Chest Pain Overview If you are having severe pain, crushing, squeezing, or pressure in your chest that lasts

more than a few minutes, or if the pain moves into your neck, left shoulder, arm, or jaw, go immediately to a hospitalemergency department. Do not drive yourself. Call 911 for emergency transport. Chest pain is one of the most frightening symptoms a person can have. It is sometimes difficult even for a doctor or other medical professional to tell what is causing chest pain and whether it is life-threatening.
y

Any part of the chest can be the cause of the pain including theheart, lungs, esophagus,muscle, bone, and skin. Because of the complex nerve distribution in the body, chest pain may actually originate from another part of the body. The stomach or other organs in the belly (abdomen), for example, can cause chest pain. Potentially life-threatening causes of chest pain are as follows:

Heart attack (acute myocardial infarction): A heart attack occurs when blood flow to the arteries that supply the heart (coronary arteries) becomes blocked. With decreased blood flow, the muscle of the heart does not receive enough oxygen. This can cause damage, deterioration, and death of the heart muscle. Angina: Angina is chest pain related to an imbalance between the oxygen demand of the heart and the amount of oxygen delivered via the blood. It is caused by blockage or narrowing of the blood vessels that supply blood to the heart. Angina is different from a heart attack in that the arteries are not completely blocked, and it causes little or no permanent damage to the heart. "Stable" angina occurs repetitively and predictably while exercising and goes away with rest. "Unstable" angina results in unusual and unpredictable pain not relieved totally by rest, or pain that actually occurs at rest. Aortic dissection: The aorta is the main artery that supplies blood to the vital organs of the body, such as the brain, heart, kidneys, lungs, and intestines. Dissection means a tear in the inner lining of the aorta. This can cause massive internal bleeding and interrupt blood flow to the vital organs. Pulmonary embolism: A pulmonary embolus is a blood clot in one of the major blood vessels that supplies the lungs. It is a potentially life-threatening cause of chest pain but is not associated with the heart. Spontaneous pneumothorax: Often called a collapsed lung, this condition occurs when air enters the saclike space between the chest wall and the lung tissue. Normally, negative pressure in the chest cavity allows the lungs to expand. When a spontaneous pneumothorax occurs, air enters the chest cavity. When the pressure balance is lost, the lung is unable to re-expand. This cuts off the normal oxygen supply in the body. Perforated viscus: A perforated viscus is a hole or tear in the wall of any area of the gastrointestinal tract. This allows air to enter the abdominal cavity, which irritates the diaphragm, and can cause chest pain. Cocaine-induced chest pain: Cocaine causes the blood vessels in the body to constrict. This can decrease blood flow to the heart, causing chest pain. Cocaine also accelerates the progression of atherosclerosis, a risk factor for a heart attack. Causes of chest pain that are not immediately life-threatening include the following:

y y

Acute pericarditis: This is an inflammation of the pericardium, which is the sac that covers the heart. Mitral valve prolapse: Mitral valve prolapse is an abnormality of one of theheart valves in which the "leaves" of the valve bulge into the upper heart chamber during contraction. When this occurs, a small amount of blood flows backward in the heart. This is believed by some to be a cause of chest pain in certain people, although this has not been proven with certainty. Pneumonia: Pneumonia is an infection of the lung tissue. Chest pain occurs because of inflammation to the lining of the lungs. Disorders of the esophagus: Chest pain from esophageal disorders can be an alarming symptom because it often mimics chest pain from a heart attack.

Exams and Tests Heart Attack In the hospital emergency department, the healthcare providers use three basic procedures to decide if a patient is having a heart attack.
y y

The first is the symptoms reported by the patient. The second is an electrocardiogram (ECG or EKG), an electrical tracing of the heart's activity. On the ECG, it may be possible to tell which vessels in the heart are blocked or narrowed. The third is measurement of enzymesproduced by the heart muscle cells when they do not receive enough oxygen. These enzymes are detectable with blood tests and are called cardiac enzymes. Angina Angina is diagnosed by the same methods doctors use to diagnose heart attacks.

y y

In angina, the test results reveal no permanent damage to the heart. The diagnosis is made only after the possibility of a heart attack has been ruled out, usually by negative results on three sets of cardiac enzyme tests. Although the ECG may show abnormalities, these changes are often reversible. Another way to diagnose angina is the stress test: these tests monitor your ECG during exercise or other stress to identify blockages in blood vessels to the heart. Cardiac catheterization is used to identify blockages. This is a special type of x-ray (angiography or arteriography) that uses a harmless dye to highlight blockages or other abnormalities in blood vessels. Aortic Dissection

y y

The diagnosis of aortic dissection is based on the symptoms the patient describes,chest x-ray, and other special imaging tests.
y y

On a chest x-ray, the aorta will have an abnormal contour or appear widened. Transesophageal echocardiography is a specialized ultrasound of the heart in which a probe is inserted into the esophagus. The technique is performed under sedation or general anesthesia. The dissection may be identified very accurately by a CT scan of the chest or angiography. Pulmonary Embolism The diagnosis of pulmonary embolism is made from a variety of sources.

Description of the patient's symptoms and results of ECG and chest x-ray all may contribute to the diagnosis, but are not definitive. The patient will be asked if they have had any symptoms of a blood clot in the leg. The healthcare provider may draw blood drawn from the patient's artery to check the levels of oxygen and other gases. Abnormalities in blood gases indicate a problem in the lungs that is preventing the patient from getting enough oxygen. A ventilation-perfusion scan (V/Q scan) compares blood flow to oxygen intake in different segments of the lung. An irregularity in just one segment can indicate an embolism. A CT scan of the lungs is another way to determine if a patient has a pulmonary embolus. It may be done instead of the V/Q scan. Chest Pain Causes Heart Attack Causes A heart attack is caused by coronary heart disease, or coronary artery disease. Heart disease may be caused by cholesterol buildup in the coronary arteries (atherosclerosis), blood clots, or spasm of the vessels that supply blood to the heart. Risk factors for a heart attack are:

y y

y y y y y

high blood pressure diabetes smoking high cholesterol family history of heart attacks at ages younger than 60 years, one or more previous heart attacks, male gender obesity

Postmenopausal women are at higher risk than premenopausal women. This is thought to be due to loss of the protective effects of the hormone estrogen atmenopause. It was previously treated by hormone supplements (hormone replacement therapy, or HRT). However, research findings have changed our thinking on HRT; long-term HRT is no longer recommended for most women. Use of cocaine and similar stimulants. Angina Causes

y y

Angina may be caused by spasm, narrowing, or partial blockage of an artery that supplies blood to the heart. The most common cause is coronary heart disease, in which a blood clot or buildup of fatty material inside the blood vessel (atherosclerosis) reduces blood flow but does not completely block the blood vessel. Angina can be triggered by exercise or physical exertion, by emotional stress, or by certain heart rhythm disorders (arrhythmias) that cause the heart to beat very fast.

Chest Pain Symptoms Heart Attack Symptoms Typical heart attack pain occurs in the mid to left side of the chest and may also extend to the left shoulder, the left arm, the jaw, the stomach, or the back.
y y y

Other associated symptoms are shortness of breath, increased sweating, nausea, and vomiting. Symptoms vary considerably from person to person. Women may experience symptoms of heart attack similar to men (chest pain), but they also may be more atypical. Atypical symptoms include: neck, jaw, shoulder, upper back abdominal discomfort, shortness of breath, nausea or vomiting, abdominal pain, heartburn, sweatiness,

y y y y y y y y y y

y y y

lightheadedness, dizziness, or unexplained fatigue. Angina Symptoms Angina is similar to heart attack pain but occurs with physical exertion or exercise and is relieved by rest or nitroglycerin.

Angina becomes life threatening when pain occurs at rest, has increased in frequency or intensity, or is not relieved with at least three nitroglycerin tablets taken five minutes apart. This is considered to be unstable angina, which may be a warning sign of an impending heart attack. Aortic Dissection Symptoms The chest pain associated with aortic dissection occurs suddenly and is described as "ripping" or "tearing."

y y

The pain may radiate to the back or between the shoulder blades. Because the aorta supplies blood to the entire body, symptoms may also include: o angina-type pain,
o o o o

shortness of breath, fainting, abdominal pain, or symptoms of stroke.

Medical Treatment Heart Attack Treatment Treatment for a heart attack is aimed at increasing blood flow by opening arteries blocked or narrowed by a blood clot.
y y

Medicines used to achieve this include aspirin, heparin, and clot-busting (thrombolytic) drugs. Other medications can be used to slow the heart rate, which decreases the workload of the heart and reduces pain. Angioplasty is a way of unblocking an artery. Angiography is done first to locate narrowing or blockages. A very thin plastic tube called a catheter is inserted into the artery. A tiny balloon on the end of the catheter is inflated. This expands the artery, providing a wider passage for blood. The balloon is then deflated and removed. Sometimes a small metal scaffold called a stent is placed in the artery to keep it expanded. Surgery may be required if medical treatment is unsuccessful. This could include angioplasty or cardiac bypass.

Angina Treatment Treatment of angina is directed at relieving chest pain that occurs as the result of reduced blood flow to the heart.
y

The medication nitroglycerin is the most widely used treatment. Nitroglycerin dilates (widens) the coronary arteries. It is often taken under the tongue (sublingually). People with known angina may be treated with nitroglycerin for three doses, five minutes apart. If the pain remains, nitroglycerin is given by IV, and the patient is admitted to the hospital and monitored to rule out a heart attack. Long-term treatment after the first episode of angina focuses on reducing risk factors for atherosclerosis and heart disease. Aortic Dissection Treatment Suspected aortic dissection often is treated with medications that reduce blood pressure.

y y

y y y

Medications that slow the heart rate and dilate the arteries are the most widely used. Close monitoring is required to avoid lowering the blood pressure too much, which can be dangerous. Surgical repair is required for any dissection that involves the ascending (upward) portion of the aorta.

Prevention Heart Attack Prevention Prevention of heart attack and angina involves living what the American Heart Association calls a "heart healthy" lifestyle. Reducing your risk factors has a significant effect on reducing your risk.
y y y y y y y

Don't smoke. Maintain a healthy weight. Eat nutritious, low-fat foods in moderate quantities. If you drink alcohol, use alcohol moderately. Engage in physical activity or exercise for at least 30 minutes every day. Control high blood pressure and high cholesterol. If you have diabetes, control your blood sugar every day. Aortic Dissection Prevention Aortic dissection may be prevented by controlling high blood pressure and getting proper screening if the patient has a familial disposition to this disorder.

Pulmonary Embolism Prevention Prevention of pulmonary embolism includes living a heart healthy lifestyle.
y

No one should smoke, but women older than 35 years who use birth control pills are at especially high risk from smoking. When traveling on extended trips that require sitting for long periods of time (plane, car, train, etc.) or other times of leg immobilization, get up and allow time for stretching and movement of the legs. Isometric contractions of the calves are helpful if getting out of the seat is not possible. If the patient has leg swelling, particularly if one is disproportionate to the other, see the doctor or healthcare provider. You should always receive preventive anticoagulant medication after surgery, especially after orthopedic surgery.

Symptoms By Mayo Clinic staff A wide range of health problems can cause chest pain. In many cases, the underlying cause has nothing to do with your heart though there's no easy way to tell without seeing a doctor. Heart-related chest pain Although chest pain is commonly attributed to heart disease, many heart patients experience a vague discomfort and they often specifically mention that pain does not seem to be an adequate description. In general, chest discomfort related to a heart attack or another heart problem may be associated with one or more of the following:
y y

Pressure, fullness or tightness in your chest Crushing or searing pain that radiates to your back, neck, jaw, shoulders and arms particularly your left arm Pain that lasts more than a few minutes, goes away and comes back or varies in intensity Shortness of breath, sweating, dizziness or nausea Other types of chest pain It can be difficult to distinguish chest pain due to a heart problem from other types of chest pain. However, chest pain that is less likely due to a heart problem is more often associated with:

y y

y y y y y

A sour taste or a sensation of food re-entering your mouth Trouble swallowing Pain that gets better or worse when you change your body position Pain that intensifies when you breathe deeply or cough Tenderness when you push on your chest The classic symptoms of heartburn a painful, burning sensation behind your breastbone can be caused by problems with your heart or your stomach. When to see a doctor If you have new or unexplained chest pain or suspect you're having a heart attack, call for emergency medical help immediately. Causes By Mayo Clinic staff

Chest pain

Chest pain has many possible causes, all of which deserve medical attention. Heart-related causes Examples of heart-related causes of chest pain include:
y y

Heart attack. A heart attack is a result of a blood clot that's blocking blood flow to your heart muscle. Angina. Thick plaques can gradually build up on the inner walls of the arteries that carry blood to your heart. These plaques narrow the arteries and restrict the heart's blood supply, particularly during exertion. Aortic dissection. This life-threatening condition involves the main artery leading from your heart your aorta. If the inner layers of this blood vessel separate, blood will be forced between the layers and can cause the aorta to rupture. Pericarditis. This condition, an inflammation of the sac surrounding your heart, is short-lived and often related to a viral infection. Digestive causes Chest pain can be caused by disorders of the digestive system, including:

Heartburn. This painful, burning sensation behind your breastbone occurs when stomach acid washes up from your stomach into the esophagus the tube that connects your throat to your stomach. Swallowing disorders. Disorders of the esophagus can make swallowing difficult and even painful. Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder or pancreas can cause abdominal pain that radiates to your chest. Muscle and bone causes Some types of chest pain are associated with injuries and other problems affecting the structures that make up the chest wall. Examples include:

y y

Costochondritis. In this condition, the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed and painful. Sore muscles. Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain. Injured ribs. A bruised or broken rib can cause chest pain. Lung-related causes Many lung disorders can cause chest pain, including:

Pulmonary embolism. This cause of chest pain occurs when a blood clot becomes lodged in a lung (pulmonary) artery, blocking blood flow to lung tissue. Pleurisy. If the membrane that covers your lungs becomes inflamed, it can cause chest pain that's made worse when you inhale or cough. Collapsed lung. The chest pain associated with a collapsed lung typically begins suddenly and can last for hours. A collapsed lung occurs when air leaks into the space between the lung and the ribs. Pulmonary hypertension. High blood pressure in the arteries carrying blood to the lungs (pulmonary hypertension) also can produce chest pain. Other causes Chest pain can also be caused by:

Panic attack. If you experience periods of intense fear accompanied by chest pain, rapid heartbeat, rapid breathing, profuse sweating and shortness of breath, you may be experiencing a panic attack. Shingles. Caused by a reactivation of the chickenpox virus, shingles can produce pain and a band of blisters from your back around to your chest wall. Treatments and drugs By Mayo Clinic staff

Treatment will vary, depending on the underlying cause of your chest pain. Medications Drugs used to treat some of the most common causes of chest pain include:
y

Artery relaxers. Nitroglycerin usually taken as a tablet under the tongue relaxes heart arteries, so blood can flow more easily through the narrowed spaces. Some blood pressure medicines also relax and widen blood vessels. Clot-busting drugs. If you are having a heart attack, you may receive drugs that work to dissolve the clot that is blocking blood from reaching your heart muscle. Blood thinners. If you have a clot in an artery feeding your heart or lungs, you'll be given drugs that inhibit blood clotting to help prevent more clots from forming. Antacids. If your chest pain is caused by stomach acid splashing up your esophagus, the doctor may suggest medications that reduce the amount of acid in your stomach. Anti-anxiety drugs. If you are experiencing panic attacks, your doctor may prescribe anti-anxiety drugs to help control your symptoms. Surgical and other procedures Procedures used to treat some of the most dangerous causes of chest pain include:

Balloons and stents. If your chest pain is caused by a blockage in an artery feeding your heart, doctors insert narrow tubing into a large blood vessel in your groin and then thread it up to the blockage. They then deploy a balloon to reopen the artery. In many cases, a small wire mesh tube (stent) is inserted to keep the artery open. Bypass surgery. During this procedure, surgeons take a blood vessel from another part of your body and use it to create an alternative route for blood to go around the blocked artery. Dissection repair. You may need emergency surgery to repair an aortic dissection a lifethreatening condition that can result in the rupture of the artery that carries blood from your heart to the rest of your body. Lung reinflation. If you have a collapsed lung, doctors may insert a tube in your chest, which allows the lung to reinflate.

Tests and diagnosis By Mayo Clinic staff

Chest pain doesn't always signal a heart attack. But that's what emergency room doctors will test for first because it's potentially the most immediate threat to your life. They may also check for lifethreatening lung conditions such as a collapsed lung or a clot in your lung. Immediate tests Some of the first tests you may undergo include:
y

Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show that a heart attack has occurred or is in progress. Blood tests. Your doctor may order blood tests to check for increased levels of certain enzymes normally found in heart muscle. Damage to heart cells from a heart attack may allow these enzymes to leak, over a period of hours, into your blood. Chest X-ray. An X-ray of your chest allows doctors to check the condition of your lungs and the size and shape of your heart and major blood vessels. A chest X-ray can also reveal lung problems such as pneumonia or a collapsed lung. Follow-up testing Depending upon the results from these initial tests, you may need follow-up testing, which may include:

Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart in motion. In some cases, a small device may be passed down your throat to obtain better views of different parts of your heart. Computerized tomography (CT scan). Different types of CT scans can be used to check your heart arteries for signs of calcium, which indicate areas where plaque blockages are accumulating. CT scans can also be done with dye to check your heart and lung arteries for blockages and other problems. Magnetic resonance imaging (MRI). MRI is an imaging technique that uses magnetic fields and radio waves to create cross-sectional images of your body. MRI of the heart is sometimes done to look for evidence of damage to the heart or aorta. Stress tests. These measure how your heart and blood vessels respond to exertion, which may indicate if your pain is related to your heart. There are many kinds of stress tests. You may be asked to walk on a treadmill or pedal a stationary bike while hooked up to an ECG. Or you may be given a drug intravenously to stimulate your heart in a way similar to exercise. Coronary catheterization (angiogram). This test helps doctors identify individual arteries to your heart that may be narrowed or blocked. A liquid dye is injected into the arteries of your heart through a catheter a long, thin tube that's fed through an artery, usually in your groin, to arteries in your heart. As the dye fills your arteries, they become visible on X-ray and video.