Evaluation of Chest Pain

Dr. Nekkanti Rayudu,Senior Consultant Cardiologist at Apollo Hospitals, Jubilee Hills explains in detail about chest pain.

Chest pain is a common and “alarming complaint” and causes fear in patients mind. The cause may vary from harmless diseases like muscle and bone pains to serious and emergency disorders, like, heart attack (ischemic heart disease).proper identification of heart pain is important with our over testing and over treating patients with less serious causes. Pain due to non cardiac causes can be treated with pain relievers. Approximately 15 million people seek medical help every year for chest pain in India. Among them 15% has pain due to heart problem. The chest contains apart from heart and its vessels, the skin, subcutaneous tissue, rib muscles, lungs, blood vessels of lungs, food pipe, wind pipes,  lymph nodes, bones ( ribs, cartilage, sternum, vertebra, vertebral discs), and nerve tissues. Any disease of these structures can cause chest pain.

Apart from chest structures (thoracic organs), pain from neck, shoulder, clavicles (collar bone), and pain from abdominal organs, especially stomach, colon (gases from abdomen), gall bladder, and pancreas spread to the chest and closely mimics heart pain.

The most important and first step to identify heart pain is by probability of getting heart disease and description of pain. “Certain groups” of patients are more prone for Heart Attack. They are Smokers, Diabetics, High blood pressure Patients, Patients with high LDL Cholesterol and Patients with previous history of Heart Disease.

Though heart attack is more common in these individuals, on and off we also see low risk individuals (without risk factors mentioned above), can also suffer from heart attack because of bad life style diseases like overweight, obesity, lack of exercise, excessive mental and physical stress, loss of loved ones (loss of spouse or parents). So, a high index of suspicion is needed.

Apart from risk probability, the description of the pain is very important to identify the origin of pain.

“Pain is a feeling” and there is no instrument, device or test to identify the type, and severity of pain. So, a detailed (good) description of pain to the doctor is important.

Chest pain due to Heart Diseases is felt as “heaviness, Discomfort, uneasiness, Burning, Pressure in middle of the chest(Breast Bone) or Both sides of the chests or only to the left chest.” It is felt as a “deep feeling” inside chest and over wider area and may spread to back of chest, one or both shoulders or arms. It may be felt in the neck or to the Jaw and or to pit of the stomach. Cardiac pain generally will come along with sweating, anxiety, breathlessness, increased Heartbeat, giddiness and sometimes with nausea and vomiting. Many times the discomfort may not be severe and thought of as indigestion. People bleach or move body to relieve it but not relieved. Taking water antacid, changing position, massaging the chest or abdomen doesn’t relieve heart pain. Chest discomfort may be absent may 20% of heart attack patients. Breathing difficulty or unexplained weakness (fatigue) may be the only symptom.

Chest discomfort radiating to arms or Shoulder is more often considered as very classical of heart pain and it is a common alarming symptom which needs immediate attention of doctors. If the discomfort spreads to both shoulders or arm most often is due to heart pain especially associated with sweating

The most common disease that closely resembles heart pain is “esophageal spasm(food pipe spasm), gastro-esophageal reflux disease (GERD)” and gastritis. Excess acid produced in the stomach, gets back into the food pipe and produce symptoms similar to heart disease. Even experienced doctors find difficulty in differentiating. Acid pain may improve by antacids but not heart disease pain. Flatulence (excess gas) in the stomach and colon, often cause chest discomfort.

Localised pricking or sharp brief pain lasting 1-2 seconds, not spreading to other parts of chest, pain on movement of chest, pain on pressing the chest is less likely of cardiac origin. On the other hand pain on exertion or emotion and activity more likely heart pain. Other serious disorders with chest pain is lung artery block (Pulmonary embolism) great vesselrupture(Aortic dissection). A distressing cough may cause thoracic muscular aches & cause pain in the chest.

“Musculoskeletal pains” many times causes distressing pain and may be confused as heart pain. Rib pains, Cartilage pain and pain from the spine, spondylitis pains, Muscular pains, Muscular spasm due to stress and inflammation of the skin are often confused with heart pain. Musculo skeletal pains are more Common in certain situations like long time computer operators, bad position while working, long journeys in bad roads, Excessive physical and mental strain. Musculoskeletal pains are often relived with pain relievers like paracetamol or by Hot water fomentation.

“Sometimes heart attack may be silent.” Diabetic patients with Neuropathy, Very elderly patients with Neurological problems may not have chest pain. Patients under the effect of anaesthesia, hypnotics, Individual under the influence of alcohol, psychiatric and inebriated drugs may not feel pain. In many cases breathlessness may be the only symptom. Sometimes patient may fall to the ground with out any complaint. In women breathlessness, weakness , anxiety may be more common than chest discomfort.

Incase of suspicion report to nearest medical centre and electrocardiogram (ECG) has to be taken and follow the medical advice. Sometimes patient may be kept under observation and second ECG or cardiologist opinion is asked. Important blood test now available in many centres is high sensitivity troponin(Trop I ) test.  It is an enzyme released by heart muscle cell damage and if positive detect even mild heart attack even if ECG is normal. Trop I blood test is now available in many hospitals. The Three clinical signs of heart disease are chest discomfort, ECG changes and increased Trop I in blood(Positive Trop I). If Heart disease is detected blood thinners like aspirin, clopidogral or ticagrilor are given to prevent further clot formation. Coronary angiography may be needed and blocked vessels are opened by coronary angioplasty and stenting. These procedures are lifesaving by improving blood flow to the heart muscle and pumping function of the heart.

By proper awareness, early recognition and timely help heart failure, Sudden cardiac collapse and death can be prevented and many patients can lead a normal and healthy life.

For Appointment : Dr. Nekkanti Rayudu,Senior Consultant Cardiologist at Apollo Hospitals, Jubilee Hills .