins the mouth to the stomach. It runs straight down the middle of the chest behind the heart. Reflux oesophagitis is common condition, occurring at any age, caused by acid splashing up into the oesophagus from the stomach. Reflux oesophagitis causes a burning sensation behind the breast bone, often described as heartburn although it can be difficult to distinguish from heart pain particularly if it spreads to neck, shoulders or arms. If the oesophagus becomes very inflamed there may be difficulty with swallowing and long term reflux may lead to narrowing of the gullet. Bending, stooping, heavy lifting and tight clothes all force acid up into the oesophagus and cause heartburn. With reflux oesophagitis the relation to lying flat or bending, with relief on belching or swallowing antacid, helps to differentiate it from heart pain.

X-ray examination or a look into the oesophagus with a flexible fibreoptic scope may help to determine the cause, although it is often possible to pin this down on the story alone and the good response to acid suppression using drugs. Simple antacid preparations can be bought from the pharmacist without prescription, more potent acid suppressive drugs (such as the proton-pump inhibitors) require a prescription from your doctor. Patients with reflux oesophagitis can make a big difference to their symptoms by maintaining an ideal weight, avoiding alcohol, stopping smoking and avoiding large meals, particularly last thing in the evening. Since reflux symptoms often come and go over a prolonged period of time, it is well worth investing in these lifestyle changes.

Pain coming from the lungs

Many problems affecting the lungs can cause pain when the lining of the lung becomes inflamed. The pain is often worse on breathing and coughing and may be accompanied by shortness of breath as well as other symptoms.

Pneumonia

Infection of the lung tissue (pneumonia) can cause chest pain. This pain is often located on one side of the chest and is usually worse with breathing and coughing. There will often be a fever, there may be a productive cough where the sputum is yellow, green or blood stained and the patient may be short of breath and confused. The doctor will often be able to detect the presence of infection in the lung during the examination. Treatment is with appropriate antibiotics and if warranted admission to hospital for further support and oxygen.

Pulmonary embolism (clot on the lung)

A pulmonary embolus occurs when a clot from a vein, originating in the calf muscles or especially the thigh or the pelvis, detaches and becomes lodged in the arteries in the lung. The pain may start suddenly with an associated episode of collapse. There may be angina pain as well if the clot is large. There is often shortness of breath, the lips and tongue may be blue and there may be a mild fever. The pain will continue as pleurisy which is a sharp knife like pain worse on deep breathing. Blood may be coughed up. A pulmonary embolus can be very serious or fatal. More often it is successfully treated and then thought must be paid to why it occurred.

Risk factors for clots include immobility (e.g. during and after surgery, or after a prolonged journey on a plane or coach) and conditions that make the blood more likely to clot (e.g. taking the combined contraceptive pill which contains oestrogens). Patients with cancer are more likely to suffer from clots.

If your doctor thinks this is a possibility you will be investigated in hospital. It is possible to look for clots in a variety of ways including radioactive scanning, x-ray scanning of the chest and by injecting dye that shows up on x-rays. The treatment of clots will include identifying the cause and thinning the blood with drugs like warfarin. The duration of treatment will depend on the precipitating cause.

Pneumothorax (punctured lung)

Rarely, the lining of the lung in the chest can rupture causing a small leak of air around the lung. This causes the lung to collapse, making breathing more difficult and may be accompanied by pain. Young, tall men seem to the most vulnerable in the absence of other risk factors. Smoking causes an increased risk of a spontaneous pneumothorax: nine fold increase in females, 22 fold increase in males. Patients with asthma and emphysema are at higher risk and the condition may follow trauma to the ribs.

Possible features include a sudden onset of sharp knife like pain made worse by breathing and accompanied by sweating and a fast pulse. The patient may look pale. Shortness of breath is a common but not inevitable feature. Your doctor may be able to detect a possible pneumothorax on examination, although a chest x-ray would usually be taken to confirm the diagnosis.
Treatment options include watchful waiting if the degree of lung collapse is small or insertion of a tube to drain the air from around the lung to allow it to re-expand.

Pleurisy

This is inflammation of the lining of the lung. Features are principally chest pain, which is localised, sharp, and made worse by coughing or deep inspiration. Causes include viral infection, pneumonia, pulmonary embolus, cancer affecting the lung or its lining and tuberculosis. The pain may be treated with anti-inflammatory medication (e.g. ibuprofen), although the cause needs to be determined.
Nerve pain affecting the chest

Shingles

Shingles is an infection caused by chicken pox virus reactivation. After the original chicken pox infection (usually in childhood) the virus hides in the nervous system. Occasionally (and unpredictably) the infection can reactivate itself. It usually affects a stripe of skin on one side of the body that is supplied by one nerve. There is a rash characterised by crops of small, initially clear, blisters on an inflamed red base. These crust over and settle over a 1-2 week period. The pain may be described as burning in quality. The pain may precede the rash by a week but the rash is diagnostic and your doctor should have no difficulty identifying shingles once the rash is out. Shingles will usually settle without treatment but vulnerable patients may be offered anti-viral drugs like aciclovir to settle the rash quickly. Unfortunately, some patients can go on to experience a very unpleasant burning pain in the area of skin that was affected by shingles. This can go on for months and sometimes years and occurs more commonly the older the patient is. It is very difficult to treat but your doctor may suggest a low dose of an anti-depressant drug called amitriptyline which is sometimes very helpful for treating nerve type pain. Amitriptyline can make people dopey and tired and tends to cause a dry mouth and eyes and constipation.

Pain from the spine

The sensation of the muscles of the chest wall and the overlying skin is supplied by nerves that come off the spine at the level of each rib. Pain affecting these nerves will often be felt spreading around the chest in a stripe from the back towards the front of the breast bone. Depending on the cause there may also be pain affecting the spine itself or tenderness where the rib and spine join. Causes include dislocation of the rib from the spine, fracture of the spine (for example, patients with osteoporosis), infection or cancer. The former two tend to have a sudden onset and settle with time (often weeks) whilst the latter tend to start insidiously and get progressively worse. There may be associated feature, for example, fever in the presence of infection or symptoms such as general ill health and weight loss in the case of undiagnosed cancer.

Cardiac neurosis

Some patients develop pain that they believe is heart pain in the absence of heart disease. It is usually very worrying. The pain is often situated around or under the left breast (where the heart lies, but not where the body actually feels heart pain) and may be associated with a tender spot. Unlike true heart pain this tends to be of long duration and not eased by rest. Associated symptoms such as difficulty breathing, palpitations, headaches and fatigue may suggest associated hyperventilation. If your doctor is sure that your pain is not from the heart, then he will provide an explanation and reassurance. Further tests are often unnecessary and can lead to further worry and stress in this situation.

Bornholm disease— epidemic myalgia

Bornholm disease is due to infection with Coxsackie B virus. It is an uncommon condition that is characterised by a severe immobilising, pleuritic chest pain and sometimes abdominal pain. There may be variable symptoms of fever and sometimes sore throat. The condition will persist for several days before spontaneous resolution. Diagnosis of the condition may made by isolation of the virus from the throat or stool. The diagnosis may be made retrospectively by blood tests.

Aortic dissection

About 500 people in the UK are affected annually by a tear in the main blood vessel running out of the heart - the aorta. Aortic dissection presents with the sudden onset of a 'tearing' pain of extreme severity. The site of the pain depends on that of the dissection and will alter as the dissection progresses. Often, the pain starts in the anterior or posterior chest or in the abdomen, and nearly always involves the upper back. The neck, arms, trunk or legs may also be involved. The patient often appears shocked - pale, sweaty, and a racing pulse. Alternatively, presentation may be with acute abdominal pain, a stroke affecting one whole side of the body with paralysis, or a heart attack (due to involvement of the coronary arteries reducing the blood supply to the heart. In this situation you will be admitted to hospital as an emergency for further investigation and emergency treatment. This condition carries a high mortality depending on whether surgical repair can be achieved.

Pericarditis (inflammation of the lining of the heart)

Pericarditis is inflammation of the lining layer of the heart. We do not see this very often. The most common cause is viral e.g. Coxsackxie virus. Other causes include heart attack, pneumonia next to the heart, Dressler's syndrome (inflammation of the lining of the heart occurring about 3 weeks after a heart attack), kidney failure, tuberculosis, an underactive thyroid, trauma, connective tissue disorders e.g. Systemic Lupus Erythematous, Rheumatoid Arthritis, Polyarteritis Nodosa, breast or lung cancer invading the lining of the heart, and radiotherapy.

Possible symptoms include chest pain that is sharp, localized, relieved by leaning forward, and. Sometimes pain may spread to left shoulder, or down the arm or into the abdomen.
Your doctor may be able to detect pericarditis when he listens to the heart with the stethoscope. An ECG will show characteristic changes and if there is concern you will be referred to the hospital for further investigation.