Chest Pain

August 3, 2011

Chest pain is one of the cardinal manifestations of heart disease. However, chest pain can also occur due to various other disease states. It is very important for the patient and physician alike to differentiate chest pain due to cardiac causes from that due to noncardiac etiologies.

CHARACTERISTIC FEATURES OF CARDIAC CHEST PAIN

Quality

Cardiac chest pain is variously described as a constricting, squeezing, pressure-like, “heaviness,” burning, “weight in the center of my chest,” or “band-like feeling across my chest.” Usually this pain is incited by exercise, cold weather, heavy meals, physical exertion, or emotional/mental stressors. Patients are sometimes awakened by early morning chest pain. This pain usually lasts between 5 and 15 minutes, but can last as long as 30 minutes. Patients with severe coronary heart disease can have pain at rest with the above characteristics; pain of that severity is worrisome for a myocardial infarction (heart attack).

Location

The pain is usually located in the center of the chest (substernal), radiating down either arm, up to the neck, jaw, teeth, or into the upper back (interscapular).

Associated Symptoms

Patients may note shortness of breath, choking sensation, diaphoresis, dizziness, nausea, vomiting, or palpitations.

DIFFERENTIAL DIAGNOSIS

Other disease states can be confused with cardiac chest pain.

Esophageal Pain

Usually this type of discomfort is substernal and epigastric in location, and is associated with food intake and acid reflux. It can be burning in character and can be brought on by lying down after meals. This pain can easily be confused with cardiac chest pain, but it usually occurs more predictably with food intake. Antacids help to alleviate the discomfort. The difficulty in differentiating cardiac pain from esophageal pain is confounded by the fact that these two conditions often coexist.

Peptic Ulcer Disease

Burning discomfort in the mid-epigastrium, relationship with food intake, and relieved by antacids are important differentiating features for this type of pain.

Acute Pancreatitis

The pancreas is an abdominal organ which releases digestive juices and hormones such as insulin. Inflammation of the pancreas may occur due to alcohol dependence or biliary disease, among other etiologies. Pain is usually described as a sharp or dull ache in the epigastrium; it may be similar to cardiac pain, but is position dependent and radiates to the back.

Pericarditis or Pleuritis

These conditions—inflammation of the lining of the heart or the lungs, respectively—can cause chest pain which is sharp, increases with respiration, and is positional. This discomfort is often associated with a cough or respiratory tract infection.

CAUSES OF CARDIAC CHEST PAIN

The most common cause of cardiac chest pain is an obstructive or flow-limiting lesion in the coronary arteries due to atherosclerotic (cholesterol) plaque. The accumulation of plaque causes slow narrowing in the lumen of the artery until complete obstruction occurs. These plaques can rupture or break, thereby compromising blood flow to the heart suddenly, and thus causing a myocardial infarction. For these reasons, risk factor modification is crucial in order to prevent the occurrence of atherosclerosis.

Less common, but seen in women more often than in men, is spasm of the coronary artery leading to reduced blood flow, thus causing chest pain. Treatment for this is different from the treatment for coronary artery obstruction.

In some patients (most commonly, but not limited to, those with diabetes mellitus), chest pain can occur due to small vessel disease rather than to atherosclerosis involving large coronary arteries. This disease entity, called “microvascular angina,” cannot be visualized with the angiographic techniques we have today, but will often respond to similar treatments as other forms of coronary artery disease.

WORKUP FOR CHEST PAIN

A detailed clinical history and physical examination help to differentiate most other etiologies of chest pain from cardiac chest pain. Further clues can be obtained from blood tests and from a 12-lead electrocardiogram (ECG). If indeed the discomfort is felt to be cardiac (related to the heart) chest pain, the patient will often undergo an ECG, stress test, and/or cardiac catheterization (coronary angiography). A cardiac catheterization is a procedure during which a special chemical that is highly visible on x-ray (contrast agent) is injected into the coronary arteries in order to visualize (opacify) them. In this manner, flow-limiting lesions can be imaged by fluoroscopy (x-ray movies), and treated by balloon angioplasty or stenting (both specialized procedures in which an instrument inserted into the blood vessel is used to remove/reduce the effect of the obstruction in the vessel), if suitable. In some cases, the individual may be referred for heart surgery (coronary artery bypass grafting) if the disease is severe and widespread.

TIME IS MUSCLE

Patients who experience cardiac chest pain should seek medical attention immediately. Chewing four baby aspirins can reduce mortality, if the cause of chest discomfort is indeed a myocardial infarction. Administration of other medications as quickly as possible will save more muscle from suffering and dying, and thus will reduce complications and mortality. Performing coronary angioplasty and restoring blood supply to the muscle as soon as possible is very important.

WOMEN AND CHEST PAIN

While the majority of women presenting with acute myocardial infarction do complain of chest pain, other, more nonspecific complaints such as upper abdominal pain, shortness of breath, fatigue, and nausea occur more frequently in female than in male patients. Furthermore, chest pain is a less specific finding in women than in men, a fact that has led symptoms of chest pain in women to be discounted frequently. A heightened level of awareness must be present among physicians in order to prevent delays in the diagnosis and treatment of myocardial infarction in women.

Furthermore, as discussed in the entry on “Coronary artery disease,” the underlying pathology of myocardial infarction may differ in women when compared to men, and this difference may make the timely diagnosis of coronary artery disease more difficult in women.

Interestingly, women tend to have normal coronary angiograms in the presence of chest pain and/or abnormal stress tests more commonly than men, pointing to the likely presence of microvascular disease as a more frequent etiology of pain in women.

CARDIAC SYNDROME X

This syndrome was first described 100 years ago as “pseudoangina”; patients manifested chest pain, and had an abnormal stress test, but had normal coronary arteries by angiography. Kemp et al. coined the term “cardiac syndrome X” in 1973 for this clinical scenario. The incidence is higher in postmenopausal women. The underlying pathophysiology is unclear, but different authors have proposed several mechanisms. Problems with the release of endogenous vasodilators leading to spasm of the coronary arteries could be one of the reasons for this symptom complex. Therefore, women with normal coronaries are sometimes given ergonovine in the cardiac catheterization lab in order to induce coronary artery spasm and reproduce the symptoms. Another reason why these women have chest pain despite normal coronary arteries is due to “microvascular angina”—a disease of small vessels which cannot be seen clearly during cardiac catheterization, as mentioned above. overall prognosis for this group of women patients is dependent on the underlying cardiac risk factors, especially diabetes mellitus. Some authors have suggested that postmenopausal estrogen therapy may be helpful in improving symptoms of cardiac syndrome X in postmenopausal women, although this therapy should be administered cautiously given new findings of overall harm associated with it. Though mortality is not higher, these patients suffer from significant morbidity. Physicians need to be aware of this clinical condition and work with patients to modify cardiac risk factors and offer reassurance.

SEE ALSO: Anxiety disorders, Coronary artery disease, Mitral valve prolapse

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