Chest Pain - Signs and Causes

A chest pain does not necessarily mean a heart attack. Most people seeking medical care in emergency rooms because of chest pain are not having a heart attack, but less severe problems such as muscle pain, reflux or anxiety attacks.

However, because chest pain can mean a health-threatening, the best thing is not to risk but check. Many patients delay seeking help for a heart attack because they think the symptoms are not severe or that the pain will improve spontaneously. Often, this waiting time at home can be that period between surviving and having a heart attack.
Chest pain
Chest pain


A study done some years ago at the University of Michigan evaluated 400 patients who arrived at the emergency sector with complaints of chest pains. The diagnostic evaluation showed that 53% had no organic etiology, or their chest pains were not caused by any disease of the internal organs such as heart, lungs and esophageal cancer, for example. More than a half were only cases of anxiety. 36% were caused by musculoskeletal pain or disorders of the esophagus, and only 11% were due to more serious causes such as cardiovascular disease.

So let's talk a bit about chest pain, emphasizing the danger signals. It's always good to remember that what follows are only general guidelines and should never be a basis for self-diagnostics. Only a physician, through clinical history, physical examination and complementary examinations, when necessary, may establish diagnosis for chest pain.

At times I use the term thorax pain instead of chest pain, since this is more accurate, because many diseases that can manifest themselves as chest pain, may do so by involving the entire chest, including the back. Also it's worth saying that the term does not include a heart attack, calling it in the most correct way, i.e., myocardial infarction or ischemic heart disease.

What factors are important in the evaluation of chest pain?

There are two major factors in the clinical evaluation of chest pain:
  • Characteristics of pain
  • A history of the patient

Characteristics of chest pain

When you have a chest pain, the first thing you should try to clarify is whether it indicates an anginal pain, or pain of cardiac ischemia (heart attack). Angina pectoris presents some typical characteristics that can be used to remove or raise the suspicion of cardiovascular disease.

Anginal pain
Anginal pain
Characteristics of chest pain of cardiac ischemia:
  • It is more of a burden or a strong feeling of tightness in the chest than a proper pain (it's very common for the patient to describe the pain touching his fist in front of the chest, to show that the pain is in distress)
  • It is triggered by physical exertion or emotional stress
  • There is a diffuse pain on the left and center of the chest, often radiating to left arm, back and / or neck
  • It is accompanied by sweating, shortness of breath, pallor, or hypotension
  • It is accompanied by palpitations
  • There can be a pain that lasts several minutes
  • There is a pain that does not yield to common analgesics
  • A sign of extreme gravity that speaks in favor of heart disease is the loss of consciousness after the onset of chest pain

In most cases the infarct presents as very annoying and severe pain. However, the intensity of pain is not a determining factor, since up to one third of heart attacks occur with mild discomfort. Diabetics or elderly patients may have mild pain, and sometimes complain more of fatigue and malaise than actually chest pain.

Characteristics of chest pain that speak against cardiac ischemia:
  • There is a pain that lasts a few seconds and occurs without physical exertion or emotional stress
  • A short-term pain that comes and goes without precise triggering factors
  • Pain is very well located, and the patient is able to point the exactly where it aches
  • Pain worsens when you press the spot with your finger or make any movement in the chest
  • There can be a stabbing pain that worsens with deep breathing that often comes from another heart attack
  • There can be a pain that comes and goes many years without signs of progression or worsening
  • Pain can improve with a simple analgesic
  • Pain does not radiate and is not accompanied by other symptoms such as shortness of breath, sweating, vomiting, hypotension, etc...

We must emphasize that the above mentioned features are only guidelines, and are in no way sufficient to rule out or diagnose chest pain. Some people with anxiety attacks can present symptoms very similar to a heart attack, complaining of palpitations, sweating, shortness of breath, dizziness, etc...

It is also worth remembering that cardiac ischemia is not the only cause of severe chest pain, which may also be caused by pneumonia, pulmonary embolism and aortic aneurysm, for example, diseases with distinct symptoms of myocardial infarction.

A history of the patient with chest pain

In addition to the pain characteristics, clinical data from the patient are also extremely relevant. The approach of a chest pain in a patient of 19 years is completely different from a patient of 63 years, obese, with a history of diabetes, hypertension and smoking.

The more risk factors for cardiovascular disease a patient has, the greater are the chances of chest pain to indicate a more severe disease. The question is can a patient without known risk factors for heart attack develop it? It may happen but it is uncommon, and this should always be taken into account.

The main risk factors for cardiovascular disease should be evaluated in a patient with chest pain are:
Chest pain risk
Chest pain risk

From the data discussed above, along with physical examination, the doctor is able to establish the differential diagnosis for patient's chest pain. If clinical assessment indicates a risk of pain of cardiac origin, the doctor will order tests to diagnose or rule out this cause. In evaluations of chest pain it is often more important to rule out serious causes than to establish a definitive diagnosis for the pain.

Causes of chest pain

Chest pain always brings the fear of a heart attack, but there are dozens of causes for chest pain. In fact, chest pain can be caused by disease in any of the organs inside and outside the thorax, including heart, esophagus, lungs, pleura, mediastinum, great vessels, ribs, cartilage, joints, chest muscles, skin etc...

Below there is a list of the main causes of chest pain, some already covered in other texts on this site:
Chest pain causes
Chest pain causes
  • Aortic aneurysm
  • Pneumothorax
  • Pleural effusion
  • Pulmonary embolism
  • Pneumonia
  • Gastroesophageal reflux
  • Pericarditis (inflammation of the pericardium)
  • Tumors of the lung or mediastinum
  • Esophagitis (inflammation of the esophagus)
  • Spasm of the esophagus
  • Pulmonary hypertension
  • Costochondritis (inflammation of the cartilage connecting the ribs to the sternum)
  • Lesions in the ribs
  • Muscle injuries
  • Arthritis
  • Fibromyalgia
  • Rheumatoid arthritis
  • Herpes zoster

In addition to the organs and tissues of the chest, sometimes problems in the organs of the abdomen can also cause chest pain, including:
As can be seen, the diagnosis of chest pain is very complex, since this symptom may indicate a wide range of different diseases. When in doubt, the ideal is to visit a doctor. If your pain is different from what you felt before, seek professional help, especially if you have risk factors for cardiovascular disease.

Anxiety and gases as a cause of chest pain

People with anxiety attacks, panic attacks, depression and hypochondria also often have frequent chest pains. At least one third of patients who go to emergency rooms with chest pain, do so at root psychological / psychiatric causes.

The relationship between gas and chest pain is well known. Usually the pain does not provoke gases in the chest, but in the lower ribs, which we call hypochondrium. These pains occur due to dilatation of the stomach and esophagus, often pinching the nerves around them. People with hiatal hernia, a condition when there is a protrusion of the stomach into the thorax, may have chest pain with accumulation of gas in the stomach.

Another common cause of pain in the hypochondrium and ribs, but that can be confused with chest pain that occurs after strenuous exercise. This pain is caused by muscle fatigue responsible for breathing. It can appear during exercise, but is quite different from the pain of heart attack, because it occurs late in the activity, does not radiate, is very localized, it is not right in the chest, and looks more like a cramp than the crushing pain as in case of the infarct.

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User discussion

25 July 2012
In the case of a patient having a myocardial infarction, treatment is surgery or may be drug? My father is having symptoms and has already marked this cardiologist.
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