The heart, lungs, esophagus, and great vessels receive afferent innervation from the same thoracic ganglion. Pain impulses from these organs are most often perceived as chest pain, but because there is decussation of afferent nerve fibers in the dorsal ganglia, chest pain can be felt anywhere between the epigastric region and the jugular fossa, including the arms and shoulders (as referred pain).
Pain impulses from the chest organs can cause discomfort described as pressure, fullness, burning, aching and sometimes sharp pain. Since these sensations have a visceral basis, many patients describe them as pain, although they are more accurately interpreted as discomfort.
Causes of chest pain
Many diseases are accompanied by discomfort or pain in the chest. Some of them (eg, myocardial infarction, unstable angina, thoracic aortic dissection, tension pneumothorax, esophageal rupture, pulmonary embolism) pose an immediate threat to life. Some diseases (stable angina, pericarditis, myocarditis, pneumothorax, pneumonia, pancreatitis, various chest tumors) pose a potential threat to the patient’s life. Other conditions [such as gastroesophageal reflux disease (GERD), peptic ulcers, dysphagia, osteochondrosis, chest trauma, biliary tract disease, herpes zoster] cause discomfort but are usually harmless.
Chest pain in children and young adults (under 30 years of age) is rarely due to myocardial ischemia, but myocardial infarction can develop in the 20s. Muscle, skeletal or lung diseases are more common in this age group.
Chest pain is the most common reason for calling an emergency doctor. The main diseases of the cardiovascular system, in which severe pain in the chest is noted, are:
- angina,
- myocardial infarction,
- aortic dissection,
- pulmonary embolism,
- pericarditis.
A classic example of pain or discomfort in the chest is angina pectoris. With “classic” exertional angina, pain or unpleasant sensations of pressing or squeezing nature occur behind the sternum during physical activity. Pain during angina pectoris quickly disappears after stopping the exercise (after stopping), usually within 2-3 minutes. Less often within 5 minutes. If you immediately take nitroglycerin under the tongue, the pain will disappear in 1,5-2 minutes. Angina pain is caused by myocardial ischemia. With spontaneous angina, pain occurs at rest (“angina at rest”), but the nature of the pain during typical attacks is the same as with angina pectoris. In addition, most patients with spontaneous angina have concomitant exertional angina. Isolated (“pure”) spontaneous angina is extremely rare. With spontaneous angina, in most cases there is a clear effect from taking nitroglycerin. For chest pain that occurs at rest, the effect of nitroglycerin is of very great diagnostic value, indicating an ischemic origin of the pain.
Unstable angina and myocardial infarction are characterized by more intense pain, accompanied by fear and severe sweating. During a heart attack, pain is usually not associated with exercise. At least it doesn’t go away with rest after stopping the load. The duration of pain during a heart attack can reach several hours or even days. Nitroglycerin in most cases does not eliminate pain during myocardial infarction. Until an accurate diagnosis is established for pain in the chest, the nature of which corresponds to unstable angina or myocardial infarction, the term “acute coronary syndrome” is used.
With aortic dissection, the pain is usually very severe, immediately peaks and usually radiates to the back.
Chest pain with massive pulmonary embolism is often very similar to pain during a heart attack, but at the same time there is almost always severe shortness of breath (increased respiratory rate – tachypnea). In the event of a pulmonary infarction, after 3-4 days pain appears on one side of the chest of a pleural nature (intensified by deep breathing and coughing). Diagnosis is facilitated by taking into account risk factors for pulmonary embolism and the absence of signs of infarction on the ECG. The diagnosis is clarified after hospitalization.
Pericarditis is characterized by increased pain with deep breathing, coughing, swallowing, and lying on your back. Often the pain radiates to the trapezius muscles. The pain is relieved by bending forward or lying on the stomach.
The main noncardiac diseases in which chest pain is noted include diseases of the lungs, gastrointestinal tract, spine and chest wall.
In diseases of the lungs and pleura, pain is usually on one side, in the lateral parts of the chest, and intensifies when breathing, coughing, or moving the body. Diseases of the esophagus and stomach most often cause sensations such as heartburn and burning, which are associated with food intake and often worsen when lying down. In emergency situations, the pain can be acute (“dagger-like”). Diagnosis is facilitated by the absence of a history of angina pectoris, identification of a connection with food intake, pain relief in a sitting position, after taking antacids. Pain caused by damage to the spine and chest wall is characterized by the onset or intensification with body movements and pain on palpation.
Thus, chest pain caused by extracardiac diseases is almost always noticeably different from pain in the typical course of diseases of the cardiovascular system.
Many people experience pain in the heart area of a “neurotic” nature (“neurocirculatory dystonia”). Neurotic pain is most often felt on the left in the area of the apex of the heart (in the area of the nipple). In most cases, you can indicate the location of pain with your finger. Most often, neurotic pains of two types are observed: acute, short-term pains of a “piercing” nature, which do not allow one to breathe, or prolonged aching pains in the heart area for several hours or almost constant ones. Neurotic pain is often accompanied by severe shortness of breath and anxiety, up to so-called panic disorders, and in these cases, the differential diagnosis with acute coronary syndrome and other emergency conditions can be quite difficult.
Thus, with typical manifestations of pain, it is quite easy to establish a diagnosis of all of the listed emergency cardiac conditions. Chest pain caused by extra-cardiac pathology, with a typical clinical picture, is also always noticeably different from pain caused by damage to the cardiovascular system. Difficulties arise with atypical or completely atypical manifestations of both cardiovascular and extracardiac diseases.
After hospitalization and examination of patients with chest pain, 15-70% are diagnosed with acute coronary syndrome, approximately 1-2% are diagnosed with pulmonary embolism or other cardiovascular diseases, and in the remaining patients, the cause of chest pain is non-cardiac diseases.
Symptoms of chest pain
The symptoms that appear in severe diseases of the chest organs are often very similar, but sometimes they can be differentiated.
- Unbearable pain radiating to the neck or arm indicates acute ischemia or myocardial infarction. Patients often compare myocardial ischemic pain with dyspepsia.
- Exercise-related pain that disappears with rest is characteristic of exertional angina.
- Excruciating pain radiating to the back indicates a dissection of the thoracic aorta.
- Burning pain spreading from the epigastric region to the throat, worsening when lying down and decreasing when taking antacids, is a sign of GERD.
- High body temperature, chills and cough indicate pneumonia.
- Severe shortness of breath occurs with pulmonary embolism and pneumonia.
- Pain may be triggered by breathing, movement, or both in both severe and mild illnesses; these precipitating factors are not specific.
- Brief (less than 5 seconds), sharp, intermittent pain is rarely a sign of serious pathology.
Objective examination for chest pain
Symptoms such as tachycardia, bradycardia, tachypnea, hypotension, or signs of circulatory compromise (eg, confusion, cyanosis, diaphoresis) are nonspecific, but their presence increases the likelihood that the patient has a serious illness.
Absence of breath sounds on one side is a sign of pneumothorax; a resonating percussion sound and swelling of the jugular veins indicate tension pneumothorax. Fever and wheezing are symptoms of pneumonia. Fever is possible with pulmonary embolism, pericarditis, acute myocardial infarction or esophageal rupture. A pericardial friction rub is evidence of pericarditis. The appearance of a fourth heart sound (S4), a late systolic murmur of papillary muscle dysfunction, or both of these signs appear with myocardial infarction. Local lesions of the central nervous system, the sound of aortic regurgitation, asymmetry of the pulse or blood pressure in the arms are symptoms of thoracic aortic dissection. Swelling and tenderness of the lower extremity indicate deep vein thrombosis and thus a possible pulmonary embolism. Chest pain on palpation occurs in 15% of patients with acute myocardial infarction; this symptom is nonspecific for diseases of the chest wall.
Additional research methods for chest pain
The minimum scope of examination of a patient with chest pain includes pulse oximetry, ECG and chest x-ray. Adults are often tested for markers of myocardial damage. The results of these tests, together with data from the anamnesis and objective examination, allow us to make a presumptive diagnosis. Blood tests are often not available during the initial examination. Individual normal indicators of markers of myocardial damage cannot be a basis for excluding cardiac damage. In the event that myocardial ischemia is likely, the studies must be repeated several times, just like an ECG; it is also possible to perform a stress ECG and stress EchoCG.
Diagnostic administration of a nitroglycerin tablet under the tongue or a liquid antacid does not reliably differentiate between myocardial ischemia and GERD or gastritis. Any of these medications can reduce the symptoms of each disease.
Diagnosis of chest pain
Clarifying the location, duration, nature and intensity of pain, as well as the factors that provoke and reduce it, is very important. Pre-existing heart disease, use of drugs that can cause coronary artery spasm (eg, cocaine, phosphodiesterase inhibitors), and risk factors for coronary artery disease or pulmonary embolism (eg, leg pain or fractures, previous immobilization, travel, pregnancy) also play a role. The presence or absence of risk factors for coronary heart disease (such as arterial hypertension, hypercholesterolemia, smoking, family history) increases the likelihood of coronary artery disease, but does not help in identifying the causes of acute chest pain.
Treatment of chest pain
Treatment of chest pain is carried out in accordance with the diagnosis. If the cause of chest pain is not fully understood, the patient must be taken to the hospital for cardiac monitoring and a more in-depth examination. Opiates may be prescribed symptomatically (as needed) until diagnosis is made.