Managing Chest Pains

A survey conducted on 832 persons who went to their family doctor with a complaint of chest pain gives us some idea of the common causes of chest pain.

1. Angina Pectoris (The most common cause of chest pain)
   Angina pectoris is a chest pain arising from the heart. The cause of the pain is narrowed blood vessels that supply the heart muscle with blood. The narrow blood vessels limit the amount of blood flowing to the muscle so that anything that causes the heart to beat faster will mean that there is not enough blood to supply the needs of the heart muscle and the person will experience chest pain. As soon as the individual rests the heart will slow down and the demand for blood in the muscle will decrease and the pain will be relieved. For many people with angina the onset of pain is very predictable. These individuals know that walking up stairs, up a hill or too quickly will bring on the chest pain. Some people experience the pain when they become nervous or upset. The pain experienced from angina is identical to that from a heart attack or from esophageal pain (food tube from throat to stomach). It is described as a tightness or in more severe episodes a crushing feeling in the center of the chest usually at or below the nipple line or high in the stomach area. The tightness is usually not sharp but very uncomfortable. The pain often radiates up into the jaw, into the shoulder, or down into the arm as far as the elbow or even the wrist. The main characteristic of angina is that the pain almost always goes away after five or ten minutes of rest or stopping whatever caused the increased heart rate. A heart attack pain is identical but continues and is not affected by rest or position change. Any chest pain of this description that lasts more than thirty minutes should be considered a heart attack until found to be something else. Most people suffering from angina are over fifty, are familiar with their condition, have drugs (nitro-glycerine )that will quickly relieve the pain and also may take drugs that slow the heart rate and thus reduce the risk of developing angina pain.
2. Chest Wall Pain
   The second most common cause of chest pain is caused by stretching or pulling on the muscles of the rib cage. The muscles between each rib are quite sensitive since, unlike most muscles in the body, they never rest but have to move with every breath. Pain from muscle strain in the chest wall may occur anywhere in the chest but most often occurs on the front of the chest either on the left or right upper half of the chest where the muscles from the arms are attached. The pain is sharp and localized to a specific area that is tender when you press on it. The pain can be quite severe and can be worse with breathing or movement.
3. Pain from the Stomach and Esophagus (third most common cause of chest pain)
   The nerves that are sensitive to pain in the heart are the same nerves that are sensitive to irritation in the esophagus and the upper stomach. Pain from stomach irritation is often described as having a burning quality but it may be identical to angina. Sometimes the pain may be relieved by use of an antacid but this does not insure that the heart is not the source of the discomfort. The main distinguishing feature is age. If the person is under 40, the pain is most likely from the stomach or esophagus. This is especially true if they have recently consumed large amounts of alcohol or have recently suffered from gastric irritation (nausea or vomiting). If the person is between 40 and 60 and complains of angina like pain it is difficult to sort out and should be assumed to come from the heart until proven otherwise. If the sufferer is over 60 then the pain is likely of cardiac origin. In spite of years of research it remains very difficult for physicians to accurately tell the difference between a pain of cardiac origin from a pain of stomach or esophageal origin even with blood tests.^2,3 The result of this dilemma is that a number of people need to be observed in hospital for several days for accurate diagnosis. Several studies have shown that people with chest pain from their stomach who are admitted to hospital for several days and treated as if they were having a heart attack, suffer considerable emotional trauma. Some do not recover rapidly.⁴ A recent simple blood test now available in the emergency rooms is able to tell the physician whether a pain is from the heart or stomach. This should reduce the problems of inappropriate admissions to the hospital.
4. Costochondritis (Fourth most common cause)
   Costochondritis is an inflammation or arthritis in the joints between the breast bone (sternum) and the ribs . If you pass your fingers down the right or left side of your breast bone you will feel a row of small bumps. These bumps are costochondral joints that can become inflamed. As in the rib cage these joints never stop moving, as every breath requires their movement. If one of these joints becomes inflamed, the pain often causes spasm in the muscles of the rib cage. This means that pain my be felt right across the front of the chest and may radiate around to the sides of the rib cage. Pressing the bumps along either side of the breastbone will make the tender joint obvious and may causes the pain to radiate around the chest. This pain can seem similar to angina but the tenderness of the joint clearly distinguishes it.
5. Anxiety
   People with anxiety may have chest pain. This pain is usually described as sharp, usually occurring in the sides of the chest but may even occur in the back. It is likely from spasm in the muscles in the rib cage. It lasts only seconds or minutes and usually moves from one area to another. There is no local spot that is the centre of the pain or tenderness, as you would find in chest wall pain. There may be occasions where this pain is difficult to distinguish from angina but its rapidly changing quality usually allows for this distinction.
6. Pleurisy
   Pleurisy is a very distinctive pain that comes from inflammation of the pleura membrane surrounding the lungs. The membrane becomes inflamed in association with an infection (pneumonia) or inflammation in the lung. The pleura is very sensitive. Every breath causes a rubbing of the inflamed surfaces, which produces pain. Any deep breath, cough, sneeze, or change of position will aggravate this extremely sharp and unpleasant pain. Although the inflammation may occur anywhere on the lung surface it most commonly occurs at the sides of the chest. The pain often radiates widely over the chest.
7. Trauma
   Trauma does not usually present a diagnostic dilemma as the cause and the injury is obvious. Broken ribs present a severe pain similar to that of chest wall. The pain causes spasm in the muscles of the rib cage so the pain tends to radiate. Every breath aggravates pain from broken ribs or even from bruising of the muscles of the rib cage.
8. Other Causes of Chest Pain
   There are many other rare causes of chest pain that account for about 10% of all people presenting to their family doctor. Most of the causes like shingles have characteristics that distinguish them from cardiac pain.
9. Myocardial Infract
   Only 3% of all persons complaining of chest pain when they visited their family doctor were actually having a heart attack. These individuals may have had typical angina in the past or silent heart attacks with no pain. This pain is not relieved by rest, change of position or use of drugs like nitro-glycerine. It lasts longer than half an hour and usually makes the sufferer look pale, sweaty, feel unwell with some nausea and vomiting. It often evokes feelings of discomfort, restlessness, shortness of breath and anxiety. Anyone with these symptoms should immediately take one adult aspirin and be transported to a medical facility as soon as possible. The objective of seeking rapid treatment is the demonstrated benefits of receiving early thrombolytic therapy. These drugs prevent clot formation. The heart attack is caused by clots of blood forming to block the coronary arteries that transport blood to the heart muscle. The longer the heart muscle is deprived of blood and oxygen the more it will be permanently damaged. Thrombolytic therapy stops clot formation and may reverse their formation so those blood vessels that were being blocked open up.⁵ This is why it is so important for a person suffering the symptoms of a heart attack to get medical attention quickly. The benefits of thrombolytic therapy decline within three hours of the onset of chest pain and after six hours it is too late to see any benefit. Aspirin is recommended because it has a thrombolytic effect and its immediate use aids the thrombolytic process.⁶ Sometimes when a blood clot forms in a coronary artery the change in blood flow affects the "electrical" system in the heart causing the heart to stop, beat very slowly or to beat rapidly and ineffectively. When this happens the victim suffers sudden collapse and has no pulse and stops breathing. In some situations this is because the heart is so severely affected that nothing further can be done. However in many situations by initiating cardiac resuscitation procedures the situation can be reversed and the patient can survive and with thrombolytic therapy and rehabilitation live many more productive years. The possibility of saving lives is the incentive for as many people as possible in the population to have taken an acute cardiac resuscitation coarse and to maintain their skills. There is evidence that the more people in a community with these skills, the more the lives that are saved.

   In the more recent literature there continue to be debates over the best way to differentiate those with chest pain from heart trouble and those with chest pain from other sources. One idea is develop units in hospitals where people with undifferentiated chest pain can be observed for 24 or 48 hours. Analysis of benefits of this approach found no measurable benefit and considerable cost.(7) Another study assessing the value of the troponin T and I tests concluded that persons at low risk of MI and with a low troponin T or I test after 6 hours had a low probability of having a heart attack. (8)

1. A Report from ASPN. An exploratory report of chest pain in primary care. JABFP 1990; 3(3): 143-150.
2. Craven MA, Waterfall W. The esophagus as a source of noncardiac chest pain. Can Fam Physician 1988; 34: 663-668.
3. Young AJ, McMahon LF, Stross JK. Prediction rules for patients suspected of myocardial infarction. Applying guidelines in community hospitals. Arch Intern Med 1987; 147: 1219-1222.
4. Ockene IS, shay MJ, Alpert JS, et al. Unexplained chest pain in patients with normal coronary arteriograms: a follow up study of functional status. N Engl J Med 1980; 303: 1249-1252.
5. Cairns JA, Gent M, Singer J, et al. Aspirin, sulfinpyrazone, or both in unstable angina. N Engl J Med 1985; 313: 1369-1375.
6. Basinski A, Naylor CD. Aspirin and fibrinolysis. Lancet 1988;ii: 1188-1189
7. Goodacre SW. Should we establish chest pain observation units in the UK. A systematic review and critical appraisal of the literature. J Accid Emerg Med 2000;17:1-6.
8. Ebell MH, White LL, Weismantel D. A systematic review of troponin T and I values as a prognostic tool for patients with chest pain. J Fam Pract 2000; 49:746-753.