Chest Pain & Tightness of Chest are one of the most common symptoms of the people visiting Emergency room. The first thing that comes to our mind while experiencing chest pain is a Heart attack. A heart attack is one of the many reasons for chest pain. Chest pain may be the only symptom of most cardiac and vascular diseases or may be accompanied by breathlessness, palpitations, dizziness, and syncope. A quarter of the total population suffers from chest pain that is caused by pathological conditions of lungs, esophagus, muscle, ribs or nerves. Chest pain may be life-threatening in some individuals while some chest pain is not that serious. The outcome of chest pain depends upon the underlying disorders that cause chest pain.Chest pain may be dull, aching, sharp, stabbing, tight, squeezing or crushing sensation.Many of the heart diseases and the peripheral vascular diseases remain asymptomatic initially and lasts for many years. Chest pain is the first symptom of cardiovascular disease in the majority of cases.
Causes of Chest Pain & Tightness of Chest
Chest pain is symptoms of the underlying disease. Causes of chest pain may be due to underlying heart disease, Pathologies of lungs, esophageal, disorder of muscle nerve of the chest or due to the inflammation of the ribs. The causes of chest pain are listed as below:-
Central chest pain is caused by the following:
- Cardiac causes:-
- Myocardial infarction
- Angina pectoris
- Aortic causes:-
- Aortic dissection
- An aortic aneurysm
- Esophageal causes:-
- Mallory Weiss syndrome
- Esophageal Spasm
- Massive pulmonary embolus
Peripheral chest pain is due to the following conditions:-
- Pulmonary infarct
- Musculoskeletal causes are:-
- Costochondritis(Tietze`s syndrome)
- Rib fracture
- Intercostal muscle injury
- Neurological causes include prolapsed intervertebral disc, herpes zoster, and thoracic outlet syndrome.
It is very important to distinguish the cardiac chest pain and non-cardiac chest pain.Cardiac chest pain is central, diffuse radiating to jaw, neck, and shoulders while non-cardiac chest pain is peripheral and localized to a part of the chest.Cardiac chest pain is tight, Squeezing and choking in character while non-cardiac chest pain is sharp and stabbing in character.
Cardiac chest pain is precipitated by exertion and emotion and is relieved by nitrates.Non-cardiac chest pain is spontaneous not related to exertion and precipitated by respiration or palpation and is not relieved by rest and have slow or no response to the nitrates.
Some of the causes of chest pain or tightness of the chest is:-
- Myocardial Infarction
Myocardial infarction is caused due to the blockage of the blood vessels by the atheromatous plaques on the walls of the arteries.Chest pain is sudden in onset and is located in the retrosternal region, which radiates to the jaw, throat, and shoulders often occurring spontaneously and is not relieved by rest and nitrates.It is a chest pain accompanied by vomiting, sweating, and Anxiety.
- Angina pectoris
It is the most common cause of the cardiac pain. Angina pectoris is usually caused by Myocardial ischemia but also occurs in conditions such as aortic stenosis. The chest pain is located in the retrosternal region and is usually precipitated by exertion.It shows a dramatic response to nitrates.Chest pain is rapidly relieved by nitrates and rest. Chest pain usually lasts for two to ten minutes.
- Aortic Dissection
Tears in the intima of the wall of aorta allow blood under high pressure to penetrate into the medial layer of the aorta thus cleaving the aortic wall.This is known as aortic dissection.Chest pain is sudden is sudden,Severe and tearing type which is often felt first between the shoulder blades and/or behind the sternum.It has no relieving factor and it tends to persist. The patient often becomes restless with the pain.
- Pericardial Pain
Inflammation of the pericardial sac around the heart secondary to the myocardial infarction, Viral infection, Angioplasty, radiotherapy etc initiates the precordial pain.It is characterized by sharp anterior retrosternal chest pain which may radiate to the left shoulder or back which is made worse changes in posture and respiration and is relieved by nonsteroidal anti-inflammatory drugs.
Pneumothorax is the presence of air in the pleural space. Tension pneumothorax is a clinical type of pneumothorax occurring mostly in a patient suffering from the chronic obstructive pulmonary disease(COPD), Tuberculosis and lung abscess.It is a medical emergency. It is associated with sudden onset of unilateral (chest pain on one side of the chest, Rapid progressive breathlessness. Chest pain is not relieved by the analgesics or nitrates and is only relieved after the aspiration of the air entrapped in the pleura.
Inflammation of the lining of the lungs and the chest is called pleurisy or pleuritis.Chest pain is felt while coughing, sneezing and breathing.Causes of pleurisy are bacterial and viral infections.Pulmonary embolism, Cancer and autoimmune diseases like rheumatoid arthritis and systemic lupus erythematosus
Bacterial infections of the lung cause either pleuritic chest or deep chest pain which comes on suddenly and is accompanied by fever, Chills, and cough.
- Gastroesophageal reflux disease
Gastric acids flow back into the esophagus.Pain because of acid reflux is similar to cardiac pain as heart and esophagus are anatomically in close proximity and they share a common nerve network.
- Muscle strain
The intercostal muscles are injured while coughing hard. These injured muscles can cause chest pain.The pain persists for a long time and worsens on physical activities.
Inflammation of the cartilage, which joins the sternum with ribs is called costochondritis. It causes chest pain. It can be relieved by the use of non-steroidal anti-inflammatory drugs.
Diagnosis of Chest Pain & Tightness of Chest
History, clinical examination and lab investigations are required to diagnose the underlying cause of chest pain.
It involves the recording of the electrical activity of the heart with the help of the 12 leads attached to the skin of your chest. It is the first and most important test for patients above 40 years of age and presenting with chest pain.
- Blood tests
Cardiac enzymes such as Troponins and creatinine phosphokinase are leaked from injured heart muscles in the blood.These are important markers of a heart attack.
- Chest X-Ray
Chest x-ray helps in diagnosing the pulmonary causes of chest pain.It also gives visual information about the size of the heart and major blood vessels and shape.
- CT Scan of Chest
Computerized tomography of the chest can be used in suspected cases of pulmonary embolism to look for the blood clots or in aortic dissection to visualize the aorta.
- Coronary angiogram
It is used to visualize the individual arteries of the heart of the wrist and groin to see the narrowed or blocked arteries.The dye-filled blood vessels are visible on x-rays and videography.
- Endoscopy of upper GIT
If your doctor suspects peptic ulcer disease or gastroesophageal reflux disease as a cause of the chest pain, a thin, flexible tube containing camera can be inserted through the mouth to visualize the esophagus, Stomach and upper part of the duodenum.
Treatment of Chest Pain & Tightness of Chest
Treatment of the chest pain depends on the underlying cause of the chest pain and is variable.
- Dilators of an artery:
Nitroglycerine puff or tablets are usually given sublingually (beneath the tongue).It helps in the relaxation arteries of the heart. So, more blood can flow through the previously narrowed blood vessels.
Aspirin is given if the chest pain is due to the ischaemia is the heart. Aspirin 300mg chewed is given in the acute myocardial infarction.
These are clot buster drugs.They help to break the clots in the arteries of the heart as in heart attack, for example, I/v Streptokinase, I/v Tissue Plasminogen activators
- Antiplatelet drugs:
Antiplatelet drugs such as clopidogrel help in the thinning of the blood by inhibiting the aggregation of the platelets and inhibits thrombus formation. Clopidogrel and aspirin both are antiplatelet drugs.
- Lipid-lowering agents such as atorvastatin, rosuvastatin helps to lower the cholesterol level in the blood preventing atherosclerosis.
Antiulcerants like pantoprazole, Ranitidine etc helps in the acid suppression and reduces the incidence of the gastroesophageal reflux disease and peptic ulcer disease which are gastrointestinal causes of chest pain.
Antidepressants like Amitryptiline along with Benzodiazepines helps in reducing chest pain due to the panic attacks, Psychological and behavioral therapy is also recommended.
Prevention of Chest Pain & Tightness of Chest
- Daily physical exercise
Light physical exercise such as running, sit-ups, pushups for at least 30 mins for 5 days in a week is good for cardiac health.It also helps in losing the weight.
- Weight loss
Obesity is a high-risk factor for many causes of chest pain such as gastrooesophageal reflux disease, Myocardial infarction, Weight loss by either diet control or physical exercise helps in the prevention of chest pain.
- Dietary habits
Fast foods contain very high amounts of bad cholesterol(LDL).so, Avoiding fast food and consumption of foods like fatty fish, salmon, trout containing a huge amount of good lipoprotein(HDL) is good for cardiac health.
- Avoid smoking:
Smoking is associated with diseases like Myocardial infarction, Lung cancer, Pulmonary embolism angina pectoris.These causes of chest pain can be avoided by restricting on smoking.
- Reduce alcohol consumption:
Excessive consumption of alcohol causes hyperlipidemia, which is bad for cardiovascular health.Ingestion of excessive amount of alcohol should be avoided.
- Diseases such Hypertension and diabetes should be controlled either by lifestyle changes or dietary modifications by consumptions of the prescribed medicines.