Patient education: Chest pain (Beyond the Basics)

CHEST PAIN OVERVIEW — Different things can cause chest pain or discomfort, many of which are not serious. Having chest pain does not necessarily mean you are having a heart attack. But because chest pain can be a sign of a heart attack, it is important to seek help and get treatment as quickly as possible.

When to seek help — If you have chest pain that is new, severe, prolonged, or worrisome, call for an ambulance immediately (in the United States and Canada, dial 9-1-1). The emergency medical services (EMS) personnel in your community are prepared to respond rapidly and will take you to the nearest hospital. If it turns out that you are having a heart attack, every minute is important, and the faster you get to a hospital, the sooner you can receive treatment.

Do not drive yourself to the hospital and do not ask someone else to drive you. Calling for an ambulance is safer than driving for two reasons:

●From the moment emergency personnel arrive, they can begin evaluating and treating chest pain. If you drive to the hospital, treatment cannot begin until you arrive in the emergency department.

●If a dangerous complication of a heart attack (for example, a serious irregular heart rhythm) occurs on the way to the hospital, EMS personnel are trained to treat the problem immediately.

The important causes, typical signs and symptoms, diagnostic tests, and initial treatment of chest pain will be reviewed here.

CHEST PAIN CAUSES — Chest pain generally originates from one of the organs in the chest (heart, lung, or esophagus) or from the components of the chest wall (skin, muscle, or bone). Occasionally, organs near the chest, such as the gallbladder or stomach, can cause chest pain. Pain in the chest may also be the result of "referred pain" from the neck or shoulder joint.

Depending upon the cause, chest pain can have varying qualities (sharp, dull, or burning, pressure, tightness or squeezing) and can be located in one or several areas (middle of the chest, upper or left chest, back, arms, jaw, neck, or the entire chest area). Pain may worsen with activity and improve with rest, and there may be other symptoms (sweating, nausea, rapid heart rate, shortness of breath).

The following sections discuss some of the possible causes of chest pain.

Heart-related causes

Angina — All organs and tissues in the body require oxygen and nutrients carried in the blood. The heart pumps oxygen and nutrient-rich blood through a huge network of arteries throughout the body, which includes vessels that supply blood to the heart muscle. These vessels, called coronary arteries, lie on the surface of the heart and branch into smaller vessels located within the muscle (figure 1).

In people with coronary heart disease (CHD), the coronary arteries become clogged with fatty deposits (figure 2). The deposits, called plaques, cause the coronary arteries to narrow and may prevent a normal amount of oxygen-rich blood from reaching the heart muscle. When this happens, it is called "cardiac ischemia." "Angina" is the term for chest pain caused by ischemia.

Angina is particularly common during physical activity, when the heart rate and pressure are increased due to the heart's demand for more oxygen. Angina develops if the demand for oxygen exceeds the amount of oxygen delivered to the heart muscle by the coronary arteries.

More information about angina is available separately. (See "Patient education: Angina treatment — medical versus interventional therapy (Beyond the Basics)" and "Patient education: Medications for angina (Beyond the Basics)".)

Heart attack — A heart attack, or myocardial infarction (MI), occurs when the surface covering of a fatty plaque ruptures. A blood clot (also called a thrombus) can form on the plaque, which can partially or completely block the artery. This blockage slows or blocks blood flow to the area of heart muscle fed by that artery. If this continues for more than 15 minutes, the muscle can become damaged or "infarcted" (which means that the tissue in that area dies) (figure 1). A person having a heart attack may feel chest discomfort that is similar to an episode of angina, but more prolonged and intense.

Other cardiovascular problems — In some cases, chest pain is caused by a heart-related problem that is not related to blood flow in the coronary arteries.

●Variant angina – Some people without coronary artery disease may develop the classic pain of angina. This is called "variant angina" and may be caused by a temporary spasm of the coronary arteries. In people with variant angina, the arteries are usually normal and have no plaque-related narrowing or obstruction, although there may be partial blockage caused by the spasm.

●Pericarditis – This is the medical term for inflammation of the membranes around the heart. It can cause chest pain that gets worse when you take a deep breath, cough, or sneeze. Pain may be relieved when sitting forward. The person may have abnormal heart sounds and changes in the electrocardiogram (ECG). (See "Patient education: Pericarditis (Beyond the Basics)".)

●Myocarditis – This is inflammation of the heart muscle itself. It can cause chest pain that may mimic angina. Myocarditis is often caused by a viral infection.

●Problems related to the heart muscle or valves – Certain heart conditions, such as hypertrophic cardiomyopathy, mitral valve prolapse, and aortic stenosis, can cause chest pain.

●Aortic dissection – This is an uncommon but serious cause of chest pain. The aorta is the main artery in the body; it comes out of the heart and carries blood to the rest of the body. In an aortic dissection, the inner wall of the aorta ruptures or tears, causing the blood to flow into parts of the body outside of the circulatory system. This is a very serious condition that often requires emergency surgery. The pain of aortic dissection is usually severe; comes on very suddenly; is felt in the chest, in the back, or between the shoulder blades; and is often described as a ripping or tearing sensation.

Characteristics of cardiac pain — While it is not always immediately obvious whether chest pain is related to a cardiac problem or something else, there are some things that can help a health care provider determine the cause. For example:

●Characteristics of the pain – People with angina are likely to report chest discomfort rather than pain. This can feel like a squeezing, tightness, pressure, constriction, strangling, burning, heartburn, fullness in the chest, band-like sensation, knot in the center of the chest, ache, heavy weight on the chest, or a bra that is too tight.

People with pain that is not angina often describe their pain as sharp or stabbing.

●Location of the pain – Angina is usually not felt in any specific spot, but rather throughout the chest. It often involves the center of the chest, shoulder, or upper abdomen.

Pain that is felt only on the right or left side, and not in the center of the chest, is less likely to be angina.

●Radiation of pain – With angina, the pain often spreads to other areas of the upper body. This may include the neck, throat, lower jaw, teeth, or shoulders and arms. Sometimes, pain is felt in the wrists, fingers, or back (between the shoulder blades).

●Timing of the pain – Angina tends to come on gradually; the pain typically gets worse over several minutes. It is usually aggravated by exertion and gets better with rest.

By contrast, non-cardiac pain can come and go suddenly and feel worse in the beginning. It is often unrelated to exertion. Non-cardiac pain may last only a few seconds or may persist for hours. Pain that has been unchanged in severity and constant over days or weeks is not likely to be angina or a heart attack.

●Things that make the pain better or worse – If the pain begins during an activity that increases physical exertion, such as walking up stairs, sexual intercourse, or raking leaves, and gets better within minutes of resting, it could be angina. This is because exercise increases the heart's need for oxygen-rich blood, and this need decreases as you rest. Other things that can increase oxygen demand in the heart include emotional stress, exposure to cold, and physical activity shortly after a meal.

If the pain is relieved within a minute or two with nitroglycerin, a medicine used to treat angina, it suggests (but does not prove) that ischemia is the cause (see 'Nitroglycerin' below). Other conditions, especially muscular spasms or esophageal spasm, may also improve with nitroglycerin. If eating a meal or taking antacids always relieves the pain, it could be caused by a problem with the esophagus or stomach.

Angina is not usually affected by taking a deep breath or by pressing on the area of discomfort. It also tends to be the same regardless of body position.

●Other symptoms – People who are having severe angina or a heart attack may have other symptoms in addition to (or even instead of) chest pain. These may include:

•Shortness of breath

•Nausea, vomiting, or belching

•Sweating

•Cold, clammy skin

•Irregular or rapid heart rate

•Palpitations

•Fatigue

•Dizziness

•Fainting

•Indigestion, vomiting

•Vague abdominal discomfort

•Tingling sensation in either arm (more often the left) or shoulder

Heart attack is discussed more below. (See 'Symptoms of a heart attack' below.)

Other physical causes

Chest wall — A number of conditions can cause the skin, muscles, bones, tendons, soft tissue, and cartilage of the chest to become painful:

●Physical activity that involves the chest muscles – Especially when it is new or more strenuous than usual, physical activity can cause muscle soreness. The pain is longer-lasting than most episodes of angina, and it often gets better or worse with certain positions. Taking a deep breath may make the pain worse, and it may only affect a specific, localized area of the chest. Pressing on this area of the chest usually causes the pain to become worse.

●Costochondritis – This is when the cartilage that connects the ribs to the breastbone becomes inflamed, causing pain.

●Medical conditions – Diseases such as rheumatoid arthritis or fibromyalgia may also cause chest wall pain. Shingles (herpes zoster) is an infection that affects the nerves of the chest wall and can cause discomfort in addition to a painful skin rash. (See "Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)" and "Patient education: Fibromyalgia (Beyond the Basics)" and "Patient education: Shingles (Beyond the Basics)".)

●Trauma – Any kind of trauma or injury, including recent surgery, can cause the chest wall to hurt.

Esophagus — The esophagus is the tube that connects the mouth and throat to the stomach. Because the esophagus and the heart are served by some of the same nerves, and are adjacent to each other in the chest, some cases of esophageal pain can be confused with angina. In some cases, esophageal pain is caused by spasm and may be relieved by nitroglycerin. (See 'Nitroglycerin' below.)

A number of conditions can cause pain in the esophagus, including:

●Gastroesophageal reflux disease – Gastroesophageal reflux disease (GERD) causes acid from the stomach to flow back into the esophagus. The main symptom of GERD is heartburn, which can feel like a burning sensation in the center of the chest; it can also cause chest pain or discomfort. (See "Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)".)

●Spasm of the esophagus and motility disorder – With these conditions, the muscles around the esophagus contract abnormally, causing pain.

●Esophagitis – This is the term for inflammation of the esophagus, which is sometimes due to certain medications.

Gastrointestinal tract — A number of problems related to the stomach and intestines can cause pain that spreads to or even begins in the chest. Examples include ulcers, gallbladder disease, pancreatitis, and irritable bowel syndrome. (See "Patient education: Peptic ulcer disease (Beyond the Basics)" and "Patient education: Gallstones (Beyond the Basics)" and "Patient education: Acute pancreatitis (Beyond the Basics)" and "Patient education: Irritable bowel syndrome (Beyond the Basics)".)

Lungs — A number of problems related to the lungs can cause chest pain. In many of these cases, the pain gets worse with breathing.

●Pulmonary embolism – This is a blood clot in the lung. It almost always occurs in people who are at high risk due to recent surgery, bed rest, pregnancy or recent pelvic surgery, or sitting still for a long time (such as during a long airplane flight). With a pulmonary embolism, pain occurs suddenly, is accompanied by shortness of breath, and may be worsened with deep breaths. (See "Patient education: Pulmonary embolism (Beyond the Basics)".)

●Pneumonia – Infection in the lungs (pneumonia) can cause pain, cough, and fever. (See "Patient education: Pneumonia in adults (Beyond the Basics)".)

●Pleurisy or pleuritis – These terms mean inflammation of the tissues surrounding the lungs. They can occur with a viral illness or as a complication of pneumonia, pulmonary embolism, or chest injury.

●Pneumothorax – This is a collapsed lung, which allows air to escape to the space between the chest wall and the lung.

Psychological causes — Conditions such as panic disorder or depression may cause a person to feel pain in the chest. Breathing very fast (hyperventilation), which can happen when a person has a panic attack, can cause chest pain as well.

Referred pain — "Referred" pain can occur when the same nerves supplying areas of the chest wall also supply the tissues around the lungs, the diaphragm, or the lining of the abdomen. A herniated disc or arthritis in the neck can cause "band-like" chest pain.

CHEST PAIN DIAGNOSIS — As discussed above, many different things can cause pain in the chest. Some are serious conditions, such as a heart attack, while others require evaluation but are not life-threatening.

Symptoms of a heart attack — Most people think that a heart attack is sudden, intense, and dramatic, but this is not always true. Many heart attacks start slowly as mild pain or discomfort, which builds in intensity with time. It is common for a person with a heart attack to have other symptoms, such as discomfort in one or both arms, back, neck, jaw, or stomach, shortness of breath, breaking out in a cold sweat, nausea, or light-headedness. However, some heart attacks occur without these symptoms. Studies have shown that people often delay seeking help for a heart attack because they thought the symptoms were not serious or would go away.

The best advice for anyone with chest pain is to seek help immediately. Every minute that passes between the start of the attack and getting treatment means increased loss of heart muscle. (See 'When to seek help' above.)

Evaluation — A health care provider can help determine the cause of your chest pain. They will ask you questions about your pain (for example, whether it feels like tightness, pressure, discomfort, or sharp pain), how severe it is and whether certain activities make it better or worse, where the pain is located, and whether it radiates to other areas (such as your neck, throat, jaw, or arms). They will also ask about any other symptoms you have.

Testing — There are also several different tests that are used to determine the cause of chest pain.

Electrocardiogram — An electrocardiogram (ECG) depicts the progress of the electrical wave through various parts of the heart muscle (figure 3). In people with ischemic chest pain (caused by the heart not getting enough oxygen-rich blood), there are often changes in the ECG. A normal ECG means that a heart attack is less likely, but it does not rule out angina or a heart attack.

Blood tests — Blood tests, including tests to measure troponin, creatine kinase (CK), or CK-MB, can be used to measure certain enzymes normally found in the heart muscle. During a heart attack, these enzymes leak out of the heart into the blood. Tests of cardiac enzymes are usually repeated over the course of several hours.

Stress test — An exercise stress test involves having and ECG while you walk or run on a treadmill (figure 4). It is also helpful in diagnosing ischemia (when the heart is not getting enough oxygen-rich blood). During this test, the ECG is continuously monitored, looking for evidence of ischemia. If an individual is unable to exercise, a medication can be given to stress the heart. An image of the heart's response to exercise will often be obtained with an echocardiogram or a nuclear scan.

Cardiac catheterization — Cardiac catheterization, also known as coronary angiography, involves using X-ray guidance to pass a small catheter to the coronary arteries, where dye is injected to show the outline of any blockages. This test is usually recommended for people who are considered to have a high risk of coronary artery blockage based upon the results of other factors, such as their coronary risk factors or the results of the tests described above.

CHEST PAIN TREATMENT — Treatment depends on what is causing your chest pain.

Nitroglycerin — If you have had chest pain before or know that you have coronary heart disease, your health care provider may prescribe nitroglycerin, a medication used to treat angina. Nitroglycerin is a small pill that you place under your tongue if you get chest pain. After you put the pill under your tongue, allow the nitroglycerin to dissolve. If your mouth is dry, a drink of water can help to moisten the pill, but do not swallow it. You should sit down when you take your nitroglycerin, as it may make you feel dizzy or lightheaded.

After you have taken a dose (one pill) of nitroglycerin, wait five minutes (use a watch, clock, or smartphone to time this). If your chest pain does not go away after five minutes, call for an ambulance immediately (in the United States and Canada, dial 9-1-1) and take a second pill unless you have specifically discussed a different plan with your provider. If you have frequent angina, your provider may recommend taking an additional (third) dose of nitroglycerin; some clinicians recommend a total of two or three doses (one every five minutes) before calling for emergency help.

Care of a heart attack — If a person is having a heart attack, a number of treatments and tests will be performed. This is discussed in detail separately. (See "Patient education: Heart attack (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Chest pain (The Basics)
Patient education: Coronary artery disease (The Basics)
Patient education: Medicines for heart failure with reduced ejection fraction (The Basics)
Patient education: Medicines after a heart attack (The Basics)
Patient education: ECG and stress test (The Basics)
Patient education: Nuclear heart testing (The Basics)
Patient education: Echocardiogram (The Basics)
Patient education: Cardiac catheterization (The Basics)
Patient education: Pleuritic chest pain (The Basics)
Patient education: Costochondritis (The Basics)
Patient education: Myocarditis (The Basics)
Patient education: Aortic dissection (The Basics)
Patient education: Coronary artery disease in women (The Basics)
Patient education: Stress cardiomyopathy (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Medications for angina (Beyond the Basics)
Patient education: Pericarditis (Beyond the Basics)
Patient education: Fibromyalgia (Beyond the Basics)
Patient education: Shingles (Beyond the Basics)
Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)
Patient education: Peptic ulcer disease (Beyond the Basics)
Patient education: Acute pancreatitis (Beyond the Basics)
Patient education: Irritable bowel syndrome (Beyond the Basics)
Patient education: Gallstones (Beyond the Basics)
Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)
Patient education: Pneumonia in adults (Beyond the Basics)
Patient education: Angina treatment — medical versus interventional therapy (Beyond the Basics)
Patient education: Heart attack (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Microvascular angina: Angina pectoris with normal coronary arteries
Evaluation of the adult with chest pain of esophageal origin
Clinical evaluation of musculoskeletal chest pain
Diagnosis of acute myocardial infarction
Outpatient evaluation of the adult with chest pain
Major causes of musculoskeletal chest pain in adults
Chronic coronary syndrome: Overview of care
Angina pectoris: Chest pain caused by fixed epicardial coronary artery obstruction
Stress testing for the diagnosis of obstructive coronary heart disease
Management of isolated musculoskeletal chest pain

The following organizations also provide reliable health information.

●National Heart, Lung, and Blood Institute

(http://www.nhlbi.nih.gov/health/health-topics/topics/angina)

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●American Heart Association

(www.americanheart.org)

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