Chest Pain

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the website Patient UK, authored by Dr Gurvinder Rull (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Chest pain refers to pain felt anywhere in the chest area from the level of your shoulders to the bottom of your ribs. It is a common symptom. There are many causes of chest pain and it can often be difficult to diagnose the exact cause of chest pain without carrying out some tests and investigations.

Causes

Common causes of chest pain

There are many possible causes of chest pain. Below is a brief overview of some of the more common causes:

Angina

Like any other muscle in the body, the heart (coronary) muscle needs a good blood supply. The coronary arteries supply blood to the heart muscle.

Angina is a pain that comes from the heart. It is usually caused by narrowing of the coronary arteries. This narrowing causes a reduced blood supply to part, or parts, of the heart muscle. The narrowing is caused by fatty patches or plaques (atheroma) which develop within the inside lining of arteries. Plaques of atheroma can form gradually over years. They may be in one or more places in the coronary arteries.

The reduced blood supply to the heart muscle due to atheroma may be good enough when you are resting. However, when your heart works harder (for example, when you are walking fast or climbing the stairs), your heart muscle needs more blood and oxygen. If the extra blood cannot get past the narrowed coronary arteries, your heart responds with pain.

The chest pain caused by angina may feel like an ache, discomfort or tightness across the front of your chest when you exert yourself. Pain may also (or sometimes just) be felt in your arms, neck, jaw or stomach. Angina pain usually eases within 10 minutes when you rest. Angina pain can also occur with coronary artery spasm or cardiac syndrome X.


Heart attack (myocardial infarction)

During a heart attack, a coronary artery or one of its smaller branches is suddenly blocked. This means that the part of the heart muscle supplied by this artery loses its blood and oxygen supply. Unless the blockage is quickly removed, this part of the heart muscle is at risk of dying. A heart attack is often referred to as a myocardial infarction. When part of the heart muscle is damaged, it is said to be infarcted. The term myocardial infarction means damaged heart muscle.

The blockage of the coronary artery during a heart attack is usually caused by a blood clot. A blood clot may form if there is some atheroma within the lining of the artery. A crack can develop in the patch of atheroma and this can trigger the clotting mechanism in the blood to form a blood clot over the patch of atheroma. Treatment with clot-busting medication or a procedure called angioplasty can break up the blood clot. This means that blood flow through the artery can be restored. If this treatment is given quickly, it can prevent damage to the heart muscle or limit the extent of the damage.

The most common symptom of a heart attack is severe chest pain at rest. This often feels like a heavy pressure sensation on your chest. The pain may travel up into your jaw, or down your left arm, or down both arms. You may also sweat, feel sick, feel faint and feel short of breath. The pain may be similar to angina but it is more severe and lasts longer.


Gastro-oesophageal reflux disease

This is a general term which describes a range of situations including:

• Acid reflux: when acid leaks up (refluxes) from the stomach into the gullet (oesophagus).
• Oesophagitis: when there is inflammation of the lining of the oesophagus. This inflammation is due to irritation of the lining caused by the reflux of stomach acid.

When we eat, food passes down the oesophagus into the stomach. Usually a band of muscle (a sphincter) at the bottom of the oesophagus prevents acid refluxing from the stomach back up into the oesophagus. If this sphincter is not working well then acid reflux can occur.

Heartburn is the main symptom of gastro-oesophageal reflux disease. This is a burning feeling that rises from the upper tummy (abdomen) or lower chest towards the neck. Other common symptoms include pain in the upper abdomen and chest, feeling sick, an acid taste in the mouth, bloating, belching and a burning pain when you swallow hot drinks. The symptoms tend to come and go and to be worse after meals. Severe chest pain can develop in some cases and can be mistaken for a heart attack.


Costochondritis

The rib cage is a bony structure that protects the lungs inside. Bones are hard and solid and so don't tend to bend or move. However, the rib cage needs to move as our lungs expand when we take in a breath during breathing. Cartilage is a softer and more flexible material that is found in joints around the body. Cartilage attaches the ribs to the breastbone (sternum) and the sternum to the collar bones (clavicles). This means that the rib cage is able to move during breathing. The joints between each rib and the cartilages are called the costochondral joints. The joints between the cartilages and the sternum are called the costosternal joints. The joints between the sternum and the clavicles are called the costoclavicular joints.

In costochondritis, there is inflammation in either the costochondral, the costosternal or the costoclavicular joints (or a combination). Costochondritis causes chest pain, felt at the front of the chest. This is typically a sharp, stabbing chest pain and is worse with movement, exertion and deep breathing. Pressure over the affected area also causes sharp pain. The pain is usually confined to a small area, but it can spread (radiate) to a wider area. The most common sites of pain are close to the sternum at the level of the 4th, 5th and 6th ribs.


Strained chest wall muscle

There are various muscles that run around and between the ribs to help the rib cage to move during breathing. These muscles can sometimes be strained and can lead to chest pain in that area. If a muscle is strained, there has been stretching or tearing of muscle fibres, often because the muscle has been stretched beyond its limits. For example, a strained chest wall muscle may sometimes develop after heavy lifting, stretching, sudden movement or lengthy (prolonged) coughing. The chest pain is usually worse on movement and on breathing in.


Anxiety

Anxiety is quite a common cause of chest pain. As well as feeling fearful, worried and tense, anxiety can sometimes cause physical symptoms including chest pain. In some people, the chest pain can be so severe that it is mistaken for angina. Chest pain due to anxiety is known as Da Costa's syndrome. Da Costa's syndrome may be more common in people who have recently had relatives or friends diagnosed with heart problems, or in people who themselves have recently had a heart attack. Investigations show that the coronary arteries are normal with no narrowing.

Less common causes of chest pain

Some of the less common causes of chest pain include the following:

Pleurisy

Pleurisy is due to inflammation of the pleura, a thin membrane with two layers - one which lines the inside of the muscle and ribs of the chest wall, the other which surrounds the lungs. Between the pleural cavity (the two layers of pleura) is a tiny amount of fluid. This acts like lubricating oil between the lungs and the chest wall as they move when you breathe.

Pleurisy is most often caused by a viral infection. It can cause a 'pleuritic' chest pain. This is a sharp, stabbing chest pain. The pain can be felt anywhere in the chest, depending on the site of the inflammation. The pain is typically made worse by breathing in or by coughing, as this causes the two parts of the inflamed pleura to rub over each other.

There are other more serious causes of pleuritic pain, but these are much less common than viral pleurisy. Anything that causes inflammation or damage at the edge of the lung next to the pleura can cause pleuritic pain.

For example:

• Pneumonia
• A blood clot in the lung (pulmonary embolism, or PE)
• A collapsed lung (pneumothorax)

These conditions are likely to have other symptoms and the pleuritic pain is just part of the problem.


Peptic ulcer

A peptic ulcer is an ulcer caused by stomach acid. An ulcer occurs where the lining of the gut is damaged, and the underlying tissue exposed. If you could see inside your gut, an ulcer looks like a small, red crater on the inside lining of the gut. A stomach ulcer is one type of peptic ulcer. A stomach ulcer is sometimes called a gastric ulcer. The most common type of peptic ulcer is a duodenal ulcer. The duodenum is the first part of the small intestine and connects to the stomach.

A common symptom of a peptic ulcer is pain in the upper tummy (abdomen) just below the breastbone (sternum). The pain usually comes and goes and can sometimes be felt as chest pain. Sometimes food makes the pain worse. The pain may wake you from your sleep. Bloating, retching and feeling sick are other symptoms. You may also feel particularly 'full' after a meal. Complications of peptic ulcers can occur in some cases and can be serious.

Complications include:

• Bleeding of the ulcer
• Perforation - the ulcer goes right through (perforates) the wall of the stomach. Food and acid in the stomach then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.
  
  

Shingles

Shingles is an infection of a nerve and the area of skin supplied by the nerve. It is caused by a virus called the varicella-zoster virus. It is the same virus that causes chickenpox. Anyone who has had chickenpox in the past may develop shingles. The virus does not completely go after you have chickenpox. Some particles of virus remain active in the nerve roots next to your spinal cord. They do no harm there and cause no symptoms. For reasons that are not clear, the virus may begin to multiply again (reactivate). This is often years later. The reactivated virus travels along the nerve to the skin to cause shingles. Shingles is sometimes called herpes zoster.

The virus usually affects one nerve only, on one side of the body. Symptoms occur in the area of skin that the nerve supplies. The usual symptoms are pain and a rash. If a nerve supplying the skin on the chest is affected, shingles can cause chest pain. The pain is a localised band of pain and can range from mild to severe. A rash typically appears two to three days after the pain begins. Red blotches appear that quickly develop into itchy blisters. The rash looks like chickenpox but only appears on the band of skin supplied by the affected nerve. The blisters gradually dry up, form scabs and then fade away.


Pulmonary embolism (PE)

A PE occurs when there is a blockage in one of the artery blood vessels in the lungs - usually due to a blood clot (thrombus). A PE can be in an artery in the centre of the lung or one near the edge of the lung. The clot can be small and there can be more than one clot. If there are severe symptoms, which occur with a large clot near the centre of the lung, this is known as a massive PE. It is very serious.

In almost all cases, the cause is a thrombus that has originally formed in a deep vein - known as deep vein thrombosis (DVT). This clot travels through the circulation and eventually gets stuck in one of the blood vessels in the lung. The thrombus that has broken away is now called an embolus (and can therefore cause an embolism). Most DVTs come from the veins in the legs or pelvis. Occasionally, a PE may come from a blood clot in an arm vein, or from a blood clot formed in the heart.

A PE usually causes sharp chest pain felt when breathing in (pleuritic chest pain). In a large PE, chest pain can be felt in the centre of the chest behind the sternum. Often you feel like you cannot breathe deeply. You can also feel breathless and the degree of breathlessness will depend on the size and position of the PE. Coughing up blood (haemoptysis), a mildly high temperature (fever) and a fast heart rate are other symptoms. You may also feel faint, or even collapse because a large blood clot can cause the blood pressure to drop significantly. There may also be symptoms of a DVT such as pain in the back of the calf in the leg, tenderness of the calf muscles or swelling of a leg or foot. The calf may also be warm and red.


Pneumothorax

A pneumothorax is air that is trapped between a lung and the chest wall. The air gets there either:

• From the lungs: The common type of pneumothorax is a primary spontaneous pneumothorax. The pneumothorax develops for no apparent reason in an otherwise healthy person. It is thought to be due to a tiny tear in an outer part of the lung. Air then escapes from the lung and gets trapped between the lung and the chest wall. A secondary spontaneous pneumothorax is also possible. The pneumothorax develops as a complication of an existing lung disease which can make the lung more liable to tear. For example, chronic obstructive pulmonary disease (COPD).
• From outside the body: For example, an injury to the chest from a stab wound or a car crash can cause a pneumothorax.

A pneumothorax typically causes sudden, sharp, stabbing chest pain on one side. The pain is usually made worse by breathing in and you can become breathless. Usually, the larger the pneumothorax, the more breathless you become.

What should I do if I have chest pain?

There are many different causes of chest pain. Some are more serious than others. It is important to take chest pain seriously because it can sometimes indicate a serious underlying problem. Any new, severe, or persisting chest pain should be discussed with your doctor. This is particularly important if you are an adult and have a history of heart or lung disease. If the chest pain is particularly severe, especially if it is radiating to your arms or jaw, you feel sick, feel sweaty or become breathless, you should call for an emergency ambulance. These can be symptoms of a heart attack.

What investigations may be advised?

Your doctor will usually ask you some questions to try to determine the cause of your chest pain. He or she may also examine you. Based on what they find, he or she may advise you to have some investigations, depending on what cause for your chest pain they suspect.

Investigations for chest pain can include: 

A 'heart tracing' (electrocardiogram, or ECG)

There are usually typical changes to the normal pattern of the 'heart tracing' in a heart attack. 

Blood tests

A blood test that measures a chemical called troponin is the usual test that confirms a heart attack. Damage to heart muscle cells releases troponin into the bloodstream. Another blood test that may be suggested is a D-dimer test. This detects fragments of breakdown products of a blood clot. A positive D-dimer test may raise the suspicion of a DVT or PE.


Chest X-ray

A chest X-ray can look for pneumonia, collapsed lung (pneumothorax) and other chest conditions.


Myocardial perfusion scintigraphy

This is a test which is often done to confirm the diagnosis of heart chest pain (angina). The test involves having an injection of a small amount of radioactive substance. A special camera, known as a gamma camera, is then moved around you for 10-20 minutes. The gamma camera picks up the radioactive trace and produces pictures to reveal how well blood is reaching your heart. This is done both when you are resting and when your heart is beating faster. You may be asked to increase your heart rate by exercising (for example, by walking or jogging on a treadmill).


Cardiac magnetic resonance imaging

This is also a test to confirm heart chest pain. It is now being increasingly used and in some hospitals they may do this test rather than myocardial perfusion scintigraphy. The test is a magnetic resonance imaging (MRI) scan that can take up to 30 minutes and an injection of dye is required. Pacemaker devices and metal objects can become disrupted and can interfere with the magnet, so you will be asked detailed questions before being allowed to have an MRI scan.


CT coronary angiogram

This is another test being increasingly used to make a diagnosis of heart disease, in particular to establish whether coronary artery atheroma is present. It is much quicker than the MRI scan but again an injection of dye is needed. It is not suitable for all cases and the healthcare team will decide which test is the most appropriate in each individual case.


Angiogram

This may be recommended for some people with chest pain. In this test a dye is injected into the heart (coronary) arteries. The dye can be seen by special X-ray equipment. This shows up the structure of the arteries (like a road map) and can show the location and severity of any narrowing.


Isotope scan and CTPA scan

These are specialised scans which look at the circulation in the lung. CTPA stands for 'computerised tomography pulmonary angiogram'. They are useful because they can show quite accurately whether or not a PE is present.


Endoscopy

This is a test that can confirm a peptic ulcer. In this test, a doctor looks inside your stomach by passing a thin, flexible telescope down your gullet (oesophagus). They can see inflammation or ulcers.

What may be advised to help manage the problem?

This will depend on the cause that is found for your chest pain. 

If the problem is not an emergency, your doctor may refer you to a consultant for further specialist investigations, as described above.

About the author

BSC (Hons), MBBS, FRCP, MA (Medical Ethics)

Gurvinder qualified in 2000 and joined the authoring team at EMIS in 2007. She is also a Consultant in Clinical Pharmacology, Therapeutics and General Internal Medicine at St Bartholomew’s Hospital and the Royal London Hospital. She specialises in the management of hypertension and general internal medicine. She is an expert in Hypertension resistant to treatment, Hypertension with suspected underlying cause, Hypertension in patients with multiple drug intolerance and complex hypertension. She has an interest in autonomic nervous system dysfunction, POTS and baroreceptor failure. She is a member of the International Society of Hypertension and the British and Irish Hypertension Society. She also manages patients with general medical problems and is an advanced life support trainer.

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