Chest Pain

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What is Chest Pain?

Chest Pain is the pain that is felt in the region of the chest and more commonly on the front side. The pain may be of varying nature and intensity, and may or may not be associated with other symptoms. A number of medical conditions, including more commonly, those related to the heart and the lungs can present as Chest Pain.

Is Chest Pain condition a Medical emergency?

Chest Pain can be an indication of a medical emergency and requires prompt evaluation.

Types

Chest Pain may be mainly classified as:

  • Cardiac or heart related
  • Non-cardiac or non-heart related

Causes

A number of medical conditions can result in Chest Pain and may include the following:

  • Cardiac:
    • Acute coronary syndrome
      • Stable and unstable angina
      • Myocardial infarction
    • Aortic dissection
    • Aortic aneurysm
    • Prinzmetal angina due to coronary vasospasm
    • Hypertrophic cardiomyopathy
    • Pericarditis
    • Myocarditis
    • Cardiac tamponade
    • Mitral valve prolapse
    • Aortic stenosis
    • Arrhythmias
  • Respiratory:
    • Pulmonary embolism
    • Bronchitis
    • Pleurisy
    • Pneumonia
    • Asthma
    • Lung cancer
    • Pneumothorax
    • Hemothorax
  • Gastrointestinal:
    • GERD
    • Esophageal spasm
    • Esophagitis
    • Esophagial rupture
    • Acute gastritis
    • Acute pancreatitis
    • Acute cholecystitis
    • Perforated peptic ulcer
  • Chest wall and other related conditions:
    • Costochondritis
    • Precordial catch
    • Tuberculosis
    • Rib fracture
    • Osteoarthritis
    • Herpes zoster affecting the chest region
    • Thoracic outlet syndrome
    • Prolapsed intervertebral disc
    • Hiatus hernia
  • Psychological:
    • Anxiety
    • Panic attack
    • Hypochondria
  • Others:
    • Carbon monoxide poisoning
    • Lead poisoning
    • Sarcoidosis
    • Hyperventilation syndrome

Symptoms & signs

Chest Pain may be of varying nature, intensity, duration and may or may not be associated with other symptoms. Some common types of Chest Pain include:

  • Pressure like sensation
  • Stabbing pain
  • Burning pain
  • Fullness or tightness
  • Sharp pain or persistent dull pain
  • The pain may radiate to the jaws, neck, back, shoulders, arms, and/or upper abdomen

Symptoms that may be seen along with Chest Pain include:

  • Shortness of breath
  • Cold sweats
  • Dizziness
  • Nausea and/or vomiting
  • Difficulty swallowing
  • Sour taste in the mouth
  • Pain on touch
  • Increase or decrease in pain when changing body position

Investigations

Some investigations that are advised for the evaluation of Chest Pain include:

  • Laboratory tests:
    • CBP & ESR
    • Liver and renal functions tests
    • Complete metabolic panel
    • Cardiac markers: Troponin i or t
    • Creatine kinase
    • D-dimer (To rule out pulmonary embolism)
    • Serum Lipase: (To rule acute pancreatitis)
  • Imaging tests:
    • Chest – X-Ray
    • CT Scan
    • Echocardiography: If there is a known history of cardiac disease
    • CT pulmonary angiogram: If pulmonary embolism is suspected
  • ECG: It is usually the first test that is advised
  • Coronary catheterization

Diagnosis

A diagnosis of the underlying cause responsible for Chest Pain is established based on medical history, clinical evaluation, and results of the investigations done.

Treatment options

The treatment of Chest Pain depends on identifying the underlying medical condition and treating it. Treatment of Chest Pain may include medical and surgical interventions based on the underlying cause and the general health of the individual.

Medical management

Medical management of Chest Pain may include:

  • Analgesics: For the management of pain
  • Thrombolytics: to help dissolve the clot and restore the blood flow. It is advisable to administer via injection within 30 minutes of the onset of symptoms
  • Nitroglycerin: To improve the blood flow through the arteries
  • Antiplatelet drugs: To prevent the formation of clots within the arteries
  • Angiotensin-converting enzyme (ACE) inhibitors: To increase the blood flow and decrease blood pressure, thereby decreasing the workload of the heart
  • Angiotensin receptor blockers: To reduce the blood pressure and the workload of the heart
  • Beta-blockers: To reduce the blood pressure and the workload of the heart
  • Statins: To reduce the amount of cholesterol in the blood and to stabilize existing plaques and preventing them from rupturing
  • Antacids: For reducing the production of acid if certain gastrointestinal causes are responsible for causing Chest Pain
  • Antidepressants: For the management of panic attacks or anxiety

Interventional including surgery and indications for surgery

Interventions for the management of Chest Pain depend on the underlying cause and its severity, as well as on the general health of the individual.

For cardiac causes of Chest Pain, the following may be done:

  • Angioplasty and stenting: Which is a minimally invasive interventional cardiology procedure such as percutaneous coronary interventions are done in which a balloon is guided through a catheter to unblock or widen the arteries and in addition, a tiny tubular metal mesh called a stent is placed inside the artery to act as a support and keep the artery open. It is advisable to perform this procedure within 90 minutes from the onset of symptoms.
  • Coronary bypass surgery or coronary artery bypass grafting (CABG): It is a procedure where the blockage is significant and an arterial graft is used to bypass the blocked artery and restore the blood supply to the heart.
  • Dissection repair: If aortic dissection is present

Other procedures for the management of non-cardiac causes may include procedures for the management of lung or gastrointestinal conditions that can cause Chest Pain.

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Some of the measures that can be taken include:

  • Quitting smoking
  • Eating a healthy diet that includes fruits, vegetable, lean meats, and low-fat dairy
  • Getting regular exercise and staying physically fit
  • Maintaining proper body weight
  • Monitoring and keeping blood cholesterol levels under control
  • Monitoring and controlling blood pressure levels
  • Reducing mental and emotional stress
  • Keeping a check on alcohol consumption
  • Cognitive-behavioural therapy: If psychological causes are identified
  • Physical therapy: If mechanical causes are identified

Prognosis

The prognosis depends on the underlying cause, as well as the general health condition of the individual. It is due to cardiac causes in about 20-25% of the cases, while other medical conditions contribute are responsible in the remaining cases.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek immediate medical attention if there is Chest Pain especially with other symptoms such as dizziness, sweating, etc.

Indications for hospitalization if required

Depending on the underlying cause of Chest Pain, hospitalization may be required for its management in certain conditions.

Suggested clinical specialist/ Departments to consult for this condition

  • Emergency medicine
  • Cardiology
  • General medicine
  • Gastroenterology
  • Pulmonology
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