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An understandable guide to chest pain and why it should not be ignored.

heart-disease-visual-guide-s3-man-holding-heart

Image from: http://www.medicinenet.com/heart_disease_pictures_slideshow_visual_guide/article.htm

When experiencing chest pain the first thing that comes to mind is heart attack. However, there are numerous causes of chest pain. In fact, as much as a quarter of the U.S. population experiences chest pain that is not related to the heart. Chest pain may also be caused by problems in your lungs, esophagus, muscles, ribs, vasculature, and even nerves. Although not every cause of chest pain is from the heart, some of the other sources of chest pain can be life-threatening as well. For this reason, it is very important to see your doctor immediately about any chest pain that you have experienced.

 

CAUSES OF CHEST PAIN

Angina and Heart Attack:

What is a heart attack? A heart attack is when the blood supply to the heart becomes compromised. The heart needs oxygen in order to pump oxygen-rich blood to your body so when an artery that supplies your heart becomes blocked (often from atherosclerosis), the heart is not getting the blood it needs to function properly. This is called ischemia-tissue that is deprived of oxygen. This can eventually lead to infarction, which is death of the heart tissue.Chest tightness or pressure that radiates down the left arm is the most common presentation. However, it is extremely important to note that not everyone experiences heart attacks the same way so it is critical to see your doctor for any chest pain.

myocardial_infarction_small

Image shows dead or infarcted heart tissue after an occlusion due to an atherosclerotic plaque. Image courtesy of: http://www.tabletsmanual.com/wiki/read/myocardial_infarction

 

Risk factors for heart attack include:

  1. High cholesterol
  2. Hypertension
  3. Diabetes
  4. Genetic predisposition
  5. Smoking

heart-disease-visual-guide-s5-myocardial-infarction

This image shows normal heart vasculature on the left and the same heart with an occluded vessel on the right.

heart-disease-visual-guide-s6-plaque-buildup-in-artery

Image shows inside of an occluded vessel in the heart. This occlusion is the result of atherosclerotic plaque. This is known as coronary artery disease. The red blood cells are unable to get through the vessel resulting in a heart attack. Image from: http://www.medicinenet.com/heart_disease_pictures_slideshow_visual_guide/article.htm

 

Treatment:

Medicine and often surgery are needed to re-establish blood flow to the heart. Your cardiologist will use a special balloon to open the area of stenosis or attach a nearby artery to the blocked artery to restore blood flow.

 

 

Pulmonary Embolism

A pulmonary embolism is a blood clot that usually forms in the legs that has reached the lungs and occluded a vessel inside of the lung. The occlusion inhibits blood from reaching the lung. Moreover, when the lung is compromised in this manner, the rest of the body can be deprived of oxygen-rich blood that it needs in order to function. This can result in permanent damage to the lung tissue, damage to other organs in your body, and low oxygen circulation in your blood. Chest pain and shortness of breath are commonly associated with this condition.

 

DVT

A. DVT

PE

B. PE

Image: A blood clot forming at the distal femur  (A) and a blood clot and lung vasculature (B). Images from: http://www.medicinenet.com/heart_disease_pictures_slideshow_visual_guide/article.htm

 

Risk factors for a pulmonary embolus include:

  1. Prolonged sedentary state (long flights, being bedridden, sitting on couch).
  2. Recent surgery-especially hip surgery
  3. Birth control pill use
  4. Pregnancy
  5. Fractures
  6. Cancer

Image above shows a blood clot or pulmonary embolus trapped and occluding in the vein of the right lung. This occlusion can lead to ischemia (oxygen deprivation) and possible cell death.

Image above shows a blood clot or pulmonary embolus trapped and occluding a vein of the right lung. This occlusion can lead to ischemia (oxygen deprivation)of lung tissue and possible sudden death.  Image from: http://www.sirweb.org/patients/deep-vein-thrombosis/

 

Treatment:

Medicines known as blood thinners are used to treat pulmonary embolisms. Rarely, surgery may be indicated and a catheter will be placed into the vein in order to retrieve the clot or dissolve it on site. If necessary, a surgeon will put a filter into the femoral vein of the leg in order to catch any further clots.

 

Aortic Dissection:

The aorta is the biggest artery in the body.  It originates from the left ventricle and supplies virtually every part of the body with oxygenated blood.  A dissection is a tear of the innermost layer of tissue of the vessel.  This causes blood to flow into the middle layer of tissue and damages it causing it to become weak.  This is different from a ruptured aorta because there is not a hole in the vessel where blood can escape out.  Aortic dissection is often a surgical emergency that requires careful management. Aortic Dissection typically presents as a severe tearing pain that radiates to the back.

Image shows the two type A and one type B aortic dissection. In the DeBakey classification system, a type I dissection involves the entire aorta, while a type II dissection in­volves only the ascending aorta, and a type III dissection involves only the descending aorta. New staging systems that incorporate other aortic pathology have been devised, but are used primarily for research purposes.  Image from: http://www.bcmj.org/articles/aortic-interlude-dr-michael-debakey-aortic-dissection-and-screening-recommendations-abdomin

Image shows the two type A and one type B aortic dissection.In the DeBakey classification system, a type I dissection involves the entire aorta, while a type II dissection in­volves only the ascending aorta, and a type III dissection involves only the descending aorta. New staging systems that incorporate other aortic pathology have been devised, but are used primarily for research purposes.  Image from: http://www.bcmj.org/articles/aortic-interlude-dr-michael-debakey-aortic-dissection-and-screening-recommendations-abdomin

intima

Image shows the tear in the aorta is between the tunica intima (closest to the vessel lumen) and the tunica media (which is the middle layer of the artery). The blood accumulates in between these two layers and will eventually grow larger and larger and eventually can rupture the aorta due to increasing pressure.  Image taken from: http://quizlet.com/9121320/cp2-17b-anatomy-of-blood-vessels-flash-cards/

 

Risk Factors for aortic dissection include:

  1. Hypertension
  2. Marfan Syndrome
  3. Ehlers-Danlos Syndrome
  4. Polycystic Kidney Disease
  5. Pregnancy
  6. Cocaine use

Treatment:

Treatment includes emergency surgery for type A and medical intervention for type B. For more information on Aortic Dissection, please see our blog page: https://drbenzur.com/patient-resources/blog/

 

GERD

A very common cause of chest pain is GERD. GERD stands for gastroesophageal  Reflux Disease and is commonly known as heart burn. GERD occurs when stomach contents erupt through the esophagus. The pain from the stomach acid interacting with the lining of the esophagus can be confused with a heart attack.

GERDGERD

Image shows the lower esophageal sphincter closed on the left and relaxed on the right allowing acid and stomach contents to travel upward through the esophagus. Image from: http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/page2.htm

Risk Factors:

  1. Obesity
  2. Smoking
  3. Pregnancy
  4. Diabetes
  5. Asthma
  6. Dry Mouth
  7. Wearing pants too tight in the waist
  8. Hiatal hernia
  9. Connective tissue disease like Scleroderma
  10. Drinking too much carbonated beverages
  11. Excessive use of ibuprofen

Treatment:

  1. Avoid risk factors if possible
  2. Antacids
  3. Histamine type II receptor antagonists (H2RA’s)
  4. Proton Pump Inhibitors
  5. Endoscopic treatments to strengthen the sphincter muscle
  6. Avoid spicy and fatty foods

 

Pneumothorax:

A pneumothorax is commonly known as a collapsed lung. The lung is typically held against the chest wall by negative forces. However, due to trauma or spontaneous cause, the lung can become dislodged from the wall and collapse. Although typically seen in very tall and thin people, a pneumothorax can happen to anyone, especially in individuals with lung disease. A pneumothorax feels like a sudden sharp chest pain accompanied by a sudden shortness in breath.  Rarely, a tension pneumothorax can occur which is a medical emergency and must be treated immediately.

pneumo

Image from: http://www.medicinenet.com/pneumothorax/article.htm

 

Risk factors:

  1. Tall and think stature
  2. Asthma
  3. Any activity that may lead to trauma to the ribs
  4. Being male
  5. Smoking
  6. Being ages 20-40 years old
  7. Any lung disease-especially COPD
  8. Genetic  factors
  9. Mechanical ventilation
  10. A history of prior pneumothorax

 

Treatment Options:

A pneumothorax may go away on its own. However, if you have chest pain or think that you might have a pneumothorax, please see your doctor immediately or call 911. Typically, a physician will insert what is known as a chest tube into your pleural space. A pleural space is a small space between the lung and the chest wall that allows the lungs to move while breathing. The chest tube will be placed in the pleural space to decompress the area and restore negative pressure so that breathing and lung expansion return to normal. In rare cases where pneumothoraxes continue to occur, medical intervention may be needed to attach parts of the lung permanently to the chest wall to avoid further insults.

last pneumo

Image from: http://www.sw.org/HealthLibrary?page=NICU%20-%20Chest%20Tube

 

 

Costochondritis:

Costochondritis refers to inflammation of sternum (breastbone) where the ribs attach. Most cases happen spontaneously with no explanation.  However, trauma, viral infection, heavy lifting, tumors, and arthritis can also cause these symptoms. Costochondritis presents with chest pain that typically hurts when a deep breath is taken. In addition, it also becomes tender when the sternum is touched on its sides.

costo

Image shows the rib cartilage in blue that can become inflamed and feel like a heart attack. If you experience these symptoms, please see your doctor immediately or call 911.

Risk Factors:

Since most causes of this disease are unknown, the risk factors are unknown as well. It can be caused by heavy lifting so know your limitations.

Treatment:

  1. NSAID’s (Ibuprofen, Naproxen, etc.)
  2. Cortisol injection to affected area
  3. Bacterial causes should be treated with IV antibiotics and then followed by oral antibiotics for several weeks after.
  4. For costochondritis that does not resolve, surgery to remove the affected area may be warranted.

Pericarditis:

Pericarditis is typically caused by infection of the sac that surrounds the heart. This sac is called the pericardium, so when the sac becomes inflamed it is called pericarditis. Other causes for this inflammation are:

  • kidney failure
  • systemic lupus
  • cancer
  • heart attack
  • radiation
  • rheumatoid arthritis

The pain associated with pericarditis can cause shortness of breath and a sharp, intense pain that may radiate to the neck or arm. There may be pain in swallowing, coughing, and weakness and fatigue. A hallmark of this condition is that it is typically relieved when leaning forward and worsens while lying down. This condition can mimic many others so please consult your physician if you think you may have pericarditis. Pericarditis may present with nausea and even a fever and can lead to a more significant problem called cardiac tamponade. Cardiac tamponade is a condition in which the sac that surrounds the heart becomes so tight with fluid that it prevents blood flow from returning to the heart and requires surgery to drain this fluid.

pericardium

Image from Nucleus Medical Media, Inc.

Risk Factors:

Risk factors include a weakened immune system or any of the reasons listed above.

Treatment:

  1. NSAID’s
  2. Corticosteroids
  3. Antibiotics for bacterial infection of the pericardium
  4. A pericardiocentisis may be needed to drain fluid from the pericardial sac

 

Always remember, it’s better to be safe than sorry. Always consult your physician if you have chest pain or dial 911.

 

 

Uri M. Ben-Zur, M.D., F.A.C.C. completed a residency in internal medicine and fellowships in interventional cardiology, clinical cardiology, and clinical electrophysiology.  He currently practices at the The Paulette Tashnek-Wagner Cardiovascular Institute of Greater Los Angeles located in Tarzana, CA.

 

 

 

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