The sensation of pain (or discomfort, discomfort) felt in the chest is a very common condition: it is estimated that it affects 4 out of 10 people in the course of life . It is the second cause for which one goes to the ER.
The chest is the front part of the chest, located between the neck and the abdominal cavity, from which it is separated by the diaphragm muscle. It is an anatomical area that contains:
- Numerous organs: lungs, heart, esophagus, trachea;
- Great vessels: first of all the aorta, the largest artery in the body, which sorts the oxygenated blood from the lungs to all tissues;
- Bones: the ribs, the breastbone;
- Muscles: mainly the respiratory muscles.
So what does it mean to have chest pain ?
Chest pain can be induced by several causes , which must be identified before establishing the therapeutic approach. Of course, the time available to understand the reasons behind the pain is greatly reduced in the case of acute coronary disease , which can represent a serious risk of death and which requires prompt intervention.
The search for the causes of pain is not always a linear operation, because its perception responds only partially to criteria of objectivity and because the same pathology can manifest itself in different patients with different levels of pain.
Pain can be localizedin a specific point of the chest or radiate towards an arm , back or abdomen . Similarly, the pain felt in the chest can be the consequence of an alteration affecting other organs.
When to go to the emergency room?
In general, the greatest fear that seizes in experiencing a pain in the chest is that of a heart attack . But the causes of this symptom can also be very trivial.
It is therefore necessary to understand when chest pain should worry , how to distinguish its different origins and how to recognize the circumstances that require an emergency consultation.
One of the most reliable criteria to distinguish a pain of cardiac origin from one coming from other districts is to breathe deeply and observe if its intensity changes. If the answer is yes, it is most likely not a heart condition.
Although avoiding dramatizations is always advisable, in order to maintain the necessary clarity to make the correct decisions, it is also true that one should not hesitate to go to the emergency room if:
- The pain is accompanied by a feeling of pressure, constriction in the chest, distress and impending death ;
- Chest pain is not intermittent, but worsens with the passage of time or constant for more than 10 minutes and finds no other explanation;
- There are also breathing difficulties, nausea or vomiting , profuse sweating ;
- The affected person has a history of previous cardiovascular diseasesor in any case a documented cardiovascular risk (for example if the patient is a smoker, elderly, diabetic, overweight …).
Myocardial infarction is an acute coronary syndrome in which the occlusion of one or more coronary arteries leaves a more or less extensive area of the heart devoid of blood supply , causing necrosis. Although the events that occur in the heart tissue are the same, the cases of heart attack can manifest themselves with different symptoms. Some patients describe subtle symptoms, while others experience much stronger signs. Cardiovascular disease is the leading cause of death in the world ; myocardial infarction kills 36,000 people a year in Italy alone .
In the United States, half of people with heart attacks die before they get to the hospital.
What Happens During Myocardial Infarction
The heart attack is caused by the obstruction of the coronary arteries (the arterioles that feed the heart): downstream of the block (a thrombus ), the blood supply is reduced, causing ischemia in the corresponding area of the heart muscle, which goes into necrosis . It is precisely the ischemia that triggers the pain. The greater the time interval from the onset of ischemia to the dissolution of the thrombus, the greater the amount of tissue (and therefore functionality) will be lost. Also, a large scar makes the heart less elastic and therefore less able to pump blood efficiently. This is why it is crucial that the patient receives rapid and targeted help.
Symptoms of myocardial infarction
The symptoms of heart attack are on average composed of:
- Pain (or discomfort) in the chest, mostly to the left , located behind the breastbone, which can radiate to the upper limbs, left shoulder, back, neck, jaw and stomach. It is not punctually localized, but widespread : when asked where he feels pain, the patient points to the chest with the open hand, not with the tip of the finger;
- Sense of constriction, heaviness in the chest: it is not a stabbing but a burdening pain;
- Difficulty in breathing(dyspnea);
- Heaviness in the stomach, felt by the patient as indigestion or heartburn;
- Nausea or vomiting;
- Vertigo, feeling lightheaded, dizziness;
- Profuse sweating;
- Anguishand a feeling of impending doom.
Diagnosis of heart attack
It is essential that the diagnosis of myocardial infarction is timely, in order to proceed with the therapy and restore blood circulation in the ischemic areas.
The diagnosis of heart attack is made on the basis of:
- Electrocardiogram (ECG): it is the most important test because it provides the picture of the situation, but it is not always diagnostic;
- Blood tests: cardiac enzymes (LDH…) and other substances contained in the cells of the heart (such as troponin ), released into the blood after necrosis and used as biological markers of heart attack, are evaluated ;
- Angio CT scan: detects thrombi possibly present in coronary arteries;
- Contrast- enhanced coronaryangiography: detects thrombi, but is less sensitive than CT angiography.
Heart attack therapy
Treatment of myocardial infarction includes:
- The immediate administration (at the point where the patient is rescued) of antiplatelet drugs(such as acetylsalicylic acid ) and oxygen ;
- The administration in hospital of thrombolyticdrugs (which dissolve the clot, restoring proper blood circulation in the coronary arteries), anticoagulants (such as heparin, which prevents the formation of new clots) and antianginal drugs (nitroglycerin) and the continuation of the infusion of antiplatelet agents (acetylsalicylic acid, clopidogrel);
- Coronary angioplasty: a coronary stent is applied to the patient, ie a device inserted into an artery of the arm and positioned in the occluded coronary artery, in order to open it and keep it open;
- Coronary artery bypass grafting: In the case of extensive necrosis, the heart surgeon may choose to perform an coronary artery bypass graft. In this case, a vessel of the leg is taken from the patient, with which a bridge is built, inserted at the coronary level to bypass the block.
After the emergency treatment, the patient must be monitored from a cardiological point of view and acquire habits that limit risk factors (abolish cigarette smoking, control blood pressure, adopt a balanced diet low in fat of animal origin ).
The possible complications of myocardial infarction
Immediately after a myocardial infarction, the picture of cardiac activity is very unstable and serious complications can occur for the patient:
- Congestive heart failure: occurs when the heart is no longer able to pump blood and causes the formation of edema (swelling) in the lower limbs and difficulty in breathing (dyspnea);
- Heart rupture: occurs in one in 10 cases of heart attack and leads to death within 5 days of the event;
- Arrhythmias: Life-threatening arrhythmias, such as ventricular fibrillation, can occur.
Many people who habitually suffer from anxiety attacks can recognize chest pain caused by this emotion. A pain that can take on different connotations in different people and that is accompanied by a sense of constriction, of oppression felt in the chest.
The person who is affected feels the breathing become superficial and shorten more and more , so much so as to have almost the sensation of water in the throat. Sometimes the pain can be stabbing and mimic a real heart attack.
People new to this experience can easily confuse the source of the chest pain and wonder if it is caused by anxiety or an impending heart attack. It is not uncommon for them to rush to the hospital, where they are subjected to diagnostic investigations and reassured with a diagnosis that is not negligible but much more reassuring.
Generalized anxiety disorder should not be confused with the normal episodes of apprehension and tension that can dot our daily experiences in a more or less dense way. Pathological anxiety is an emotion that interferes with professional activities and social relationships, limiting them dramatically.
The symptoms induced by generalized anxiety disorder (DAG) can be:
- Important states of muscle contracture: it is not uncommon among people who suffer from it, bruxism, that is the tendency to grind the teeth during sleep. This habit disturbs the physiology of sleep, causing a feeling of tiredness during the day, difficulty in finding concentration and pain in the jaw and jaw bones.
- Feeling of dizziness, mental confusion , tingling in the limbs;
- Tachycardia and chest pain(present in 10% of patients), accompanied by difficulty in breathing and a feeling of suffocation; chest pain from anxiety is initially perceived as a series of local pinpricks which then becomes oppression;
- Effects on the digestive system: difficulty in swallowing, long and laborious digestion, loss of appetite, nausea;
- Irritability, hypersensitivityto stimuli, continuous tension.
Confusing the causes of the symptom and believing that chest pain is caused by an impending heart attack only worsens the state of worry, triggering a vicious cycle that self-feeds.
It is important to remember that:
- Chest pain from anxiety usually appears at rest, while pain associated with heart problems during or after exertion;
- Pain due to anxiety is reduced in intensity when agitation subsides, as opposed to heart attack, which remains constant or worsens over time.
The diagnosis of DAG is made when at least three psychophysical symptoms are present among those specified in the DSM (Diagnostic and Statistical Manual of Mental Disorders) in addition to persistent anxiety and worry and not commensurate with the actual severity of the events or without triggers .
Even the panic attack can simulate, in part, a heart attack, also determining the onset of chest pain and breathing difficulties typical of the cardiovascular accident, as well as the emotional aspects of anxiety and the feeling of imminent death.
Angina pectoris is an acute coronary syndrome that causes a temporary reduction in blood flow to the heart . Induced ischemia causes coronary spasms , which are responsible for the pain typical of this disease, but is not such as to cause necrosis.
Chest pain from angina is localized to the left behind the breastbone and can radiate, like heart attack, to the left arm, neck and back.
The term angina derives from the Greek αµχουη, a term that indicates both anguish and constriction , both present in anginal manifestations.
Diagnosis of angina pectoris
Generally, the angina attack is triggered by physical or emotional fatigue and improves if the patient rests and calms down. This is an important distinguishing parameter with respect to myocardial infarction which can manifest itself with a similar symptomatology.
The diagnosis of angina pectoris is made after performing:
- Electrocardiogram (ECG): records the electrical activity of the heart and provides an overall picture. It is also possible to monitor 24 hours of cardiac activity, with the Holter ;
- Exercise tolerance test: this is the recording of the electrocardiogram while the patient is under stress (generally while pedaling on the exercise bike) until the maximum effort is reached;
- Myocardial scintigraphy: evaluates exercise ischemia in patients with doubtful ECG. It is a diagnostic procedure that requires the infusion of a radioactive tracer;
- Echocardiogram: it is an imaging procedure that visualizes the anatomical structures that make up the heart and their functioning;
- Coronarography: is the angiographic exploration of the coronary arteries, after injection of a contrast medium;
- Cardiac CT scan: evaluates the presence of calcifications due to atherosclerosis;
- Cardiac MRI: provides detailed images of the heart’s structure and any morphological changes.
The therapy of angina pectoris
Angina therapy involves a symptomatic approach (nitrates and calcium channel blockers) to manage seizures and chronic treatment that reduces the risk of heart attack.
- Nitrates: Trinitrine (nitroglycerin) is an arterial vasodilator, which is administered for the purpose of controlling symptoms of pain and constriction;
- Calcium antagonists: vasodilators;
- Antiplatelet drugs: the cardiologist prescribes substances such as acetylsalicylic acid and clopidogrel to limit the risk of thrombus formation;
- Beta blockers.
As in the case of myocardial infarction, angina therapy involves the adoption of behavioral measures that reduce risk factors.
An aneurysm is a permanent dilation of the arterial wall, congenital or acquired , a strain where the wall thins and exposes the artery to the risk of rupture .
Among the most alarming causes of chest pain, aortic aneurysm is one of the most dangerous. This pathology affects 3-6% of the population between 65 and 74 years. The greatest risk is represented by tearing of the aortic wall, which causes severe, sudden pain in the chest and back and profuse bleeding into the thoracic and / or abdominal cavity. The leakage of blood causes hypovolemic shock (ie consequent to the reduction of the circulating blood volume), which can lead to death in a very short time.80% of patients die before arriving in hospital and 50% of survivors do not pass the emergency surgery .
Causes of aortic aneurysm
While the congenital aneurysm is a malformation present from birth, the acquired one is due to pathological conditions such as:
- Atherosclerosis: the formation of plaques on the inner wall of the arteries (due to the deposition of cholesterol) narrows their caliber and their calcification stiffens the vessel, reducing its elasticity and increasing the likelihood of exhaustion due to blood pressure ;
- Hypertension: blood under pressure stresses the arterial wall, which can yield at points of greater fragility (for example at the level of plaques).
Symptoms of aortic aneurysm
The presence of the aneurysm compresses the structures adjacent to the vessel and triggers chest pain and symptoms such as dysphagia (difficulty in swallowing), dyspnea (difficulty in breathing) and changes in the tone of the voice .
Diagnosis of aortic aneurysm
In case of chest pain in patients at cardiovascular risk, the cardiologist or vascular surgeon may prescribe the execution of an ultrasound to evaluate the possible presence of an aneurysm.
If the diagnosis is positive and the conditions for carrying out the operation are not met (the only type of therapy possible), the patient is monitored with periodic ultrasound scans in order to keep the size of the alteration under control.
Aortic aneurysm surgery
More sophisticated tests such as CT and MRI are used to study the aneurysm in anticipation of surgery, during which the aortic wall is reconstructed. The planned surgical intervention has a mortality of 3%, a value not comparable with that relating to the management of the emergency. Despite this, not all patients suffering from aneurysm undergo surgery: for each the cardiac surgeon or vascular surgeon assess the risk-benefit ratio.
Check out the best healthcare facilities for aortic aneurysm (not ruptured):
Best hospitals for Aortic Aneurysm (not ruptured)
Hypertrophic cardiomyopathy is the thickening of the heart muscle, which makes it less elastic and therefore less efficient in pumping blood into the circulation.
It is a disease that does not always manifest itself with specific symptoms and which often allows a normal life.
When present, the symptoms are represented by:
- Chest pain;
- Heart failure;
- Myocardial ischemia.
The cause of hypertrophic cardiomyopathy is a genetic mutation : therefore the disease is chronic and requires continuous monitoring and drug therapy. The diagnosis of hypertrophic cardiomyopathy is made by performing an electrocardiogram and other investigations on cardiac activity, such as echocardiography and holter . It is also useful to perform genetic tests to assess the presence of the genetic mutation.
Hypertrophic cardiomyopathy is treated with drugs that protect the heart from overexertion ( beta blockers and calcium channel blockers ) and with surgeryin cases where it is necessary to reduce the thickening of the myocardium.
The strain on the heart in trying to make up for the reduced pumping efficiency can cause congestive heart failure , which must be treated pharmacologically.
Pericarditis is inflammation of the membrane that surrounds the heart (pericardium). The physiological function of the pericardium is to ensure that the heart organ can expand and compress during its pumping activity, without creating friction with the surrounding anatomical structures. The pericardial sac is humidified by the presence of a lubricating liquid. When the pericardium becomes inflamed, the membrane increases the secretion of fluid, which accumulates and compresses the heart and adjacent organs. This phenomenon triggers pain in the center of the chest .
The causes of pericarditis
In most cases these are viral infections, while bacterial ones are less frequent. Pericarditis can also occur as a side effect of cancer chemotherapy or as a consequence of other diseases, in particular some autoimmune diseases (lupus) . Pericarditis is more common in males between the ages of 20 and 50.
Symptoms of pericarditis
The chest pain is always present symptom, different than from myocardial infarction because it tends to change in intensity in the different phases of respiration (may be intermittent ) and to change when the patient is lying in position supine .
The symptoms of pericarditis are those typical of heart failure, because the pathological circumstances are the same: the compressed heart is unable to pump blood and the slowing down of its activity causes the formation of edema in the lower limbs and difficulty in breathing.
The diagnosis of pericarditis
The diagnosis is made on the basis of auscultation: the cardiologist hears the typical noise produced by the rubbing of the pericardial sheets. Confirmation comes from electrocardiogram and echocardiogram .
The therapy of pericarditis
Treatment involves taking antipyretics and anti-inflammatories to control the infection (including antibiotics if the etiology is bacterial). It is also important that the patient stays at rest, so as not to further strain an already tried heart.
In the most severe forms, it may be necessary to administer cortisone .
In cases where the accumulation of fluid in the pericardial sac is significant, a puncture is made to drain it.
Reflux esophagitis occurs due to the rise of the acids produced by the stomach , that is gastroesophageal reflux , a disease associated with a lack of sealing of the valve located between the stomach and esophagus (cardia). Unlike the stomach, which is internally lined with a protective mucosa, the esophagus is vulnerable to attack by acidic juices. When it comes in contact with stomach contents, it becomes inflamed and can trigger retrosternal pain, which radiates to the upper limbs and back , and burning in the chest . Sometimes, reflux pains are so similar to heart attacks that you fear the worst. The War of the Roses scene is popular
, an American comedy of the ’80s in which Michael Douglas rushes to the ER with all those he considers the paradigmatic symptoms of heart attack. Except then discover that he simply overdid the dishes cooked by the hated wife Kathleen Turner.
Esophagitis pain occurs mostly after meals, particularly if you lie down and wear tight belts. Sometimes, the pain is not easily attributable to a digestive disorder, because the rising of the acids may not be felt in itself by the patient.
Gastroesophageal reflux is diagnosed through gastroscopy (esophagogastroduodenoscopy).
In mild forms , therapy begins with the intake of drugs based onalginic and hyaluronic acid , protective of the esophageal mucosa to be taken as needed.
In the most important cases , the gastroenterologist immediately prescribes proton pump inhibitors.
For patients with gastroesophageal reflux, lifestyle matters as much as medication in controlling the symptoms of the disease.
- Do not lie down immediately after eating;
- Giving up smokingcigarette;
- Modify the diet, from which it is necessary to eliminate the processed dishes;
- Give up alcoholand reduce the consumption of coffee, tea and chocolate.
Pulmonary embolism is a very serious acute pathological circumstance caused by the obstruction of one or more pulmonary arteries by part of thrombi originating in other areas, in particular in the venous trunks of the legs and pelvis.
It can be a consequence of circulatory disorders of the lower limbs (phlebitis, thrombophlebitis ) or of long periods of immobilization.
The risk of death from pulmonary embolism is very high: in the United States alone it causes death for 85,000 people out of 350,000 new cases each year.
The patient suffering from pulmonary embolism manifests:
- Difficulty breathing (dyspnoea);
- Chest pain;
- Vertigo,feeling faint, dizziness
Diagnosis is made on the basis of observation of clinical signs and execution of CT angiography .
Pulmonary embolism therapy involves the administration of anticoagulants and thrombolytics .
Pneumothorax is the sudden collapse of the lung due to the escape of air into the pleural space. The resulting pain :
- It is localized in the chest;
- It is very sharp and intense;
- Worsens during inhalation and with coughing.
Pneumothorax compresses the lungs and hinders the return of venous blood to the heart. It can be caused by trauma or by diseases such as chronic obstructive pulmonary disease or some cancers. It must be diagnosed in the patient’s bed , because the emergency situation it entails does not allow waiting for the outcome of the X-ray examination. Pneumothorax therapy consists of inserting an intrathoracic needle for air drainage.
Inflammation of the respiratory tract
L ‘ inflammation of the trachea, bronchus and lung because usually (although not always the case) the onset of chest pain.
In case of tracheitis, the patient experiences chest pain, in the retrosternal region, associated with a sensation of local irritation and burning. This is the symptom caused by inflammation of the trachea.
The cause of chest pain in bronchitis is mainly represented by cough , which is constantly present especially in acute bronchitis. Generally, it is a pain that arises progressively and that reaches its maximum intensity during the episode of continuous cough.
Sometimes, in the course of chronic bronchitis, a stabbing and stabbing pain in the chest may appear, more frequent after a few days of persistent cough. Often this phenomenon is interpreted by the patient as an aggravation of the infectious process and as its evolution towards pleurisy or pneumonia . But in most cases the pain originates from a traumatic injury to the intercostal muscles. A real tear of the intercostal muscles stressed for a long time and violently by the whooping cough.
In any case, the doctor must evaluate whether it is necessary, in the presence of acute bronchitis and persistent chest pain, to prescribe diagnostic investigations to detect any signs of pneumonia. Among these, the main one is thechest x-ray .
The incidence of pneumonia is in fact not negligible: in Italy every year it causes death for about 10,000 people .
If the patient is diagnosed with pneumonia, therapy should include the administration of antibiotics (bacterial forms are responsible for 20-60% of cases) and monitoring of the patient’s condition and treatment of fever and cough.
Pleurisy is inflammation of the membrane that surrounds the lungs (pleura) and which allows them to dilate and compress during breathing without creating friction with the surrounding anatomical structures.
Normally the two sheets that make up the pleura are only moistened inside by a liquid (pleural fluid), but in case of inflammation the secretion increases. The pleural fluid then collects in the pleural cavity, compressing the lungs and causing difficulty in breathing (dyspnea) and chest pain (intense, sharp and worsening upon inhaling and coughing).
In cases where this exudate does not reabsorb, a thoracentesis (insertion of an intrathoracic needle to drain the fluid) is required.
The cause of pleurisy can be a lung infection that extends to the pleural membranes, a tumor, or pulmonary fibrosis.
L ‘ Pulmonary Emphysema is a chronic progressive disease that leads to architecture degeneration of lung tissue and loss of lung function.
One of the most characteristic symptoms of pulmonary emphysema is dyspnea (difficulty in breathing), which is accompanied by evident changes in the conformation of the chest . The rib cage takes on the typical barrel shape, giving the patient a defined posture with raised shoulders or a hanger forgotten in the jacket.
The breathing becomes noisy and hissing , for the increase in bronchial resistance to the air flow.
The risk factors are represented by cigarette smoking, genetic deficits, the contextual presence of lung cancer.
Pulmonary emphysema is diagnosed through spirometry , arterial blood gases, and CT (which visualizes the change in the structure of the lung tissue).
The therapy is medical and rehabilitative and aims to train the patient to breathe better. When it doesn’t work, the only solution is surgery, during which the most compromised areas are removed. Alternatively, there is now the possibility of resorting to endoscopic treatment, in certain circumstances. The lung transplant it is performed when the patient has very limited respiratory capacity.
The lung cancer often remains asymptomatic in the early stages. Often, in fact, the disease is diagnosed by chance, during checks carried out for other reasons.
The most common symptoms, when they occur, are:
- The coughcontinues, which does not go away and which can stain the handkerchief with blood;
- The hoarseness;
- The chest pain: chest pain caused by lung cancer can escalate with breathing and with the patient’s movements. The cause may be the tumor itself or any inflammation of the pleura (pleurisy) due to infections (the frequency of which is increased in the disease) or localized metastases in the bones of the rib cage or spine. Chest pain associated with lung cancer increases with coughing or deep breaths;
- The fatigue;
- The frequent respiratory infections.
The presence of recurrent symptoms and risk factors (e.g. cigarette smoking) should prompt the patient to seek medical advice.
See the best facilities for Malignant Lung Cancer:
The best hospitals for Malignant Lung Cancer
The fracture or crack of a rib ( rib ) causes the onset of sharp, intense, stabbing pain in the chest . The symptom worsens with inhalation, can become unbearable with coughing, and make limb movements difficult.
Inflammation of the cartilage located between the sternum and the ribs (costochondritis) can also trigger chest pain : in this case the pain is radiated to the whole chest and back.
L ‘ Herpes zoster (commonly known as shingles) is a viral infection that affects the nerves. It can appear in the chest, causing pain and the appearance of a rash that follows the path of the affected nerve.
Calculosis of the gallbladder
The presence of gallbladder stones can trigger painful crises in the abdomen, chest and back. The pain is generally after the meal and associated with nausea and vomiting . The gallstones covers 15% of the population, especially women.
How does the musculoskeletal system work?
Questions and answers
WHEN SHOULD I WORRY ABOUT CHEST PAIN?
Chest pain must prompt immediate referral to the emergency room when it lasts for more than 10 minutes without the cause being identified; it is accompanied by a sense of constriction, heaviness, anguish and imminent death; appears in a person at risk for cardiovascular disease; it is associated with profuse sweating, nausea or vomiting.
HOW IS CHEST PAIN TREATED?
Chest pain can have several causes: in order to identify a cure, the diagnosis must be established.
WHAT ARE THE NON-CARDIAC CAUSES OF CHEST PAIN?
The main causes of chest pain of non-cardiac origin are reflux esophagitis, gallbladder stones, pneumothorax, pneumonia, pleurisy, fracture or crack in the ribs.
CAN INDIGESTION CAUSE CHEST AND BACK PAIN?
Poor digestion and the reflux of stomach contents into the esophagus can trigger chest pain that radiates to the back, arms and jaw.
COULD IT BE A HEART ATTACK EVEN IF THE CHEST PAIN RADIATES TO THE RIGHT ARM?
Myocardial infarction manifests itself with different symptoms in patients. Any chest pain that falls within risk cases should be evaluated by the doctor.