What is Chest Pain or Chest Tightness?
Chest pain or chest tightness or chest pressure is a discomfort or pain that a person feels along the front side of the body between the neck and upper abdomen region. Many people panic when they feel chest pain thinking they might have a heart attack, but it is not so, as there are other noncardiac causes for chest pain. Chest pain is a symptom of other underlying medical conditions. These medical conditions can be life threatening such as myocardial infarction (heart attack) or could be due to other non cardiac causes such as gastrointestinal troubles like GERD, psychological problems like depression, anxiety and panic attacks. It is very important to make correct differential diagnosis between the various causes of chest pain. Chest consists of various organs which include heart, lungs, esophagus, muscles, bones. Any of these parts can be the cause of chest pain. The stomach and other organs in the abdomen can also cause chest pain. Chest pain may also originate from another part of the body due to the complex nerve distribution in the body; it gets referred to the chest.
Classification and Types of Chest Pain or Chest Tightness
There are Two Types of Chest Pain:
- Cardiac Chest Pain:
- Non Cardiac Chest Pain:
- Herpes Zoster
Cardiac Chest Pain Causes:
- Some of the ischemic causes are coronary artery disease, aortic stenosis, coronary artery spasm, and hypertrophic cardiomyopathy.
- Non-ischemic causes include pericarditis, dissecting aortic aneurysm and mitral valve prolapse.
Non-Cardiac Chest Pain Causes:
- Gastroesophageal causes include GERD, esophageal perforation, esophageal spasm, esophagitis, peptic ulcer, pancreatitis, cholecystitis, and reflux esophagitis.
- Pulmonary causes include pneumonia, pneumothorax, pulmonary embolism, bronchitis, hemothorax, and emphysema.
- Musculoskeletal causes include costochondritis, rib fracture and myalgia.
- Herpes zoster can cause acute chest pain, described as burning sensation and present in unilateral dermatomal distribution.
Causes and Risk Factors of Chest Pain or Chest Tightness
- Cardiovascular Causes of Chest Pain or Chest Tightness Are: Angina, acute coronary syndrome, myocardial infarction (heart attack), aortic dissection, pericarditis, cardiac tamponade, arrhythmia, stable angina pectoris and myocarditis.
- Pulmonary Causes of Chest Pain or Chest Tightness Are: Pneumonia, pneumothorax, tension pneumothorax, hemothorax, pleurisy and pulmonary embolism.
- GI Causes of Chest Pain or Chest Tightness Are: Gastroesophageal Reflux Disease (GERD), stomach ulcer or gastritis, nutcracker esophagus, other neuromuscular disorders of the esophagus, spasms or narrowing of the esophagus, functional dyspepsia, hiatus hernia, gallstones and achalasia.
- Psychological Causes of Chest Pain or Chest Tightness Are: Depression, panic attacks, anxiety, somatization disorder, hypochondria, bipolar disorder and dysthymia.
- Other Causes of Chest Pain or Chest Tightness Are: Costochronditis, radiculopathy, spinal nerve problems, fibromyalgia, chest wall problems, precordial catch syndrome , breast conditions, herpes zoster (shingles), tuberculosis, carbon monoxide poisoning, sarcoidosis, hyperventilation syndrome, lead poisoning, high abdominal pain may also mimic chest pain, and strain or inflammation of the muscles and tendons between the ribs.
Pathophysiology of Chest Pain or Chest Tightness
Angina is chest pain which results when there is an imbalance between the heart's oxygen supply and its demand. This imbalance can result from an increase in demand (e.g. during exercise) without a proportional increase in supply (e.g. due to obstruction or atherosclerosis of the coronary arteries). Cardiac ischemia decreases the amount of adenosine triphosphate (ATP) in heart cells leading to acidosis. This acidosis then stimulates the myocardial nerve cells creating an increase in adenosine which sends painful stimuli to the cerebral cortex thus leading to chest pain.
Signs and Symptoms of Chest Pain or Chest Tightness
- Heart attack symptoms: Pain occurs in the mid to left side of the chest and may also extend to the left shoulder, left arm, jaw, stomach, and/or the back along with shortness of breath, profuse sweating, nausea, and vomiting. Other atypical symptoms include: Pain in neck, jaw, shoulder, upper back, discomfort in the abdomen, shortness of breath, nausea, vomiting, heartburn, sweatiness, lightheadedness, dizziness, and unexplained fatigue.
- Angina symptoms are similar to heart attack pain, but angina occurs with physical exertion or exercise and is relieved by rest or nitroglycerin. Angina becomes life threatening when pain continues at rest, increases in frequency or intensity, and is not relieved with at least three nitroglycerin tablets taken five minutes apart.
- Aortic dissection symptoms are: Chest pain that occurs suddenly and is described as "ripping" or "tearing" in nature, radiates to the back or between the shoulder blades. It can be an angina-type of pain, with shortness of breath, fainting, abdominal pain and symptoms of stroke.
- Pulmonary embolism symptoms include: Sudden shortness of breath, rapid breathing, and sharp pain in the mid chest, which increases with deep breaths.
- Pneumothorax symptoms are characterized by sudden onset of shortness of breath, sharp chest pain, tachycardia, dizziness, and fainting.
- Perforated viscus symptoms come on suddenly with severe chest pain, pain in the abdomen, and/or back pain. Abdominal pain increases with movement or when breathing in and it may be accompanied by a rigid board-like abdominal wall. Fever, tachycardia and low blood pressure may also be present.
- Pericarditis symptoms: The pain is usually sharp or stabbing in the mid-chest, worsened by deep breaths.
- Mitral valve prolapse usually has no symptoms but some people can experience palpitations and some chest pain. There are other symptoms that include lightheadedness, shortness of breath, and/or fatigue.
- Pneumonia symptoms: Prolonged or forceful coughing in pneumonia gives rise to chest pain. It is usually one-sided and is worsened by coughing with other associated symptoms like fever, coughing up mucus (sputum), and shortness of breath.
- Symptoms of gastroesophageal reflux disease include: Heartburn, painful swallowing (dysphagia), excess salivation, dull chest discomfort, chest pressure. Feelings of discomfort such as profuse sweating, nausea, vomiting, sore throat, bitter taste in the mouth or throat, hoarseness, or persistent dry cough.
Tests to Diagnose Chest Pain or Chest Tightness
Tests for finding out if the patient is having a heart attack are: Electrocardiogram (ECG or EKG), measurement of cardiac enzymes produced by the heart muscle cells.
- For diagnosing angina, apart from the above mentioned tests, stress test is done as well as cardiac catheterization to identify blockages.
- Aortic dissection is diagnosed based on symptoms of the patient, chest x-ray, transesophageal echocardiography and CT scan.
- Pulmonary embolism is diagnosed from the description of the patient's symptoms and undergoing investigations like ECG, chest x-ray, a ventilation-perfusion scan (V/Q scan) and a CT scan of the lungs.
- The diagnosis of spontaneous is made by physical exam, chest X-ray, CT scan and other lab tests.
- Acute pericarditis is diagnosed by the patient's symptoms, serial ECGs, echocardiography and other specific lab tests.
- Pneumonia can be diagnosed by the patient's symptoms, medical history, physical examination, and chest x-ray.
- Blood tests to include complete blood count, electrolytes, and renal function (creatinine), liver enzymes, creatine kinase , troponin I or T (to indicate myocardial damage), D-dimer (to detect pulmonary embolism) and serum lipase to exclude acute pancreatitis.
Treatment for Chest Pain or Chest Tightness
- Treatment of chest pain usually depends on the underlying conditions that cause chest pain.
- In case of heart attack, patient should be taken to the ER immediately. While waiting for the ambulance, the patient should be given two baby aspirins to chew or at least half of a regular aspirin. Chewing an aspirin in the early stages of a heart attack reduces the severity of the attack and also reduces the risk of death. Treatment for a heart attack is aimed at increasing blood flow by opening the blocked and medicines used for this purpose are aspirin, heparin, and clot-busting (thrombolytic) drugs. Surgery may be required if medical treatment fails. This includes angiography, angioplasty and cardiac bypass.
- If the patient has angina then nitroglycerin tablets should be placed under the tongue. Nitroglycerin acts as a vasodilator and aids in increasing blood flow to blocked or narrowed arteries. If the chest pain continues then another tablet should be placed under the tongue in the next five minutes. If even after three nitroglycerin tablets, the patient does not have relief then the patient should be taken to the nearest emergency department.
- Chest pain from acid reflux (GERD) may be relieved with antacids.
- Aortic dissection is treated with medications that reduce blood pressure, slow the heart rate and dilate the arteries. Surgical repair is required for dissection involving the ascending portion of the aorta.
- Pulmonary embolism treatment includes supplemental oxygen and medication to prevent further clotting of blood, typically heparin and in case of large embolism clot-busting medications are given. In some cases patients undergo surgery to place an umbrella-like filter in a blood vessel to prevent the migration of blood clots to the lungs from the lower extremities.
- Pneumothorax treatment involves catheter aspiration or having a chest tube inserted to restore negative pressure in the lung sac.
- Immediate surgery is required for perforated viscus.
- Pericarditis Treatment: In case of viral pericarditis, it usually improves within 7-21 days of therapy with nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen.
- Pneumonia is treated with antibiotics, and analgesics are given for chest wall tenderness.
- Costochondritis is generally treated with nonsteroidal antiinflammatory medications such as ibuprofen.