Chest pain

The heart, lungs, esophagus, and great vessels all receive afferent innervation from the same thoracic ganglion. Pain impulses from these organs are most often perceived as chest pain, but because there is a decussation of afferent nerve fibers in the dorsal ganglia, chest pain may be felt anywhere between the epigastric region and the jugular fossa, including the arms and shoulders (as referred pain).

Pain impulses from the chest cavity organs can cause discomfort described as pressure, distension, burning, aching and sometimes sharp pain. Since these sensations have a visceral basis, many patients describe them as pain, although it is more correct to interpret them as discomfort.

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Causes of Chest Pain

Many medical conditions are associated with chest discomfort or pain. Some (such as myocardial infarction, unstable angina, thoracic aortic dissection, tension pneumothorax, esophageal rupture, pulmonary embolism) are immediately life-threatening. Some medical conditions (stable angina, pericarditis, myocarditis, pneumothorax, pneumonia, pancreatitis, various chest tumors) are potentially life-threatening. Other conditions (such as gastroesophageal reflux disease (GERD), peptic ulcer, dysphagia, osteochondrosis, chest trauma, biliary tract disease, herpes zoster) are unpleasant but usually harmless.

Chest pain in children and young adults (under 30 years of age) is rarely caused by myocardial ischemia, but myocardial infarction can develop in people as young as 20 years of age. Muscle, skeletal, or lung disease are more common in this age group.

Chest pain is the most common reason for calling an ambulance. The main cardiovascular diseases that cause severe chest pain are:

• angina pectoris,
• myocardial infarction,
• aortic dissection,
• pulmonary embolism,
• pericarditis.

A classic example of pain or discomfort in the chest is angina of effort. With "classic" angina of effort, pain or discomfort of a pressing or squeezing nature occurs behind the breastbone during physical activity. The pain of angina of effort quickly disappears after the end of the load (after stopping), as a rule, 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. The pain of angina is caused by myocardial ischemia. With spontaneous angina, pain occurs at rest ("rest angina"), but the nature of the pain during typical attacks is the same as with angina of effort. In addition, most patients with spontaneous angina have concomitant angina of effort. Isolated ("pure") spontaneous angina is extremely rare. In spontaneous angina, in most cases, a clear effect of nitroglycerin is observed. In chest pain that occurs at rest, the effect of nitroglycerin has a very large diagnostic value, indicating that the pain is of ischemic origin.

Unstable angina and myocardial infarction are characterized by more intense pain sensations, accompanied by fear and severe sweating. In case of infarction, pain is usually not related to exertion. At least, it does not go away at rest after the exertion has ceased. The duration of pain during infarction can reach several hours or even days. Nitroglycerin in most cases does not eliminate pain during myocardial infarction. Until an accurate diagnosis is established, the term "acute coronary syndrome " is used for chest pain sensations corresponding to unstable angina or myocardial infarction.

With aortic dissection, the pain is usually very severe, peaks immediately, and usually radiates to the back.

Chest pain in massive pulmonary embolism is often very similar to pain in a heart attack, but at the same time, severe shortness of breath (increased respiratory rate - tachypnea) is almost always noted. In the case of a pulmonary infarction, after 3-4 days, pain appears on one side of the chest of a pleural nature (increasing with deep breathing and coughing). Diagnosis is facilitated by taking into account the risk factors for the development of 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 when lying on the back. Often the pain radiates to the trapezius muscles. The pain decreases when bending forward or lying on the stomach.

The main extracardiac diseases that cause chest pain include diseases of the lungs, gastrointestinal tract, spine and chest wall.

In diseases of the lungs and pleura, the pain is usually on one side, in the lateral parts of the chest, and increases with breathing, coughing, and body movement. Diseases of the esophagus and stomach most often cause sensations such as heartburn, burning, which are associated with food intake and often increase in the lying position. In emergency situations, the pain can be sharp ("dagger-like"). Diagnosis is facilitated by the absence of a history of angina pectoris, identification of a connection with food intake, relief of pain in a sitting position, and after taking antacids. Pain caused by damage to the spine and chest wall is characterized by occurrence or increase with body movements, and pain upon palpation.

Thus, chest pain caused by extracardiac diseases almost always differs significantly from pain sensations in the typical course of cardiovascular diseases.

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 nipple area). In most cases, you can point to the location of the pain with your finger. Most often, two types of neurotic pain are observed: sharp, short-term pain of a "piercing" nature that does not allow you to breathe in, or long-term aching pain in the heart area for several hours or almost constant. Neurotic pain is often accompanied by severe shortness of breath and anxiety, up to the so-called panic disorders, and in these cases, differential diagnosis with acute coronary syndrome and other emergency conditions can be quite difficult.

Thus, with typical manifestations of pain syndrome, it is quite easy to establish a diagnosis of all the listed emergency cardiological conditions. Chest pain caused by extra-cardiac pathology, with a typical clinical picture, also always differs significantly from pain sensations in cardiovascular disease. Difficulties arise with atypical or completely atypical manifestations of both cardiovascular and extra-cardiac 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 extracardiac diseases.

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Symptoms of Chest Pain

Symptoms that appear in severe diseases of the chest organs are often very similar, but sometimes they can be differentiated.

• Intolerable pain radiating to the neck or arm indicates acute myocardial ischemia or infarction. Patients often compare myocardial ischemic pain to dyspepsia.
• Pain associated with exertion that disappears at rest is characteristic of angina pectoris.
• Excruciating pain radiating to the back indicates thoracic aortic dissection.
• A burning pain that radiates from the epigastric region to the throat, intensifies when lying down and is relieved by taking antacids, is a sign of GERD.
• High body temperature, chills and cough indicate pneumonia.
• Severe dyspnea occurs with pulmonary embolism and pneumonia.
• Pain may be triggered by breathing, movement, or both in both severe and mild illnesses; these triggers are not specific.
• Short (less than 5 sec), sharp, intermittent pain is rarely a sign of serious pathology.

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Objective examination

Symptoms such as tachycardia, bradycardia, tachypnea, hypotension, or signs of circulatory compromise (eg, confusion, cyanosis, sweating) are nonspecific, but their presence increases the likelihood that the patient has a serious illness.

The absence of conduction of breath sounds on one side is a sign of pneumothorax; resonant percussion sound and swelling of the jugular veins indicate tension pneumothorax. Increased body temperature and wheezing are symptoms of pneumonia. Fever is possible with pulmonary embolism, pericarditis, acute myocardial infarction, or esophageal rupture. Pericardial friction rub indicates pericarditis. The appearance of the fourth heart sound (S4 ₎, late systolic murmur of papillary muscle dysfunction, or both of these signs appear in myocardial infarction. Local CNS lesions, aortic regurgitation murmur, asymmetry of pulse or blood pressure in the arms are symptoms of thoracic aortic dissection. Swelling and tenderness of the lower limb indicate deep vein thrombosis and, thus, possible pulmonary embolism. Chest pain on palpation occurs in 15% of patients with acute myocardial infarction; this symptom is not specific for diseases of the chest wall.

Additional research methods

A minimum evaluation of a patient with chest pain includes pulse oximetry, ECG, and chest radiography. Adults are often tested for myocardial injury markers. The results of these tests, combined with the history and physical examination, allow a tentative diagnosis to be made. Blood tests are often not available at the initial examination. Individual normal values for myocardial injury markers cannot be used to exclude cardiac damage. If myocardial ischemia is likely, the tests should be repeated several times, as well as an ECG, and stress ECG and stress echocardiography may also be performed.

Diagnostic administration of a sublingual nitroglycerin tablet or a liquid antacid does not reliably differentiate myocardial ischemia from GERD or gastritis. Any of these drugs can reduce the symptoms of each disease.

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Diagnosis of chest pain

It is very important to determine the location, duration, nature, and intensity of pain, as well as the factors that provoke and relieve it. Previous heart disease, use of drugs that can cause coronary artery spasm (e.g., cocaine, phosphodiesterase inhibitors), the presence of risk factors for coronary heart disease or pulmonary embolism (e.g., leg pain or fractures, previous immobilization, travel, pregnancy) are also important. The presence or absence of risk factors for coronary heart disease (such as hypertension, hypercholesterolemia, smoking, aggravated family history) increases the likelihood of coronary heart disease, but does not help in clarifying the causes of acute chest pain.

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Treatment of chest pain

Treatment of chest pain is carried out in accordance with the diagnosis. In the event that the cause of chest pain is not fully understood, the patient should be taken to the hospital for cardiac monitoring and a more in-depth examination. Symptomatically, opiates can be prescribed (if necessary) until a diagnosis is made.

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