Chest Pain: To Worry or Not to Worry, That is the Question

Chest pain is an ongoing enigma for patients and physicians. Chest pain can indicate myocardial ischemia, a lack of adequate blood flow to the heart muscle, or myocardial infarction, complete absence of blood flow to a part of the heart resulting in death of heart muscle cells. 

Obviously, this is the most important form of chest pain that needs to be identified and treated quickly.

There are certain symptoms that would indicate that chest pain is heart related rather than a different form of pain, such as if the pain worsens with exercise or exertion, walking up stairs or just walking a long distance. 

Heart pain is typically left side of the chest, squeezing or pressure type pain, a feeling like an elephant sitting on your chest. The pain can radiate up to the neck and jaw or down the left arm. 

Patients may also just have a heartburn sensation or a cramping mild left side pain. 

If you start sweating with the onset of the pain and develop shortness of breath, dizziness or lightheadedness, this would indicate cardiac type chest pain and you need to seek immediate medical assistance and call 911.

Other common causes of non-cardiac chest pain include: acid reflux and reflux esophagitis, esophageal spasm, costochondritis, lung disease, pericardial inflammation and anxiety. Most of these are self-explanatory. Patients often come to see me about "heartburn" and on further questioning it is apparent that this is not likely heartburn. The patients are sent to the cardiologist for immediate evaluation and several times per year I learn later that the patients underwent emergent cardiac catheterization and even cardiac bypass. 

They usually return to see me and report that the "heartburn" is now resolved.

Acid reflux is the primary cause of heartburn. Treatment is necessary to control the acid reflux due to the increased risk for developing esophageal strictures or narrowing or even esophageal cancer. 

Treatment is now possible with numerous medications or even surgery in patients who either require large amounts of medication or who suffer breakthrough symptoms of heart burn despite aggressive acid suppression. 

If surgery is considered, there is a standard preoperative evaluation consisting of an upper GI barium swallow to determine the esophageal anatomy, upper endoscopy to evaluate for Barrett's Esophagus, a precancerous condition of the esophagus, and an esophageal manometry to evaluate the functioning of the esophageal muscles.

If acid injury to the esophagus is severe enough, reflux esophagitis can occur. The acid can actually burn the lining of the esophagus. Unlike the stomach wall that is capable of handling acid exposure, the esophagus cannot tolerate acid or protect itself from acid. 

People with actual reflux esophagitis with ulcerations can develop severe chest pain just behind the breast bone. Acid reflux can cause someone to salivate profusely, known as water brash. The saliva contains sodium bicarbonate that can neutralize the acid. If reflux esophagitis is allowed to continue, difficulty in swallowing can occur due to healing and scarring of the lining of the esophagus, resulting in an esophageal stricture.

An esophageal spasm is basically a cramping of the muscles in the esophagus.  Normally, the muscles of the esophagus contract in an organized progressive wave starting at the top of the esophagus and progressing down toward the stomach.  The progressive wave is called peristalsis and is responsible for moving swallowed food, saliva or even stomach fluid that refluxed up the esophagus down to the stomach. 

Sometimes, the normal progression fails and the esophagus can either not contract or the entire esophagus can contract simultaneously. This simultaneious spasm is potentially extremely painful. The spasm can be spontaneous or associated with drinking ice water or other foods or liquids. The spasms may relax on their own but can also be treated with a nitro pill under the tongue or other anti-spasm medication.

Another common form of non-cardiac chest pain is costochondritis. This is an inflammation of the joint between the bony part of the rib and the cartilage part of the rib. This allows the chest wall to flex; bones don't flex very well without breaking. The joint is similar to a finger joint. It can get injured or just worn and become inflammed causing a local arthritis called costochondritis. 

People often rub the area because it hurts but this can worsen the irritation. It will also hurt more or less with lying down in certain positions or even taking a deep breath. This pain is often severe and can cause people to think they are having a heart attack.

Infection of the lung pleura, the covering of the lungs, by a virus or bacteria can cause significant chest pain. This type of irritation can be very painful. It can also result in fluid accumulating inside the chest around the lungs called a pleural effusion. Depending on the cause, rest and anti-inflammatories or steroids can be effective, or anitbiotics or antiviral agents might be needed. If there is enough fluid present, sometimes a needle is used to sample or drain the fluid, pleuracentesis.

Finally, rarely a viral infection can cause inflammation of the heart muscle and the surrounding pericardium, the membrane-like layer of the heart. When the pericardium is inflamed, it is called pericarditis. If fluid is secreted or leaked and accumulates it is call a pericardial effusion.  If no fluid accumulates it can severely decrease the heart's ability to effectively pump blood around the body. This can rapidly become a very dangerous life-threatening problem. 

Again, anti-inflammatories and steroids can be useful.  Often, if the heart's ability to pump is in jeopardy, a needle is inserted into the fluid collection and drained, a process called pericardiocentesis.

If you are having chest pain that does not quickly resolve and you become anxious about your heart you need to seek medical attention immediately. 

Remember, heart disease does not discriminate between men and women. Women are frequently the victims of heart disease.  Know your risk factors for heart disease (obesity, diabetes, hypertension, high cholesterol and triglycerides and family history) and seek out preventive care to reduce your risk factors before you have a heart attack.