Chest pain is a common symptom associated with a variety of underlying causes. It is estimated that more than six million people visit hospital energy departments in the United States annually because of chest pain. It is the second most frequently reported principal reason for visiting the emergency unit, only abdominal pain is more common (1).
The cause of chest pain in outpatients may vary from life-threatening conditions to those that are relatively harmless. The most common causes of chest pain are musculoskeletal (30-50%) and gastrointestinal conditions (10-20%).
Examples of life threatening conditions that may cause chest pain and call for immediate medical attention are; acute coronary syndrome (ACS), pulmonary embolism, tension pneumothorax, pericardial tamponade, and esophageal rupture.
It is practical to classify the underlying conditions causing chest pain into;
- cardiac (caused by heart disease)
- pulmonary (caused by lung disease)
- gastrointestinal (caused by digestive disorders)
Nowadays, all chest pain is regarded as suspected coronary artery disease until proven otherwise. Most emergency departments have chest pain units, a fast track service for patients with chest pain, relying to a large extent on blood testing, electrocardiogram, exercise testing and imaging techniques.
History Is a Key Factor in Determining the Cause of Chest Pain
History and physical examination are of crucial importance when it comes to assess the probability of different causes of chest pain and determine the need for further testing.
The character or quality of the pain is important. Chest pain may be only a vague discomfort, or it may be sharp, ripping, tearing, or a feeling of pressure, fullness or tightness in the chest.
The localization of the pain may help determine its origin. Pain due to coronary artery disease may radiate to the neck, jaw, and arms. Pleuritic pain typically worsens with respiration. Such pain is associated with several conditions of the heart and lungs.
Knowing the onset of pain is helpful. An abrupt onset may suggest pneumothorax and aortic dissection. Chest pain that lasts only for a few seconds or pain that is consistent over weeks to months is not due to coronary artery disease (2).
If and how the pain may be provoked is of importance. Chest pain provoked by exertion is typical of angina pectoris (3). Pain made worse by swallowing is likely of esophageal origin. Chest pain associated with body position or certain movements is likely of musculoskeletal origin, and so is a well-localized pain associated with tenderness on palpation (pushing on the spot).
Cardiac Causes – Heart Conditions Causing Chest Pain
1. Acute Coronary Syndrome (ACS)
The term acute coronary syndrome covers a range of conditions associated with a sudden reduction in blood flow to the heart muscle. It includes conditions such as ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (4). The underlying mechanism usually involves the rupture of an atherosclerotic plaque in a coronary artery with superimposed blood clotting (thrombosis), thereby blocking blood supply (5).
ACS and acute heart attack are one and the same and should always be treated as an emergency.
Patients with ACS typically experience pressure, fullness or tightness in the chest. Sometimes there is searing pain that may radiate to the back, neck, jaw, shoulders and arms, particularly the left arm.
The pain usually lasts more than a few minutes. If there is a complete blockage of a large coronary artery causing myocardial infarction, the pain may last for several hours. It may be associated with shortness of breath, cold sweats, dizziness or weakness, nausea, and vomiting.
2. Angina Pectoris
The term angina pectoris or angina is used to describe chest pain or discomfort, often felt like a pressure or a squeezing sensation in the chest. The pain may radiate to the shoulders, arms, neck, jaw or the back region between the shoulder blades.
Angina pectoris is not a disease. It is a symptom, usually caused by inadequate blood flow in a coronary artery resulting in insufficient supply of oxygen-rich blood to an area of the heart muscle. Hence, in most cases, angina reflects underlying coronary artery disease (3).
Typically, a patient with angina will experience no symptoms at rest. However, during exercise, the oxygen demands of the heart muscle will increase. If blood supply in a coronary artery is limited, usually because of an atherosclerotic plaque, angina will occur. If the patient stops exercising, oxygen supply will again meet demands, and angina will resolve.
3. Aortic Dissection
Aortic dissection is a serious condition in which there is a tear in the inner layer of the aorta (the large blood vessel branching off the heart). Because blood can pass the tear, the inner and middle layers of the aorta to become separated, a condition called dissection. The blood-filled channel may rupture through the outer wall of the aorta causing fatal bleeding.
Patients with acute aortic dissection usually present with acute, severe, chest and back pain which is generally sharp and may have a ripping or tearing quality. However, some patients present with only mild pain, often mistaken for a symptom of musculoskeletal condition (6).
The pain of aortic dissection is typically distinguished from the pain of ACS by its abrupt onset and maximal severity at onset, though the presentations of the two conditions overlap to some degree and are easily confused (6).
Aortic dissection is relatively uncommon. It occurs most frequently in men in their 60s and 70s.
Aortic dissection is a medical emergency. The chance of survival is improved by early detection and appropriate treatment.
4. Pericarditis and Myopericarditis
Pericarditis is an inflammation (swelling) of the pericardium, a thin membrane or sac surrounding the heart. In most cases, no specific cause is identified, although a viral infection usually presumed to be responsible.
The primary symptom may be a sudden, sharp and stabbing pain behind the sternum (breastbone). However, sometimes there may only be a dull ache.
The pain of pericarditis typically worsens when lying down or breathing in (pleuritic pain). It may often get better when sitting up and leaning forward.
Pericarditis is usually not a serious condition, and hospital admission is seldom required.
Sometimes there may be alterations on the electrocardiogram (ECG) that are typical of pericarditis. Cardiac auscultation may reveal a pericardial friction rub typical of acute pericarditis. The rub has a scratching, grating sound similar to leather rubbing against leather (7).
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy. Colchicine and corticosteroids are sometimes used.
Symptoms usually resolve within a week. However, some patients experience recurring pericarditis or chronic pericarditis where symptoms last longer than three months.
The term myopericarditis implies that there is an inflammation of the heart muscle (myocardium) as well.
5. Stress Cardiomyopathy (Takotsubo)
Stress cardiomyopathy, also called the broken heart syndrome, apical ballooning syndrome, or takotsubo cardiomyopathy was first described 1990 in Japan. Although its symptoms mimic those of an acute heart attack, it is an entirely different disorder and is not caused by blocked coronary arteries.
Patients with stress cardiomyopathy experience sudden, intense chest pain precipitated by an emotionally stressful event. It could be the death of a loved one, breakup of a relationship, domestic abuse, arguments, devastating financial losses or a natural disaster (8).
The disorder is characterized by a severely decreased contraction of a part of the heart muscle. This may sometimes lead to heart failure, irregularities of heart rhythm and shock.
Patients are usually admitted to the coronary care unit (CCU) for observation, further workup, and treatment.
Although the function of the heart muscle may be severely affected during the initial phase, recovery is usually complete.
Pulmonary Causes – Lung Conditions Causing Chest Pain
6. Pulmonary Embolism
Pulmonary embolism is a blockage in one or both of the pulmonary arteries within the lungs. It is caused by blood clots that travel from the lower extremities, through the right heart chambers, and lodge in the lungs. Pulmonary embolism can be life-threatening (9).
In most cases, a blood clot in the deep veins of the leg, called deep vein thrombosis (DVT), is the underlying cause of pulmonary embolism. Painful swelling of one leg, ankle or feet should raise the suspicion of DVT.
There are several risk factors for DVT. Among them are inherited disorders of blood clotting, prolonged bed rest, injury or surgery, pregnancy, birth control pills, smoking, and some forms of cancer.
Sitting for extended periods of time such as during long flights may also increase the risk of DVT because the leg muscles are not contracting. The leg muscles play a major role in pumping the blood through the veins. The most effective preventive measure is to contract the leg muscles, either while sitting or by walking when possible (10).
The most common symptoms of pulmonary embolism include shortness of breath, cough, and sometimes chest pain that gets worse when breathing (pleuritic pain). Signs of DVT in one or both legs may be found.
A pneumothorax is when air builds up in the pleural sac, between the outside of the lung and the inside the chest wall (11). The air can come from the lung or from outside the body if there is a chest injury. A large pneumothorax may compress the lung causing it to collapse.
Although pneumothorax caused by leaks of air from the lungs is more common in people with a lung condition, it can occur in people who are otherwise completely healthy (spontaneous pneumothorax).
Spontaneous pneumothorax is far more common in men than women. It often occurs in people between 20 and 40 years old, often in tall individuals and is commonly associated with underweight.
Patients with spontaneous pneumothorax present with sudden onset of chest pain that gets worse by breathing in (pleuritic pain). The pain may be associated with shortness of breath. A regular chest X-ray usually confirms the diagnosis.
The treatment of a pneumothorax depends on its size and whether it’s expanding. A small pneumothorax may not need any treatment as it will heal on its own, whereas a large pneumothorax will need to be drained using a syringe or a chest tube.
A tension pneumothorax is a life-threatening condition that can occur with chest trauma and usually involves an opening in the chest wall (12). This may allow air to enter the pleural space on inspiration causing pneumothorax. However, the wound may act as a one-way valve and not enable the air to exit. Without immediate treatment which involves needle drainage and insertion of a chest tube, the outcome may be fatal.
8. Pneumonia, Asthma, and Chronic Obstructive Lung Disease (COPD)
Pneumonia may cause chest pain. The pain often gets worse on inspiration (pleuritic pain). However, many patients with pneumonia don’t have chest pain.
Patients with pneumonia also often have a fever and productive cough.
Patients with asthma and chronic obstructive lung disease (COPD) typically suffer from shortness of breath. However, during exacerbations of these disorders, patients often describe chest tightness that may sometimes be interpreted as chest pain. In some cases, this may be associated with pneumonia.
9. Pleuritis (Pleurisy)
Pleuritis or pleuricy is an inflammation (swelling) of the membranes (pleurae) covering the lungs (13)
The chief symptom associated with pleurisy is a sharp, stabbing pain when breathing (pleuritic pain). The pain often gets worse when sneezing, coughing, or moving. Fever and chills may occur, depending on the underlying condition.
The most common underlying cause is a viral infection. Pneumonia, pulmonary embolism, autoimmune disorders (e.g., rheumatoid arthritis, lupus), and lung cancer may also cause pleuritis. However, sometimes the cause remains unknown.
Treatment depends on the underlying cause. Paracetamol and NSAID’s such as ibuprofen may help relieve the pain.
10. Lung Cancer
Patients with lung cancer often complain of chest pain. It is usually located on the same side as the tumor. Other symptoms include cough, hemoptysis (coughing blood), and shortness of breath.
Chest pain that is associated with lung cancer often gets worse with deep breathing, coughing, or laughing (14).
11. Pulmonary Hypertension
Pulmonary hypertension is a condition caused by elevated pressure (hypertension) in the pulmonary arteries (15).
Although shortness of breath is the main symptom of pulmonary hypertension, some patients may experience chest pain. The pain is usually most pronounced during exertion.
Gastriontestinal Causes – Digestive Disorders Causing Chest Pain
12. Gastroesophageal Reflux Disease (GERD)
Gastroesophagal reflux disease (GERD) is a common cause of chest pain (16)
It is a chronic digestive disease that occurs when stomach acid or, occasionally, stomach content, flows back (reflux) into the esophagus. The reflux irritates and may damage the lining of the esophagus causing the disease.
Most healthy people experience acid reflux and heartburn once in a while. However, when these symptoms occur at least twice each week or interfere with daily life, GERD should be suspected.
The chest pain associated with GERD may mimic angina pectoris. It may be described as squeezing or burning, perceived behind the sternum (substernal) and sometimes radiating to the back, neck, jaw or arms. It is usually relieved by antacids.
Most people can manage the symptoms of GERD with lifestyle changes and over-the-counter medications. But some patients may need prescripttion drugs, or even surgery, to reduce symptoms.
The term esophagitis describes an inflammation or swelling of the esophagus.
Common forms of esophagitis include reflux esophagitis, infectious esophagitis, pill esophagitis, eosinophilic esophagitis, and esophagitis caused by chemotherapy or radiation therapy for cancer(17). Candida esophagitis is the most common type of infectious esophagitis.
Heartburn is the most common symptom of esophagitis. Other common symptoms include upper abdominal discomfort, nausea, bloating, and fullness.
Patients with esophagitis may experience chest pain that is quite similar to angina pectoris. However, the pain of esophagitis is more persistent, usually lasts longer (more than an hour), is often associated with heartburn, and is generally relieved by antacids.
14. Esophageal Rupture
Spontaneous rupture of the esophagus (Boerhaave syndrome) is uncommon. It is believed to be caused by a sudden increase in pressure within the esophagus usually caused by straining or vomiting (18).
Esophageal rupture may cause an excruciating retrosternal (behind the sternum) chest pain.
Today, most cases of esophageal rupture are caused by trauma from medical instrumentation.
Esophageal rupture remains a profoundly serious condition, and if it is not diagnosed and treated promptly, mortality is high.
15. Primary Esophageal Motility Disorders (PEMD)
Efficient transport of food by the esophagus, from the mouth to the stomach, requires a coordinated, sequential motility pattern that propels food from above and clears acid and bile reflux from below. Disruption of this highly integrated process, commonly termed esophageal mobility disorders PEMD, may cause discomfort when swallowing (dysphagia) and chest pain (19).
The diagnosis of PEMD may be complicated. Before entertaining a diagnosis of a motility disorder, other causes of dysphagia (e.g., esophageal cancer, esophagitis) must be excluded.
Musculoskeletal Causes of Chest Pain
16. Musculoskeletal Chest Pain
A large proportion of chest pain is caused by an underlying musculoskeletal condition. These conditions may be classified as isolated musculoskeletal chest pain syndrome, usually referred to as musculoskeletal chest pain. Sometimes these may be diagnosed as costosternal (costochondritis) or lower rib pain syndromes (20).
The proportion of patients with musculoskeletal chest pain varies with the clinical setting. It affects up to a quarter of patients in the emergency setting and over a third of those in non-emergency ambulatory clinics. Chest wall tenderness is common but does not always reproduce the symptoms, and such tenderness can be present in patients with pain that is of another origin (20).
In some cases, musculoskeletal chest pain is associated with rheumatic conditions such as fibromyalgia, rheumatoid arthritis, and spondyloarthritis. Fibromyalgia is the most prevalent of the rheumatic disorders that cause musculoskeletal chest pain (21)
Several names have been given to pain syndromes involving the lower ribs, including rib-tip syndrome, slipping rib, twelfth rib, and clicking rib. The painful rib syndrome consists of three features: pain in the lower chest or upper abdomen, a tender spot on the costal margin, and reproduction of the pain on pressing the tender spot (22).
Tietze’s syndrome has been defined as a benign, painful, swelling of the costosternal, sternoclavicular, or costochondral joints, most often involving the area of the second and third ribs (23).
Psychiatric Causes of Chest Pain
17. Panic Disorder
Panic disorder is an anxiety disorder characterized by recurrent unexpected panic attacks (23).
Panic attacks are sudden episodes of extreme fear or distress, often associated with chest pain, fast heartbeat or palpitations (24), sweating, shortness of breath, and numbness. Consequently, the patient may suffer from constant fear about having further attacks and tends to avoid places or circumstances where attacks have occurred before.
It has been suggested that approximately one-quarter of patients who present to physicians for treatment of chest pain have panic disorder (25). Notwithstanding, a panic disorder very often goes unrecognized and untreated among patients with chest pain, leading to frequent return visits to emergency departments.
On the other hand, it is important to recognize that patients with panic disorder may have coexisting coronary artery disease. As a matter of fact, panic disorder is associated with elevated rates of cardiovascular disease (25).
Fortunately, panic disorder is treatable, and quality of life can be improved by psychotherapeutic methods and drug therapy. Today cognitive-behavioral therapy (CBT) is a frequently used treatment approach and is regarded as an effective, clinically proven method (26,27).
Other Causes of Chest Pain
18. Substance-Related Chest Pain
Several illegal drugs can have adverse cardiovascular effects, ranging from abnormal heart rate to heart attacks.
Cocaine is the illegal drug most often associated with visits to hospital emergency departments in the United States. Cocaine use has been related to chest pain and myocardial infarction (heart attack). In 2011, it was involved in an estimated 40.3 percent of illicit drug-related emergency department visits (505,224 visits), versus about 36.4 percent (455,668 visits) for marijuana and about 20.6 percent (258,482 visits) for heroin (28).
19. Herpes Zoster
Herpes zoster (shingles) is an infection caused by the varicella-zoster virus, the same virus that causes chickenpox. The virus may remain dormant in the nervous system for years before reactivating as herpes zoster.
Herpes zoster is characterized by a red skin rash that can cause pain and burning. Typically it occurs as a stripe of blisters on one side of the body, often on the torso, neck, or face.
Most cases of herpes zoster clear up within two to three weeks. The disorder rarely occurs more than once in the same person, but approximately 1 in 3 people in the United States will have herpes zoster at some point in their life (29).
Chest pain may be the presenting symptom of herpes zoster. The diagnosis may be tricky because the pain usually precedes the rash.