Chest Pain

Overall, the most common causes of chest pain are

• Disorders of the ribs, rib cartilage, chest muscles (musculoskeletal chest wall pain), or nerves in the chest

• Inflammation of the membrane that covers the lungs (pleuritis)

• Inflammation of the membrane that covers the heart (pericarditis)

• Digestive disorders (such as esophageal reflux or spasm, ulcer disease, or gallstones)

• Heart attack or angina (acute coronary syndromes and stable angina)

• Undiagnosed causes that go away on their own

Acute coronary syndromes (heart attack or unstable angina) involve a sudden blockage of an artery in the heart (coronary artery) that cuts off the blood supply to an area of the heart muscle. If some of the heart muscle dies because it does not get enough blood, that effect is termed a heart attack (myocardial infarction). In stable angina, long-term narrowing of a coronary artery (for example by atherosclerosis) limits blood flow through that artery. This limited blood flow causes chest pain when people exert themselves.

Some causes of chest pain are immediately life threatening but, except for heart attack or unstable angina, are less common:

• Heart attack or unstable angina

• A tear in the wall of the aorta (thoracic aortic dissection)

• A type of collapsed lung in which pressure builds up enough to obstruct blood flow returning to the heart (tension pneumothorax)

• A rupture of the esophagus

• Blockage of an artery to the lungs by a blood clot (pulmonary embolism)

Other causes range from serious, potential threats to disorders that are simply uncomfortable.

In people with chest pain or discomfort, certain symptoms and characteristics are cause for concern. They include

• Crushing or squeezing pain

• Shortness of breath

• Sweating

• Nausea or vomiting

• Pain in the back, neck, jaw, upper abdomen, or one of the shoulders or arms

• Light-headedness or fainting

• Sensation of rapid or irregular heartbeat

Although not all causes of chest pain are serious, because some causes are life threatening, the following people should seek care in an emergency department right away:

• Those with new chest pain (within several days)

• Those who have a warning sign

• Those who suspect that a heart attack is occurring (for example, because symptoms resemble a previous heart attack)

These people should call emergency services (911) or be taken to an emergency department as quickly as possible. People should not try to drive themselves to the hospital.

Chest pain that lasts for seconds (less than 30 seconds) is rarely caused by a heart disorder. People with very brief chest pain need to see a doctor, but emergency services are usually not needed.

People who have had chest pain for a longer time (a week or more) should see a doctor as soon as possible, but they do not need to go to the hospital unless they develop warning signs or the pain has steadily been getting worse or coming more often, in which case they should go to the hospital right away.

Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What they find during the history and physical examination often suggests a cause of the chest pain and the tests that may need to be done.

However, symptoms due to dangerous and not dangerous chest disorders overlap and vary greatly. For example, although a typical heart attack causes dull, crushing chest pain, some people with a heart attack have only mild chest discomfort or complain only of indigestion or arm or shoulder pain (referred pain—see figure What Is Referred Pain). On the other hand, people with indigestion may simply have an upset stomach, and those with shoulder pain may have only sore muscles. Similarly, although the chest is tender when touched in people with musculoskeletal chest wall pain, the chest can also be tender in people who are having a heart attack. Thus, doctors usually do tests on people with chest pain.

For adults with sudden chest pain, tests are done to rule out dangerous causes. For most people, initial tests include

• Measurement of oxygen levels with a sensor placed on a finger (pulse oximetry)

• Electrocardiography (ECG)

• Chest x-ray

If symptoms suggest an acute coronary syndrome (heart attack or unstable angina) or if no other cause is clear (particularly in people who are at high risk), doctors usually measure levels of substances that indicate heart damage (cardiac markers) in the blood (at least two separate times over a few hours) and do repeated ECGs.

If these tests do not show an acute coronary syndrome, doctors often then do a stress test or CT angiography before people go home or within a few days. However, if a newer cardiac marker, called high sensitivity troponin, is used and that test does not show evidence of heart damage, further testing may not be required. For a stress test, ECG or an imaging test (such as echocardiography

If pulmonary embolism is suspected, CT angiography (CT with intravenous contrast) of the lungs or a lung scan is done. If pulmonary embolism is considered only somewhat possible, a blood test to detect clots (D-dimer test) is often done. If this test is negative, pulmonary embolism is unlikely, but if the test is positive, other tests, such as ultrasonography of the legs or CT angiography, are often done.

In people who have had chest pain for a long time, immediate threats to life are unlikely. Most doctors initially do only a chest x-ray and then do other tests based on the person's symptoms and examination findings.