Most common reason for Emergency Room
Chest pain is the second most common reason for Emergency Room (ER) visits, and for most patients the first question is "Is It My Heart?"
Two Main Types of Chest Pain
How do we distinguish between the various causes of chest pain? Fortunately, the chest pain of coronary (heart) disease, anginal pain, which is due to insufficient supply of oxygen rich blood to the heart, has several characteristics. This pain is unlike all other types of chest pain, called nonanginal pain.
Typical Angina and its variants have several features, which generally include three or more of the following:
- Heaviness, squeezing, tightness or a crushing sensation felt in the front of the chest substantially (behind the breastbone) or between the shoulder blades
- Pain is precipitated by exertion, stress, meals, or cold
- Prompt relief with rest or nitroglycerine
- Pain frequently radiates to the shoulders, upper arms, face, neck or jaws
- When present, the pain usually causes the patient to stop all activities and remain at rest
Nonanginal Chest Pain is any type of chest pain other than that described above. It may occur anywhere in the chest, but does not radiate. The pain is not related to exertion, and almost always lasts less than 10 seconds or more than 10 minutes. It does not usually cause the patient to stop his activities. There is NO consistent relationship between rest or nitroglycerine and pain relief. Nonanginal or "no sweat" chest pain is much more common in younger patients, just as coronary or anginal pain increases in frequency with age and in males. Only about one out of ten patients presenting to their doctor with chest pain has a serious medical condition.
A GOOD DESCRIPTION of the chest pain is one of the most important keys to diagnosis. Angina is a powerful indicator of coronary disease, while nonanginal chest pain strongly favors a non-coronary cause. Following are three clinical histories to illustrate the two main categories.
Case 1:
A 63-year-old man is brought to the ER with a history of two hours of persistent frontal chest pain with nausea which he self-diagnosed as "a bad case of indigestion." When questioned further he admitted to tightness and heaviness in the front of the chest spreading to the shoulders and neck, sweating, and extreme weakness. His cardiogram and other finding were typical of an acute coronary (AMI-acute myocardial infarction).
Comment: New anginal chest pain as in the above case, lasting more than 15-20 minutes, should raise the high suspicion of an acute coronary (heart attack). Frequently patients describe the pain, particularly if accompanied by nausea or vomiting, as indigestion or heartburn. (Chronic recurrent angina that is precipitated by exertion, meals, or stress, and that is not relieved by rest or nitroglycerine should not be confused with the persistent anginal pain of a heart attack).
Case 2:
A 42 year old woman visited her physician on and off for five years because of recurrent aching over her left chest "under the heart", which would come on unexpectedly every few weeks or months, and lasting anywhere from minutes to hours. Sometimes she complained of sudden, sharp, poorly localized stabbing chest pains appearing "out of nowhere." She was high strung and admitted that sometimes the pain was related to stress, sometimes not. There was no relief with rest or nitroglycerine. She also complained of frequent sighing, and occasionally, feeling a "lump in her throat." The patient was subjected to a "search and destroy" diagnostic strategy with endless cardiograms, stress tests, upper endoscopies, and ultimately a coronary angiogram. All tests were normal.
Comment: This is a typical example of nonspecific chest pain syndrome, a leading cause of non-coronary chest pain. This type of pain is often described as stabbing or knife-like, prolonged, dull, or aching, and can last for moments, hours, or days, but may present with many faces.
Case 3:
A 25 year old woman was brought to the ER by her terrified boyfriend who informed the receptionist, "She's having a heart attack, she's gotta be seen immediately." The patient was pale, talking hesitantly, and between short, rapid breaths, complained of chest pain, difficulty breathing, and numbness about the mouth. On examination she appeared anxious, had a rapid pulse and respiratory rate, with a normal blood pressure. While the intern was attending her, a resident who was passing by quickly assessed the patient, called for a paper bag, and asked the patient to breathe in and out into the bag. Within minutes she felt better, the chest pain was gone, and she was discharged.
Comment: This case can also be classified as nonspecific chest pain, although some prefer to call it panic disorder or hyperventilation syndrome. Brought on by acute, unconscious or unrecognized anxiety, the patient begins to take short, rapid breaths. If this state of over breathing continues more than several minutes, the patient can lower blood calcium, causing a cascade of frightening symptoms, including chest pain or pressure, and numbness of the lips. Breathing into a paper bag reverses the process by restoring blood calcium to normal.
Gastrointestinal (GI) Chest Pain
Various common conditions of the esophagus and stomach are the second most common cause of nonanginal chest pain, accounting for up to a third of all cases. Esophageal conditions causing chest pain include the very common gastro esophageal, or GE, reflux, caused by regurgitation of stomach acid, commonly called heartburn. Sometimes disorders of swallowing may be related to chest pain. Other common causes are ulcer disease and ulcer symptoms without an ulcer. Rarely does gall bladder disease cause this kind of chest pain.
Other Non-Coronary Causes of Chest Pain
A number of other conditions may cause chest pain. Overall, they account for less than 15% - 20% of all cases. Important among these are inflammation of the rib cartilage, fractures, muscular strain, pneumonia, a blood clot to the lung, and serious abdominal conditions, such as abscess and appendicitis.
Chest pain, a common medical complaint, and a leading cause of ER visits and hospitalizations for heart attack, has many causes other than coronary disease. I have tried to simplify the understanding of chest pain by describing the principal differences between serious and "no sweat" chest pain, and by stressing two of the most common causes of the latter: nonspecific chest pain, and problems arising in the upper gastrointestinal tract. However, the diagnosis in patients with chest pain can be more difficult than I have outlined, especially when anginal and nonanginal pains coexist.
I firmly believe that the informed patient is far better off than the medically unsophisticated. Yet I continue to tell my patients, no matter how much they know:
ANY TYPE OF UNEXPLAINED CHEST PAIN ALWAYS CALLS FOR IMMEDIATE MEDICAL ATTENTION!
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"Most common reason for Emergency Room"
authored by:
Dr. Sturman has practiced internal medicine and endocrinology for eight years in New York City and seven years in Connecticut, where he was Chief of Endocrinology at the Bridgeport Hospital and subsequently assistant Professor of Radiology and Associ...
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