Chest Pain

Chest Pain and Angina

Angina: Don't Take It Lightly Heart disease remains the number one killer in the United States, and each case is a potential failure because risk management wasn't aggressive enough. There are five major risk factors for heart disease: smoking,
high blood pressure, high cholesterol, diabetes, and family history.

You can't do anything about the genes you inherited, but the other four need life long vigilance to minimize the risk of not only heart attack but also stroke and peripheral vascular disease. All risk factors involve narrowing of the arteries that supply blood to the body and the consequences that occur when organs don't get enough blood and start to fail. The chest pain from angina is a warning sign that a disaster may be on the horizon. The narrowing of a blood vessel to the heart occurs because of plaque or cholesterol buildup. When the plaque ruptures and completely blocks the artery, no blood will flow to parts of the heart muscle, and it begins to die. The clock starts when this occurs, and each minute that passes means that more heart cells die. When a patient gets to the hospital, the goal is to open the blood vessel with an angioplasty within 90 minutes.

Introduction
Chest pain is one of the most common complaints that will bring a patient to the Emergency Department. Seeking immediate care may be lifesaving, and considerable public education has been undertaken to get patients to access medical care when chest pain strikes. While the patient may be worried about a heart attack, there are many other causes of pain in the chest that the healthcare provider will need to consider. Some diagnoses are life threatening, while others are less dangerous. Deciding the cause of chest pain is sometimes very difficult and may require blood tests, xrays,CT scans and other tests to sort out the diagnosis. Often though, a careful history taken by the healthcare provider may be all that is needed to find the answer.

What are the sources of chest pain?

The source of pain may arise from a variety of potential sources:

the chest wall including the ribs, the muscles, and the skin; the back including the spine, the nerves, and the back muscles; the lung, the pleura (the lining of the lung) or the trachea; the heart including the pericardium (the sac that surrounds the heart); the aorta; the esophagus; the diaphragm, the flat muscle that separates the chest and abdominal cavities; referred pain from abdominal organs like the stomach, gallbladder, and pancreas.

While each source of chest pain may have a classic presentation of signs and symptoms, there is significant overlap among the symptoms of each condition, and the symptoms may also be affected by age, gender and race.

What are the causes of chest pain?

Pain can be caused by almost every structure in the chest. Different organs can produce different types of pain but unfortunately the pain is not specific to each cause. Each of the following causes is explained in detail in this article:

Broken or bruised ribs Pleuritis or pleurisy Pneumothorax Shingles Pneumonia Pulmonary embolus Angina Heart attack (myocardial infarction) Pericarditis The aorta and aortic dissection The esophagus and reflux esophagitis

Questions the doctor may ask about chest pain

When did the pain start? What is the quality of the pain? How long does the pain last? Does the pain come and go? What makes the pain better? What makes the pain worse? Does the pain radiate somewhere (move to another area of the body)? Has there been any preceding illness? Has there been any trauma? Have there been similar episodes of pain in the past?

Questions about the associated symptoms

Is there shortness of breath? Fever or chills? Cough? Nausea or vomiting? Sweating?

Questions about risk factors for disease Risk factors for heart disease

Smoking High blood pressure High cholesterol Diabetes Family history

Risk factors for pulmonary embolus (blood clot to the lung)

Prolonged inactivity such as bed rest, long car or airplane trips Recent surgery

Fractures Birth control pill use (particularly if the patient smokes cigarettes) Cancer

Risk factors for aortic dissection

High blood pressure Marfan syndrome Ehlers-Danlos syndrome Polycystic kidney disease Cocaine use Pregnancy

Physical examination helps refine the differential diagnosis. While chest pain may be the initial complaint, often the whole body needs to be examined. Example components of the physical exam may include: Vital signs

Blood pressure (BP), pulse rate (PR), respiratory rate (RR), temperature, and Oxygen saturation (O2 sat)

Head and neck

Looking for neck vein distension or bulging Listening over the carotid arteries for bruits (abnormal sounds) ormurmurs

Chest wall

Palpate for rib or muscle tenderness Look for rashes

Lungs

Listen for abnormal lung sounds or decreased air entry

Heart

Listen for abnormal heart sounds, murmurs or rubs (a friction sound made by two rough surfaces rubbing against each other, which may be seen with inflammation of the heart lining, called pericarditis) Listen for muffled heart tones