Chest pain: When should I be worried?

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Pain caused by pericarditis (shown here) is usually described as sharp and stabbing.
Pain caused by pericarditis (shown here) is usually described as sharp and stabbing.

After a very busy morning shift, I was finally able to settle down for a few serene moments of lunch. Just as I was biting into my sandwich, the charge nurse informed me that a patient was having chest pain and needed to be evaluated. I wondered, "Can this wait? Do I have time to finish my lunch or should I drop everything to see what's going on? Why would he be having chest pain? When I saw him earlier in the day he didn't mention anything about chest pain." As a matter of fact, in reviewing my patient list for the day, this particular man was one of my easier cases.

This is part of the challenge of taking care of a patient who complains of chest pain. When should the health-care provider get concerned? How can you tell if it warrants immediate action? How can you tell the difference between cardiac and noncardiac chest pain?

First and foremost, there are numerous causes of chest pain, many of which are entirely unrelated to the heart. As a matter of fact, practically anything can lead to chest pain, including cardiac, pulmonary, vascular, GI, and musculoskeletal problems. There are also miscellaneous causes. We will start with perhaps the most frightening cause of chest pain—problems with the heart itself.

Cardiac causes of chest pain

Angina/MI. The chest pain attributable to angina or MI is very similar. This pain can be associated with pressure, fullness, or tightness in the chest. It can also radiate to the back, neck, jaw, shoulders, and arms (especially the left arm). The pain can be accompanied by shortness of breath, diaphoresis, dizziness, or nausea. Chest pain caused by angina is typically brought on by exercise, emotional stress, meals, cold air, or smoking.

Chest pain associated with an MI is usually more severe and lasts longer. This is due to the pathophysiologic differences between angina and MI. Angina is only a temporary reduction of blood flow to the heart, whereas an MI causes permanent damage. Furthermore, an MI may occur at any time and may not be related to any particular activity.

Pericarditis. Pericarditis is an inflammation of the tissue layers surrounding the heart. The chest pain of pericarditis is usually sharp and stabbing. It can radiate to the back, neck, or arm. The pain may worsen when taking a deep breath or lying flat and lessen when leaning forward.

Mitral valve prolapse. Fatigue is the most common complaint associated with mitra valve prolapse. However, sharp chest pains are reported in some patients with this condition. Chest pain related to mitral valve prolapse is different from that of angina in that it rarely occurs during or after exercise. In addition, nitroglycerin may have little effect in relieving this pain.

Aortic stenosis. Described as substernal pressure brought on by exertion and relieved by rest, chest pain caused by aortic stenosis is similar to the type experienced by patients with coronary artery disease. Pain in aortic stenosis is caused by the heart muscle having to pump blood through a narrowed aortic valve.

Aortic dissection. This condition results in a sudden or tearing type of pain in the anterior or posterior chest. The pain may radiate into the arms, abdomen, and legs.

Premature ventricular contractions. Patients may experience a sharp, stabbing pain over the heart with premature beats. A brief choking sensation may also be described. Another contributing factor to chest pain with premature beats is the fact that the heartbeat immediately after a premature ventricular contraction is usually stronger as the ventricle contracts more forcefully than normal.

Pulmonary causes of chest pain

Pneumonia. In simple terms, pneumonia is an infection of lung tissue. Inflammation of the lining of the lungs may produce pain in the chest.

Pulmonary thromboembolism (PTE). A common, serious complication of thrombus formation within the deep venous circulation, PTE can cause chest pain on inspiration.

Pneumothorax. Also known as a collapsed lung, pneumothorax refers to the accumulation of air within the pleural space. Chest pain on the affected side can range from very minor to quite severe.

Pleurisy. Inflammation of the lining of the lungs and chest can result in pain when the individual takes a deep breath or coughs. The pain is usually very sharp.

Pulmonary hypertension. Patients with this condition have increased vascular resistance in the pulmonary artery, pulmonary vein, or pulmonary capillaries. Pain is described as a dull retrosternal discomfort similar to angina.

Pneumomediastinum. This condition occurs when air leaks from any part of the lung or airway into the middle of the chest (mediastinum). Pneumomediastinum can be caused by a traumatic injury or disease. As a result, a patient may experience pain below the breastbone that may radiate into the arms or neck. The pain may worsen when the patient takes a deep breath or swallows.

Lung cancer. Patients with lung cancer may have nonspecific chest pain. Because of metastases, the primary discomfort may be in the ribs, vertebrae, or pelvis.

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