Chest Pain is a common yet difficult condition to diagnose. Most chest pains or discomforts are benign, however, some may be a harbinger of serious cardiac emergencies. It is often alarming as the 1st episode may result in instantaneous collapse and sudden death.
About 2/3rds of chest pain are non-organic. Non-organic means not due to heart, lungs, esophagus diseases. About 30 % are due to muscular or rib conditions and about 10% are due to esophagus related disorders. Serious chest pains only form about 10% of the patients attending a doctor. However as the 1st episode itself may be due to a “heart attack” or Acute Myocardial Infarction, all chest pain cases need to be dealt with in detail. The episodes which also include heart attacks, unstable anginas or similar pains due to suspected heart ischemia are clubbed together as Acute Coronary Syndrome or ACS. This helps in deciding which patients need to be admitted or observed.
Ischemic chest pains may be recurrent, appear after a certain quantity of physical exercise, get relieved by rest or nitrate tablets under the tongue are called angina or stable angina.
The ones due to Myocardial Infarctions may be difficult to describe, occur only once or a few times in the life of an individual. These may spread to one or both arms, shoulder/shoulders or jaws. This can be accompanied by nausea, vomiting, collapse, profuse sweating or fatigue. These increase over minutes to hours. In case a myocardial infarction is suspected, aspirin in a dose of about 300 mg is given to the patient to be chewed. In case blood pressure is stable, he or she is given a sublingual nitrate and oxygen is administered if blood levels are low or not available.
Chest pains which have increased in frequency, occur at night, have become more severe or longer lasting, occur at night may suggest Unstable Angina.
Women may describe the pain as more severe and sharp compared to men.
The diagnosis of most of these cases is based on meticulous history, ECGs, Cardiac enzymes and serial observations of these. Based only on clinical evidence the diagnosis may often be wrong.
In cases of chronic stable angina, stress testing, isotope scan (Stress Thallium), provocation tests or angiography may be required.
It is important to know the risk factors for the likelihood of ischemic disease. These are age, male sex, smoking, high blood pressure, diabetes, high levels of lipids in the blood, sedentary lifestyle etc. The more the risk factors, the more likely is the occurrence of ischemic heart disease.
Non-organic cases may be due to anxiety, panic disorders etc. Musculo-skeletal causes include costochondritis (inflammation of rib cartilages). Acid peptic disease, diseases of lungs are also common but relatively simpler to diagnose. Very severe tearing pain may rarely be due to a tear in the aorta (called aortic dissection) and in hospitalized patients, Pulmonary Thromboembolism may be the underlying cause. These are rare but result in fatalities if remain undiagnosed.