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17 Important Causes of Chest Pain

Estimated reading time: 12 minutes

Chest pain is a common symptom associated with a variety of underlying causes.

More than six million people visit hospital emergency departments in the United States each year because of chest pain (1).


The cause of chest pain may vary from life-threatening conditions to those that are relatively harmless.

Chest pain is most commonly caused by disorders of muscles, ligaments, tendons, and bones. Such pain is often called musculoskeletal pain and is usually harmless.

Digestive disorders are also a common cause of chest ache.

It is practical to classify the underlying conditions causing chest pain into;

  • cardiac (heart conditions)
  • pulmonary (lung conditions)
  • gastrointestinal (caused by digestive disorders)
  • musculoskeletal (disorders of muscles, ligaments, tendons, and bones)
  • psychiatric
  • other

Nowadays, all chest pain is regarded as suspected heart disease until proven otherwise.

Actually, most emergency departments have chest pain units, a fast-track service for patients with chest pain.

History Is a Key Factor

History and physical examination are of crucial importance when determining the cause of chest pain.

The character or quality of pain is essential. Sometimes, there may be only a vague discomfort. In other cases, the pain may be sharp, ripping or tearing, or just a feeling of pressure, fullness, or tightness in the chest.

The localization of the pain may also help determine its origin.

Pain in the middle of the chest may be caused by heart disease or digestive disorders. In contrast, right or left sided chest pain often originates from the ribs or muscles and tendons in the chest cage.

Chest pain may also radiate to other parts of the body. For example, pain due to coronary artery disease may radiate to the neck, jaw, and arms.

In addition, knowing the onset of pain is helpful. An abrupt onset may suggest pneumothorax and aortic dissection.

Chest ache that lasts only for a few seconds is unlikely to be caused by coronary artery disease. The same is true for pain that is consistent over weeks to months (2).

Furthermore, if and how the pain may be provoked is of importance.

For example, so-called pleuritic chest pain typically worsens with respiration. Such pain is often left or right sided.

Chest pain provoked by exertion is typical of angina pectoris (3).

Pain made worse by swallowing is likely of esophageal origin.

Chest ache associated with body position or specific movements is likely to originate from muscles and tendons. In addition, such pain is often well-localized and associated with tenderness on palpation (pushing on the spot).

Cardiac Causes – Heart Conditions Causing Chest Pain

1. Heart Attack/Acute Coronary Syndrome (ACS)/

Acute heart attack and acute coronary syndrome (ACS) are different terms used to describe the same phenomenon.

ACS covers a range of conditions associated with a sudden obstruction of blood flow in a coronary artery. 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 coronary artery, the pain may last for several hours. Moreover, it may be associated with shortness of breath, cold sweats, dizziness or weakness, nausea, and vomiting.

ACS should always be treated as an emergency.

2. Angina Pectoris

Angina pectoris is often described as a pressure or a squeezing sensation in the chest. The discomfort 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. 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 blockage in a coronary artery, angina will occur. If the patient stops exercising, the oxygen supply will again meet demands, and angina will resolve.

3. Aortic Dissection

Aortic dissection occurs when there is a tear in the inner layer of the aorta (the large blood vessel branching off the heart).

The tear causes the inner and middle layers of the wall of the aorta to become separated. This may cause the outer wall of the aorta to rupture, causing fatal bleeding.

Aortic dissection

Patients with acute aortic dissection usually present suddenly with severe, sharp pain in the chest. The pain sometimes radiates to the back (4).

Aortic dissection is relatively rare. It is a medical emergency and always needs immediate treatment.

4. Pericarditis

Pericarditis is an inflammation (swelling) of the pericardium. The pericardium is a thin membrane or sac surrounding the heart.

In most cases, a viral infection is 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). Moreover, it may often get better when sitting up and leaning forward.

Pericarditis is usually not a serious condition and hospital admission is seldom required.

Symptoms usually resolve within a week. However, some patients experience recurring symptoms lasting longer than three months.

5. Stress Cardiomyopathy (Takotsubo)

Stress cardiomyopathy, also called the broken heart syndrome, apical ballooning syndrome, or takotsubo cardiomyopathy was first described in 1990 in Japan.

The symptoms of  stress cardiomyopathy mimic those of an acute heart attack. However, it is an entirely different disorder and is not caused by blocked coronary arteries.

Patients with stress cardiomyopathy experience sudden, intense chest pain.

An emotionally stressful event usually precipitates the pain, hence the term “broken heart syndrome.”

The stressful event could, for example, be the death of a loved one, breakup of a relationship, domestic abuse, devastating financial losses, or a natural disaster (5).

Stress cardiomyopathy is also characterized by a severely decreased contraction of a part of the heart muscle.

However, although the heart muscle’s function 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 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 (6).

In most cases, a blood clot in the leg’s deep veins, called deep vein thrombosis (DVT), is the underlying cause.

Sitting for extended periods, such as during long flights, may increase DVT risk (7).

Shortness of breath is the most common symptom. Cough is also relatively common and some patients have chest pain that gets worse when breathing (pleuritic pain).

A pneumothorax is when air builds up between the outside of the lung and the inside the chest wall. This may lead to a collapse of the lung.

7. Pneumothorax

A pneumothorax is when air builds up between the outside of the lung and the inside the chest wall (8). 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.

Pneumothorax caused by leaks of air from the lungs usually occurs in people with a lung condition. However, it can also occur in people who are otherwise entirely healthy (spontaneous pneumothorax).

Spontaneous pneumothorax is far more common in men than in women. It often occurs in people between 20 and 40 years old  and is most common in tall individuals.

The pneumothorax pain is usually sudden in onset and gets worse by breathing in (pleuritic pain).

The treatment of 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. However, a large pneumothorax will need to be drained using a syringe or a chest tube.

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 often have a fever and a productive cough as well.

Patients with asthma and chronic obstructive lung disease (COPD) typically suffer from shortness of breath. However, during worsening of these disorders, patients often describe chest tightness that may sometimes be interpreted as chest pain.

9. Pleuritis (Pleurisy)

Pleuritis or pleurisy is an inflammation (swelling) of the membranes (pleurae) covering the lungs (9)

The chief symptom associated with pleurisy is a sharp, stabbing pain in the chest. Patients often experience chest pain when breathing (pleuritic pain).

The most common underlying cause is a viral infection.

Treatment of pleuritis 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. The pain is usually located on the same side as the tumor.

Other symptoms include cough, hemoptysis (coughing blood), and shortness of breath.

Also, chest ache associated with lung cancer often gets worse with deep breathing, coughing, or laughing (10).

11. Pulmonary Hypertension

Pulmonary hypertension is a condition caused by elevated pressure (hypertension) in the pulmonary arteries (11).

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.

Gastrointestinal Causes – Digestive Disorders Causing Chest Pain

12. Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a common cause of chest discomfort (12).

GERD 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 is often described as squeezing or burning. It is usually located behind the sternum (substernal pain). Sometimes it radiates 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. Nevertheless, some patients may need prescription drugs, or even surgery, to reduce symptoms.

13. Esophagitis

The term esophagitis describes an inflammation or swelling of the esophagus.

Heartburn is the most common symptom of esophagitis. Other common symptoms include upper abdominal discomfort, nausea, bloating, and fullness.

Musculoskeletal Causes of Chest Pain

The term musculoskeletal is used to describe pain associated with muscles, ligaments, bones, and tendons.

14. Musculoskeletal Chest Pain

A large proportion of chest pain is caused by underlying conditions of muscles, ligaments, bones, and tendons.

This type of pain is usually referred to as musculoskeletal pain.

The chest wall contains a range of bony and soft tissue structures, including the spine. Hence, it may be difficult to pinpoint the exact source of pain in an individual patient.

Musculoskeletal conditions may cause both left and right-sided chest pain. Sometimes the pain gets worse when breathing.

The ache is often associated with body position or specific movements. Furthermore, it is usually well localized and associated with tenderness when pushing on the spot.

Psychiatric Causes of Chest Pain

15. Anxiety Chest Pain and Panic Disorder

Chest pain may be a symptom of anxiety (13).

Anxiety chest pain is often described as a sharp, stabbing sensation. The pain often starts suddenly and is usually not related to physical exertion.

Sometimes, however, there may be a less sharp, dull ache in the chest that is more persistent.

Panic disorder is an anxiety disorder characterized by recurrent unexpected panic attacks (14).

Panic attacks are sudden episodes of extreme fear or distress, often associated with chest pain and fast heartbeat. The patient may also experience palpitations (15), sweating, shortness of breath (16), and numbness.

Patients with panic attacks often suffer from constant fear about having further attacks. Thus, they ususllay try to avoid places or circumstances where attacks have occurred before.

It has been suggested that approximately one-quarter of patients seeking chest pain treatment have panic disorder (17). Notwithstanding, panic disorders often go unrecognized and untreated, leading to frequent return visits to emergency departments.

Fortunately, panic disorder is treatable, and quality of life can be improved by psychological methods and drug therapy (18,19).

Other Causes of Chest Pain

16. Chest Pain Related to Drug Abuse

Several illegal drugs can have adverse effects on the heart, ranging from abnormal heart rate to heart attacks.

Cocaine is an illegal drug most often associated with visits to hospital emergency departments in the United States.

Cocaine use has been related to both chest pain and heart attacks.

Chest pain may be the presenting symptom of herpes zoster (shingles). The diagnosis may be tricky because the pain usually precedes the rash.

17. Herpes Zoster

Herpes zoster (shingles) is an infection caused by the varicella-zoster virus, the same virus which causes chickenpox.

The chickenpox virus may remain dormant in the nervous system for years. In herpes zoster, it becomes activated again.

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. Approximately 1 in 3 people in the United States will have herpes zoster at some point in their life (22).

Chest pain may be the presenting symptom of herpes zoster. The diagnosis may be tricky because the pain usually precedes the rash.

The article was initially published in 2017.

It was revised, updated and republished on January 17th, 2021.




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Non-HDL Cholesterol (non-HDL-C)

Estimated reading time: 5 minutes

Non-HDL cholesterol (non-HDL-C) is a fraction that can be easily calculated from a traditional lipid panel. The value is strongly associated with an increased risk of heart disease.

Over the years, LDL cholesterol (LDL-C) has been the most commonly used lipid variable to predict risk (1). However, current evidence suggests that non-HDL cholesterol may be a better tool for risk assessment (2).

To calculate non-HDL cholesterol, you only need to know the numbers for total cholesterol and HDL cholesterol (HDL-C).

But, what makes non-HDL cholesterol such a useful measure of future risk?

The Role of Lipoproteins

Cholesterol and most other lipids are insoluble in blood. They are made soluble by attachment to specifically designed proteins. These particles are called lipoproteins.

Lipoproteins are responsible for transporting important lipids, such as cholesterol and triglycerides, to various body tissues.

Despite the critical role of lipoproteins, some seem to play a role in the formation of atherosclerosis and may promote heart disease.

Lipoproteins that are directly involved in atherosclerosis are termed atherogenic. Atherogenic lipoproteins tend to promote the formation of fatty deposits in the arteries.

There are five major lipoproteins in blood:

The Standard Lipid Profile

Screening patients for the risk of heart disease involves the measurement of blood lipids. Usually, this is accomplished by obtaining a lipid profile.

A standard lipid profile measures total cholesterol, triglycerides, and HDL cholesterol. LDL cholesterol is estimated by calculation using a specifically designed formula called the Friedewald equation(3).

It is crucial to understand that these numbers don’t reflect the number of lipoprotein particles. They only tell us how much lipid mass is carried by the different types of lipoproteins.

For historical reasons, LDL cholesterol has become a primary goal for the prevention of heart disease. Hence, recommendations regarding diet and drug therapy are usually aimed at lowering LDL cholesterol (4).

However, LDL is not the only lipoprotein involved in atherosclerosis and heart disease.

Furthermore, using LDL cholesterol to assess risk has several pitfalls (5).

Therefore, there is a need for a lipid parameter that better reflects the amount of cholesterol within all atherogenic particles. This is of particular importance when triglyceride levels are high, which is quite common, for example among people with abdominal obesity or metabolic syndrome.

The Advantage of Non-HDL Cholesterol

Both HDL and LDL lipoproteins are essential carriers of cholesterol in the blood stream. However, when it comes to atherosclerosis, they seem to play a very different role. Therefore, measuring the amount of cholesterol within these particles tells two different stories.

While high levels of LDL cholesterol are associated with an increased risk of heart disease, elevated levels of HDL cholesterol are associated with lower risk.

HDL lipoprotein particles appear to be involved in clearing and removing cholesterol from arteries and atherosclerotic plaques, while LDL particles seem to participate directly in atherosclerosis formation.

Therefore, cholesterol carried by HDL particles is often called “good cholesterol” and cholesterol carried by LDL particles is called “bad cholesterol.” Of course, it is the same cholesterol; the difference lies within the lipoproteins that carry it.

Measuring total cholesterol provides limited information about risk because it includes both HDL – and LDL cholesterol.

However, if we subtract HDL cholesterol from the total cholesterol, we will have a measure of the amount of cholesterol carried by all lipoproteins except HDL.

Doing this simple math will give us the amount of cholesterol carried withinall atherogenic lipoproteins. In other words, a measure of cholesterol carried by all the “bad” lipoproteins but not the “good” ones (which is only HDL). This fraction is termed non-HDL cholesterol (non-HDL-C).

Relying on LDL cholesterol alone may be misleading.

For example, individuals with abdominal obesity, metabolic syndrome or diabetes often have elevated triglycerides, low HDL cholesterol, and relatively normal calculated LDL cholesterol.

Despite their normal LDL cholesterol, these patients produce highly atherogenic lipoproteins such as VLDL and IDL.

Non-HDL cholesterol  appears to be a better marker of risk than LDL cholesterol in both primary and secondary prevention studies(6).

In an analysis of data combined from 68 studies, non-HDL cholesterol was the best risk predictor of heart disease of all cholesterol measures (7).

Another advantage of using non-HDL cholesterol is that you don’t need a fasting blood sample.

How to Calculate Non-HDL Cholesterol

Non-HDL cholesterol is total cholesterol minus HDL cholesterol.

This is the formula:

Non-HDL Cholesterol = Total Cholesterol – HDL cholesterol

 

So, if your total cholesterol is 220 mg/dL (5.7 mmol/L) and your HDL cholesterol is 50 mg/dL (1.3 mmol/L), non-HDL Cholesterol is 170 mg/dL (4.4 mmol/L).

What Is a Desirable Level of Non-HDL Cholesterol?

The treatment goal for non-HDL cholesterol is usually 30 mg/dL (0.8 mmol/L) above the LDL cholesterol treatment target.

For example, if the LDL-C treatment goal is <70 mg/dL (1.8 mmol/L), the non-HDL cholesterol treatment target would be <100 mg/dL (2.6 mmol/l).

Here you can see how non-HDL-C levels are looked at in terms of risk:

  • above 220 mg/dL (5.7 mmol/L) is considered very high
  • 190 – 219 mg/dL (4.9 – 5.6 mmol/L) is considered high
  • 160– 189 mg/dL (4.1 – 4.8 mmol/L) is considered borderline high
  • 130 – 159 mg/dL (3.4 – 4.0 mmol/L) is considered near ideal
  • below 130 mg/dL (below 3.4 mmol/L) is considered ideal for people at risk of heart disease
  • below 100 mg/dL (below 2.6 mmol/L) is considered ideal for people at very high risk of heart disease

How To Lower Non-HDL Cholesterol

Lowering non-HDL cholesterol always begins with lifestyle therapy, usually aimed at lowering triglycerides.

Traditionally, a reduction in total calories, especially saturated and trans fatty acids, is recommended in combination with exercise.

Reducing sugar and carbohydrate consumption can also be very useful in lowering triglycerides and non-HDL cholesterol, particularly in individuals with abdominal obesity or metabolic syndrome (7).

Foods that are high in omega-3 fatty acids may also be useful. Fatty fish such as salmon, sardines, mackerel, and herring are rich in omega-3.

Moderate physical activity can help raise HDL cholesterol and lower non-HDL cholesterol (8).

Quitting smoking will improve HDL cholesterol and reduce non-HDL-cholesterol.

Successful reduction of elevated non-HDL cholesterol may also be achieved with medical therapy.

Statin drugs lower total and LDL cholesterol leading to a reduction in non-HDL cholseterol.

Triglyceride lowering drugs such as omega-3 fatty acid preparations, fibrates, and niacin are sometimes used as well.




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Coronary Artery Calcium Score – CAC Scoring Explained

Estimated reading time: 8 minutes

Measurements of coronary artery calcium score (CAC scoring) are commonly used to assess future heart disease risk.

When we age, calcium deposits can be found in many parts of our bodies. Calcification in the arterial walls is common in people aged 65 and older.

So, to some degree, calcification of arteries can be regarded as a normal part of aging.

Due to their metallic nature and density, calcium deposits are easily detected by X-ray images.

Today, a heart scan, also known as a coronary calcium scan, is used to assess the amount of calcium in the coronary arteries.

Coronary Artery Disease

To be able to function normally, the heart needs a continuous supply of oxygen and other nutrients. The coronary arteries play an essential role in delivering these nutrients to the heart muscle.

Unfortunately, the coronary arteries are prone to a disease called atherosclerosis.

Atherosclerosis is a chronic inflammatory condition in which plaque builds up inside the arteries. A plaque is made up of inflammatory cells, cholesterol, calcium, and other substances.

Plaques in the coronary arteries may block blood flow to the heart muscle, leading to chest pain symptoms.

Furthermore, plaques may rupture, leading blood clotting at the plaque site. This may cause a sudden disruption of blood flow, leading to a heart attack.

In the early 1960s, several risk factors for coronary artery disease were defined. Since then, it has repeatedly been documented that smoking, high LDL-cholesterol, and high blood pressure are associated with increased risk.

Examples of other conditions that predispose to coronary artery disease are family history, insulin resistance, physical inactivity, mental stress, and depression.

Coronary heart disease remains the most common cause of death in the Western world. Hence, identifying individuals at risk is a significant step to reduce the burden of this disease.

Measuring the amount of calcium in the coronary arteries by CT scan may provide important information about the presence of coronary artery disease.

Coronary Artery Calcification

Most of us will ultimately get calcification in our arteries as we age. Hence, calcification of the coronary arteries can be regarded as an aging phenomenon.

However, if the amount of calcium is higher than expected by age, it may reflect an increased heart attack risk.

Coronary calcification can be seen in adolescents, although it usually starts later in life.

For many years, arterial calcification was thought to result from a degenerative process associated with aging. However, recent evidence suggests a more active process, likely arising from inflammation of the vessel wall.

Coronary Calcium Score

In the 1980s, US cardiologists lead by Dr. Arthur Agatston studied how to assess the amount of calcium in the coronary arteries.

Using an ultrafast CT scan technique, Agatston defined a method to calculate coronary artery calcium score (CAC score).

Initially, the CAC score was called the Agatston score,

The coronary arteries supply oxygen-rich blood to the muscle of the left ventricle of the heart. The amount of calcium in the walls of the coronary arteries, assessed by calculating the coronary calcium score, appears to be a better predictor of risk than standard risk factors

CAC score is an important tool to predict heart attack risk and other vascular events (2).

Furthermore, it may help to detect the presence and extent of coronary artery disease.

Nonetheless, the CAC score does not reflect the presence or absence of blockages or impaired blood flow in the arteries.

Still, a patient with a high CAC score is more likely to block a coronary artery than a patient with a low CAC score.

An individual with a CAC score of zero is very unlikely to have a severe blockage of a coronary artery.

Coronary Calcium Score Interpretation

The following definitions are used to relate the CAC score to the extent of underlying coronary artery disease (3):

  • Coronary calcium score 0: No identifiable coronary artery disease. 
  • Coronary calcium score 1-99: Mild coronary artery disease. 
  • Coronary calcium score 101-400: Moderate coronary artery disease.
  • Coronary calcium score > 400: Extensive coronary artery disease.

When interpreting the CAC score, it is essential to consider age and gender. Women, in general, have lower calcium scores than men.

A calcium score calculator is available here that provides CAC score distribution based on age, gender, and ethnicity.

Using CAC Score to Assess Arterial Age

CAC score increases with age. Hence, at a certain age, we will be expected to have a specific CAC score that would be considered normal for that age. This score would then reflect the age of our arteries or the arterial age.

If everything is normal, we would expect our arterial age to be the same as our observed age.

However, if the CAC score is high, our arterial age may be higher than our observed age. Conversely, if our CAC score is low, the arterial age may be lower than our observed age.

The table below shows how arterial age can be predicted from the CAC score (4).

Let’s take an example.

A 60-year-old man has a CAC score of 500. According to the table above, his arterial age will be 84 years.

Hence, this 60-year-old man has arteries that are consistent with the arteries of an 84-year-old man.

Arterial age based on the CAC score can also be calculated here.

When Should CAC Scoring Be Performed?

Coronary calcium score guidelines don’t recommend routine use of CAC scoring in asymptomatic individuals (5).

However, the CAC score may be useful for individuals at increased risk based on the ASCVD score.

The ASCVD score is based on several parameters such as gender, race, cholesterol levels, blood pressure, smoking, and the presence of diabetes.

ASCVD score can be calculated here.

Hence, if ASCVD score is between 5-20 percent, CAC scoring may help to guide further therapy.

CAC scoring is not recommended in individuals with ASCVD risk below 5 percent.

How Is Coronary Calcium Assessment Performed?

Lately, ultrafast spiral CT has been used to assess coronary calcium. This technique, often called heart scan, makes the scanning time very short.

The patient usually needs no specific preparation. Fasting is not necessary.

As high heart rate may reduce imaging quality, patients are often asked to refrain from smoking and drinking coffee before the scan. Sometimes beta-blockers are administered to slow heart rate.

Many experts have expressed concerns about the radiation involved with the CT scan. It has been estimated that there may be an increase in cancer risk with repeated procedures (6).

What to Do About Extensive Coronary Calcification?

There is no specific treatment available that lowers coronary calcium.

Treatment of individuals with high calcium scores should aim at reducing risk. This involves treating lipid disorders, high blood pressure, and diabetes if present.

Due to the overwhelming evidence of benefit in individuals with coronary artery disease, treatment with aspirin and statins is often advised.

Refraining from smoking is essential, and regular, moderate exercise is advised.

Further evaluation may be needed if extensive calcification is present.

Coronary Calcium Score and Statins

Treatment with statins is often advised for patients with a high CAC score. This is based on their ability to reduce plaque size and improve clinical outcomes.

Interestingly, however, statins do not reduce calcifications in the coronary arteries. In fact, some studies suggest that statins may promote coronary calcification (7).

The fact that the CAC score is associated with increased risk does not prove that calcium itself is harmful. It is simply a marker of underlying coronary artery disease.

Patients with high CAC scores have simply had their coronary artery disease detected by the high amount of coronary calcium. The calcium itself is not the problem. Indeed, it has been suggested that the calcium may represent shrinkage and stabilization of plaques (8).

Statins are often recommended if the CAC score is above 100.

Conversely, statin therapy is not recommended in patients with a CAC score of zero.

The Role of Calcium and K2 Supplements

Inadequate calcium intake can lead to decreased bone density, thereby increasing the risk of osteoporosis and bone fractures.

Supplemental calcium can increase bone mineral density and bone strength. However, recent data suggests that high consumption of calcium supplements may increase calcification of the arteries (9).

Hence, it has been suggested that elevated consumption of calcium supplements may raise the risk of heart disease.

Vitamin K2 deficiency is associated with an increased risk of calcification of the blood vessels. Furthermore, researh indicates that the use of vitamin K2 supplements is associated with decreased arterial calcification (10).

Hence, increased intake of vitamin K2 might help to reduce the health risks associated with coronary calcium.

However, further studies are needed to establish the role of K2 supplements in people with high CAC score.

The article was initially published August 19, 2014.

It was revised, updated and republished on December 20th, 2020.




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Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) – An Update

Estimated reading time: 10 minutes

Chronic fatigue syndrome (CFS), also termed myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is an illness that has attracted a good deal of attention lately, mainly because of a proposed relationship with COVID-19.

A couple of years ago, I wrote a blog post addressing 19 important causes of fatigue (1). ME/CFS was on the top of that list, not because it is widespread, but rather because of its ability to strike down where it is least expected. Those affected are typically highly functioning and healthy individuals.

ME/CFS has also been named systemic exertion intolerance disease (SEID) to reflect the condition’s hallmark, which is post-exertional malaise. Post-exertional malaise describes a massive energy crash after relatively minor exertion.

Although certain features are common to nearly all affected patients, ME/CFS is a complex illness. It is a heterogeneous disorder, meaning that symptoms vary a lot between individuals, and so does the underlying cause, which is often clouded in mystery.

Patients often have a history of an antecedent infection that precipitated the prolonged state of fatigue following the initial illness.

The presence of long-term symptoms in some individuals with COVID-19 illness has opened up a new line of research into the mechanisms underlying ME/CFS.

What Is ME/CFS?

The term chronic fatigue syndrome (CFS) was first introduced in the 1980s. The term was chosen after research failed to identify a clear viral association with what was previously called chronic Epstein–Barr virus syndrome (2).

Several biological abnormalities are present in patients with ME/CFS. It is not, as many clinicians believe, a psychological problem, although psychiatric symptoms occur in some patients (3).

For example, there is evidence of various neurologic and immunological abnormalities in patients with ME/CFS (2).

There is no diagnostic test for ME/CFS. Hence, the diagnosis is based on clinical criteria that mainly take into account the symptoms experienced by the patient.

Multiple definitions have been proposed for ME/CFS, and these have changed over time.

One of the key diagnostic criteria is that symptoms should be present for at least six months. Furthermore, symptoms should be of moderate or severe intensity at least half of the time (4).

What Are the Symptoms of ME/CFS?

Overwhelming fatigue is a crucial symptom in patients with ME/CFS. Of note is that the fatigue is very different from just being tired and is not relieved by sleep or rest.

The onset of symptoms may be sudden and is often associated with a typical infection, such as an upper respiratory tract infection.

The symptoms are characteristically exacerbated by excessive physical activity (post-exertional malaise).

Interestingly, affected patients are typically highly functioning individuals who are “struck down” with this illness.

Many patients appear outwardly healthy, sometimes causing relatives or friends to accuse them of malingering (4).

Symptoms of ME/CFS may come and go over time and often fluctuate in severity.

Primary Symptoms

Generally, three primary, or core symptoms, are required for the diagnosis of ME/CFS.

Notably, the fatigue associated with ME/CFS is not a result of unusually difficult activity and is not relieved by rest.

One of the key criteria for diagnosis is a greatly lowered ability to do activities that were usual before the illness (5).

Patients often describe what they call a “crash,” “relapse,” or “collapse,” following a relatively minor physical or mental exertion. This is called post-exertional malaise and is a hallmark of the disorder.

Post-exertional malaise usually occurs after an activity that would not have caused a problem before the illness. It may occur after shopping at the grocery store, taking a shower, or just when trying to keep up with other daily activities. Other potential triggers are emotional distress, physical trauma, and decreased sleep quantity/quality (6).

Sometimes, it may take days, weeks, or longer to recover from a crash.

Patients with ME/CFS often have sleep problems.  Falling asleep and staying asleep may be difficult, and the patient may not feel better or less tired, even after a full night of sleep.

Cognitive problems are often present. These include having trouble thinking quickly, remembering things, and paying attention to details. Patients may feel that they are not able to think clearly, often using the term “brain fog” to describe their feeling.

Patients with ME/CFS may be lightheaded, dizzy, weak, or faint while standing or sitting up. This phenomenon is called orthostatic intolerance and describes different types of discomfort upon assuming the standing position (7).

Other Common Symptoms

Several other symptoms, not classified as primary symptoms, may be present in patients with ME/CFS.

For example, muscle and joint pain are common, and so is headache.

Other symptoms include muscle weakness, shortness of breath, irregular heartbeat, tender lymph nodes in the neck and armpits, a sore throat, digestive problems, and night sweats (5).

How Common Is ME/CFS?

It is estimated that between 836.000 and 2.5 million individuals are affected by ME/CFS in the United States (8).

However, while fatigue is a prevalent complaint in primary care practice, it is believed that only a minority of these cases are due to ME/CFS. In other words, a tiny subset of patients who complain of chronic fatigue has ME/CFS (9).

Even among patients with fatigue of more than six months, the prevalence of ME/CFS seems to be well under ten percent (10).

In one study, the estimated prevalence of ME/CFS ranged from 75 to 267 cases per 100,000 persons. In contrast, the prevalence of chronic fatigue alone was strikingly higher, ranging from 1775 to 6321 cases per 100,000 persons (10).

Studies indicate that ME/CFS is three to four times more common in women than in men. It is most common in persons aged 40–50 years, but the age range is broad and includes children and adolescents (11).

What Is the Cause of ME/CFS?

The cause or causes of ME/CFS is unknown and appears to vary between patients. Both genetic and environmental factors may play a role.

Many patients report an acute onset of symptoms after a flu-like illness that does not go away, and some patients have a history of frequent infections before their illness (12). This suggests that infection can trigger the illness. However, no infectious agent has been proven to cause the disorder.

A syndrome with similarities to ME/CFS occurs in approximately 10% of patients with various infectious agents, such as Epstein-Barr Virus, Ross River Virus, Coxiella burnetti (Q fever), or Giardia (13).

Numerous other viruses have been implicated. These include human herpesvirus type 6 (HHV-6), enteroviruses, Ross river virus, and Borna disease virus. A syndrome similar to ME/CFS has been reported following classical Lyme disease that has been promptly treated (4).

It has been proposed that abnormal immune responses may be at play. One hypothesis is that activation of the immune system in the brain leads to production of cytokines that may be responsible for the symptoms (14).

Several metabolic abnormalities have been described, but their role is unclear. Among those are decreased levels of cortisol, increased levels of insulin-like growth factor, and abnormalities in serotonin activity in the brain (4).

Traumatic events in childhood and stress or emotional instability at any period in life may be associated with the development of ME/CFS.

What Is the Connection With Fibromyalgia?

Fibromyalgia is a chronic pain syndrome characterized by widespread pain, stiffness, and fatigue (1). The cause of the syndrome is unknown, and the pathophysiology is uncertain.

Cognitive complaints, known as fibrofog, are also commonly present (15).

Hence, patients with ME/CFS and fibromyalgia often have similar symptoms. Indeed, research has found that there is a thin line between fibromyalgia and ME/CFS.

The main difference may be that in fibromyalgia, fatigue often takes a backseat to debilitating muscle pain. Also, the association with different infectious agents is much more prominent among patients with ME/CFS than in patients with fibromyalgia.

ME/CFS is receiving more attention from the medical community than ever before due to the similarities with the long-term effects of COVID-19.

What Is the Relationship With COVID-19?

The short-term symptoms of COVID-19 include fever, cough, shortness of breath, anosmia (loss of smell), dysgeusia (altered sense of taste), fatigue, diarrhea, and other flu-like symptoms. Fortunately, most patients recover from these symptoms and can return to normal life activities.

However, an Italian study published last July suggested that a large portion of patients hospitalized for COVID-19 struggled with persistent symptoms for months after the initial recovery. The most common long-term complaints were fatigue and dyspnea (16).

Since then, prolonged fatigue and brain fog have been reported in many COVID-19 patients. Feeling weak and unusually tired after everyday tasks seems to be a common setback for many COVID-19 patients (17).

A recent British Medical Association press release warned that the effects of “long COVID” would be profound. Almost a third of 4.000 British doctors surveyed had seen or treated patients with symptoms they believed were a longer-term effect of COVID-19 within the first two weeks of August (19).

In many respects, the long-term symptoms of COVID-19 appear similar to those of ME/CFS.

Recently, Anthony Fauci, MD, director of the U.S. National Institute of Allergy and Infectious Diseases, talked about the potential long-term effects of COVID-19. Fauci said that many COVID-19 patients report health issues that are “highly suggestive” of ME/CFS. “If you look anecdotally, there is no question that there are a considerable number of individuals who have a post-viral syndrome that . . . can incapacitate them for weeks and weeks following so-called recovery and clearing of the virus,” Fauci said (20).

One of the key criteria used to diagnose ME/CFS is that symptoms should be present for at least six months. Hence, it remains to be seen how many people with COVID-19 will go on to develop this illness according to its current definition.

What is certain, however, is that ME/CFS is receiving more attention from the medical community than ever before due to the similarities with the long-term effects of COVID-19.

How Is ME/CFS Treated?

At present, there are no treatments that have been proven effective for patients ME/CFS. Although many therapies have been tried, none are curative.

Due to the heterogeneity of the disorder, treatment has to be individualized, addressing the most disruptive symptoms first (21).

Management should be supportive and focus on treating common symptoms such as sleep disorders, pain, depression and anxiety, memory and concentration difficulties, dizziness and lightheadedness.

Physical Activity

Remaining physically active is vital for patients with ME/CFS. However, the approach must be individualized, since exercise can exacerbate post-exertional malaise.

Post-exertional malaise can be addressed by activity management, also called pacing. The goal of pacing is to learn to balance rest and activity to avoid flare-ups (22).

To do this, patients need to find their individual limits for mental and physical activity. The aim is to keep their activity within these limits. This is sometimes referred to as staying within the “energy envelope.”

Sleep

Paying attention to sleep hygiene is very important for people with ME/CFS.

Strong sleep hygiene means having both a bedroom environment and daily routines that promote consistent, uninterrupted sleep (23).

Sleep should be made a priority. Skipping sleep in order to work, study, socialize, or exercise is not recommended.

Having the same bedtime each night is essential, and so is fixed wake-up time.

Sleep medication should be used carefully.

Pain

Patients with ME/CFS often have pain in their muscles and joints, and headaches are common.

Physiotherapy, stretching, massage, heat, and toning exercises may all be helpful.

Non-steroidal anti-inflammatory drugs (NSAIDs), like acetaminophen, paracetamol, and ibuprofen, are often used to treat pain. If these do not provide enough pain relief, patients may need to see a pain specialist.

Depression and Anxiety

Depression and anxiety may affect the quality of life in some patients with ME/CFS.

Psychotherapy and/or drug therapy may provide benefit for these patients.

Some people with ME/CFS might benefit from trying techniques like deep breathing and muscle relaxation, massage, and movement therapies (such as stretching, yoga, and tai chi) (22).

The Take Home Message

ME/CFS often affects highly functioning and healthy individuals.

There is no diagnostic test for ME/CFS. Hence, the diagnosis is based on clinical criteria that mainly take into account the symptoms experienced by the patient.

Overwhelming fatigue, post-exertional malaise, sleep problems, cognitive difficulties, pain, and orthostatic intolerance are key symptoms

One of the key diagnostic criteria is that symptoms should be present for at least six months.

Prolonged fatigue and brain fog have been reported in many COVID-19 patients. Many of these symptoms are remindful of those associated with ME/CFS.

It remains to be seen how many people with COVID-19 will go on to develop ME/CFS according to its current definition.

At present, there are no treatments that have been proven effective for patients ME/CFS.

Management should be supportive and focus on treating common symptoms such as sleep disorders, pain, depression and anxiety, memory and concentration difficulties, dizziness and lightheadedness.

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Tennis Elbow and Golf Elbow – Lateral and Medial Epicondylitis

Estimated reading time: 8 minutes

Tennis and golf are two of my favorite recreational sports.

Although the purpose of these activities is to provide breathing space and pleasure, nuisance tends to be hard to avoid. Hence, relaxation is frequently overtaken by eagerness, and amusement is replaced by frustration. In my case, this is particularly true for golf.

When I play too much (which is quite common), I often feel pain around the elbow. This can be quite tedious, and most of the time, rest seems to be the only cure.

Unfortunately, the repeated swinging of a tennis racket or a golf club may cause elbow pain, sometimes making it impossible to play. This is frequently due to an inflammatory phenomenon called lateral or medial epicondylitis.

Epicondylitis is a common disorder that affects men and women equally (1).

The Elbow Joint

The elbow joint is formed by the articulation of the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. It allows for the flexion and extension of the forearm relative to the upper arm, as well as rotation of the forearm and wrist.

A network of ligaments surrounding the joint capsule helps the elbow joint maintain its stability and resist mechanical stresses (2).

When we extend the elbow with the palm of the hand facing forward, the lateral epicondyle is in line with the thumb, whereas the medial epicondyle is in line with the little finger. Tennis elbow (T) is characterized by inflammation and pain located at the site of the lateral epicondyle whereas the pain from golf elbow (G) is located at the site of the medial epicondyle.

Many muscles originate and insert near the elbow making it a common site for injury. Repeated strenuous striking against force (as when playing tennis or golf) may cause strain on the tendinous muscle attachments. This may lead to inflammation and pain around the elbow joint.

The epicondyles are bony prominences easily felt on the medial and lateral sites of the distal humerus, above the elbow joint. The tendinous origins of the muscles that flex and extend the fingers are located at the medial and lateral epicondyle respectively (2).

When we extend the elbow with the palm of the hand facing forward, the lateral epicondyle is in line with the thumb, whereas the medial epicondyle is in line with the little finger.

Tennis elbow is characterized by inflammation and pain located at the site of the lateral epicondyle whereas the pain from golf elbow is located at the site of the medial epicondyle.

Lateral Epicondylitis (Tennis Elbow)

Pain around the lateral epicondyle is the most common type of elbow pain. It is most often caused by inflammation of the tendinous muscle attachments of the lateral epicondyle. Hence, the term lateral epicondylitis (tennis elbow).

Lateral epicondylitis is caused by repetitive strain to the extensor tendon, notably extensor carpi radialis brevis, or by forced extension or direct trauma to the lateral epicondyle (1).

The pain of lateral epicondylitis is usually well localized and is aggravated by repetitious use of the forearm and wrist (3).

Lateral epicondylitis is common among tennis players, hence the term ‘tennis elbow’. Novice players with a one-handed backhand typically suffer from the disorder.

Other risk factors are poor swing technique, a heavy racket, incorrect grip size, and high string tension (4).

Many experts believe that the use of a one-handed backhand may increase the risk of lateral epicondylitis compared with a two-handed backhand (5).

Despite being termed “tennis elbow”, lateral epicondylitis is also common among golfers.

Lateral epicondylitis is also an occupational hazard among carpenters, gardeners, dentists, and politicians. This is due to repetitive wrist turning or hand gripping, tool use, and frequent handshaking (3).

Several tests have been developed to diagnose lateral epicondylitis.

The “book test” is sometemes used to diagnose tennis elbow. It is performed by having the patient hold a book with the arm in full extension and palm facing down (pronation). A positive test is marked by pain at the lateral epicondyle (2).

Medial Epicondylitis (Golf Elbow)

Medial epicondylitis is provoked by frequent eccentric loads on the muscles that are responsible for forearm pronation and wrist flexion (1).

Medial epicondylitis is commonly referred to as “golf elbow” (or golfer’s elbow).  However, approximately 90 percent of cases occur outside of sport participation (4).

The pain is located around the medial epicondyle, hence the term “medial epicondylitis”.

Medial epicondylitis is also known as “baseball elbow”, “suitcase elbow”, or “forehand tennis elbow”. It is common among occupational settings involving repeated forceful gripping during heavy labor.

Medial epicondylitis is less common than lateral epicondylitis. It is most common in the 45- to 64-year-old age group. Women are more likely than men to suffer from the disorder, and three of four cases involve the dominant arm (6).

Elbow injuries, in general, are common among amateur and professional golfers. Interestingly, despite the term “golfers elbow”, lateral elbow injuries are more common among golfers than medial injuries.

In golfers, medial elbow injuries are thought to result from traction-based insults to the elbow during the swing. These usually affect the trailing arm (right elbow in the right-handed golfer).

Poor swing techniques may increase the risk of insults to the elbow causing medial or lateral epicondylitis. Striking the ground or other obstacles or from hitting repeatedly out of long, thick rough may also increase the risk (6).

The golfer’s elbow test may be used to help confirm the diagnosis of medial epicondylitis.

A modified version of the book test can be used to diagnose medial epicondylitis. Instead of a book, the patient is asked to hold a 3- to 5-pound (1.4- to 2.4-kg) weight with the arm raised, elbow fully extended, and palm facing upward. Discomfort at the medial epicondyle while holding the weight marks a positive test (5).

Treatment

Lateral and medial epicondylitis are self-limiting conditions, meaning that they will eventually get better without treatment. However, symptoms may sometimes last for weeks months which may be quite frustrating.

Resting the arm and stop doing the activity that caused the problem is a key issue. Hence, if you have tennis elbow, you may have to avoid playing tennis or stop carrying out manual tasks that may have caused the problem in the beginning. Alternatively, you may be able to modify the way you perform these types of movements so they do not place strain on your arm.

For athletes, the correction of faulty techniques is essential. Proper tennis stroke techniques can minimize the risk of elbow tendinopathy. In one study, instruction and stroke modification added to conservative therapy improved symptoms in 90 present of tennis players (7).

Bracing and Taping

Counterforce bracing is frequently used to treat lateral and medial epicondylitis.

Bracing applies pressure to the tendon origins of the forearm muscles, thereby reducing the forces transferred to the tendons themselves.

This method applies pressure to the tendon origins of the forearm muscles, thereby reducing the forces transferred to the tendons themselves.

Braces should be placed on the forearm 2-3 cm below the point of maximal tenderness.

Tapes that follow a similar principle may also be used. Kinesiology tapes are elastic stiffeners that are stuck to the appropriate place on the forearm (8).

Physical Therapy

Most clinicians recommend physical therapy to treat epicondylitis.

Several physical therapy programs are available. Many of them rely on eccentric and isometric strengthening of the muscles originating from the elbow.

Passive exercises and massage can also be used.

Medical Treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat lateral and medial epicondylitis.

NSAIDs may reduce pain and improve function in the short term (9). However, these agents should be used with caution due to their potential side effects (10).

Topical NSAIDs (eg, diclofenac gel) have become popular for treating tennis elbow and golf elbow. However, studies on these agents are preliminary.

Multiple trials show that glucocorticid injections improve short-term measures but do not prevent recurrence and may lead to worse long-term outcomes

Some clinicians also use glucocorticoid injections into the area of pain. The objective of such conservative care is to relieve pain and reduce inflammation, allowing sufficient rehabilitation and return to activities (11).

Multiple trials show that glucocorticoid injections improve short-term measures but do not prevent recurrence and may lead to worse long-term outcomes (6).

Studies indicate that topical nitroglycerin (applied to the skin) may improve symptoms (12).

Acupuncture

Sometimes, acupuncture is used to treat epicondylitis. It may provide short term benefits but evidence fur a sustained benefit is lacking.

Botulinum Injection

Some clinicians use injections of botulinum toxin A into the are of inflammation. However, this is not standard treatment and should be used with caution due to potential risks.

Surgery

In most cases, lateral and medial epicondylitis can be managed without surgery. Hence, surgical intervention is not recommended unless symptoms include severe pain or marked dysfunction for six months or longer (6).

Surgery may involve cutting or releasing the inflamed tendon, removing inflamed tissue, and fixing tendon tears if possible (13).

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