A patient comes in for “chest pain.” We determine right off that it’s “non-pleuritic,” meaning that it does not feel worse every time they take a breath or cough. We also find out if it’s continuous, or comes & goes; if it’s intermittent, how long does it last, how often does it occur? The topic mainly addresses acute pain, of recent onset. Our Table below lists the possible causes.
Causes of Non-Pleuritic Chest Pain
|Possibly Life-Threatening||Not Serious|
|** Coronary Artery Disease — either:|
xx— Angina Pectoris
xx— Myocardial Infarction (M.I.; heart attack)
** Thoracic Aortic Aneurysm (ruptured)
|Abdominal Diseases — especially:|
x— Esophageal Reflux (GERD) (heartburn) or
x— Dyspepsia (indigestion)
** Chest Wall Pain (e.g. muscle strain)
** Herpes Zoster (Shingles)
** Rib Fracture (without trauma)
** Breast Conditions
The diseases listed above can either come and go, or cause persistent pain. The only ones that are not intermittent are Myocardial Infarction, Thoracic Aneurysm and Herpes Zoster; once they occur, the pain remains until you get better or die (from an aneurysm, not from Zoster).
We certainly don’t want to miss our main concern, Diagnosing Coronary Artery Disease (see link for discussion; this is what causes either a Heart Attack (M.I.) or Angina). The other causes of non-pleuritic chest pain are more benign… usually.
** Aneurysms of the Thoracic Aorta aren’t so benign; in fact, once they tear or rupture, they’re usually fatal. Before that happens, they have no symptoms at all; fortunately, they’re pretty rare. These aneurysms, weakening and gradual ballooning out of the body’s main artery (the aorta) as it leaves the heart and curves across the chest, usually occur in patients over 60 years old with cardiovascular risks (smoking, hypertension, diabetes, high cholesterol). Younger patients are those with the very rare Marfan’s syndrome or a congenital heart abnormality from birth (bicuspid aortic valves).
Our main clue is sudden onset chest pain, which makes sense, since the intact aneurysm is usually asymptomatic. Pain is severe, described as “sharp,” “tearing” or “ripping,” as opposed to the dull, heavy ache of a heart attack. It may radiate to the back or anywhere, or remain in the chest.
Findings on exam might include a blood pressure more than 20 mmHg higher in the right arm than the left, or an absent pulse in the carotid artery or in the wrist, but these are usually not present. The chest x-ray (CXR) may reveal telltale abnormalities, but is normal in 1/3 of cases.
Bottom line: sudden onset of severe sharp or tearing chest pain in a patient at risk warrants a Chest CT Scan in the E.R.
** Abdominal Diseases such as Gastro-Esophageal Reflux Disease (GERD) (heartburn) or Dyspepsia (indigestion) mimic cardiac pain, because both organs share the same nerve pathways. We think of these when pain occurs after swallowing, or when supine in bed, or is accompanied by heartburn or acid regurgitation. The pain can be brief, or last hours. If there’s a sense of food getting stuck when swallowing (“dysphagia”), it’s likely due to GERD, but if it goes on persistently for one to two weeks, we refer for a Gastroenterologist to perform endoscopy to rule out esophageal cancer.
Most of all, we diagnose these abdominal diseases in the patient without cardiac risk factors. Symptoms can be so similar, that GERD / Dyspepsia are almost a “diagnosis of exclusion” (left over after ruling out everything else). As in our discussion of Coronary Artery Disease, the absence of cardiac risks is a good reason to rule out Angina or M.I., especially if pain does not increase during exertion.
Duration and Time Frame are also important — Angina lasts under 5 minutes, and recurs. Heavy chest pain lasting longer could be an M.I. if it began recently. But if the pain lasts 30 minutes or more, goes away and then recurs on a regular basis for days or weeks, it’s not the heart. Most likely GERD / Dyspepsia.
There’s no good test to diagnose GERD / Dyspepsia, except for careful history-taking. Endoscopy and barium x-rays can find scars, strictures, & cancer, but not plain-old acid reflux. There are more complex exams, but rarely done unless surgery is contemplated (see the link). Usually we just give a trial of antacid medications; if the treatment helps, the patient feels happy & so do we (even if there’s always placebo effect).
** Herpes Zoster (Shingles) is recurrence of Varicella virus; initial Varicella is called “chickenpox”. Chickenpox causes fever & an itchy rash all over, lasts a week & goes away, but latent virus remains hidden in a nerve. From there, it often reactivates many years later. When it reactivates, it causes pain along the nerve pathway (not itching), with clusters of blisters which merge into crusts.
Zoster can mimic heart pain if a left-sided chest nerve is involved. Diagnosis can be tricky at first, if not impossible, since pain may precede skin lesions by 1-2 days. We’d search the skin for even the tiniest splotches of redness or blisters, anywhere from spine to breast bone. Don’t freak out about the name; Zoster is just in the same family as the STD Herpes simplex, but it’s a completely different virus (there’s no STD of the chest).
If we diagnose Zoster for sure in a patient younger than 50, we suggest an HIV test. It’ll probably be negative, but almost everyone with HIV gets Zoster at some point, due to even very subtle immune deficiency. Not that you can’t get HIV over 50, but age by itself is enough to cause Zoster reactivation. When it comes to Zoster, 50 is “elderly” (that’s when I began to get AARP mailings. Hemlock & Neptune Societies pitches too!!!).
** “Chest Wall Pain” might feel pleuritic (with deep breaths), or might not, just hurt regardless. Certain movements of the shoulder or torso (twisting, reaching, etc.) bring it out. Often we find tenderness on palpating the chest, pushing on & between the ribs. However, if this tenderness is localized to a point on just one rib, & it’s tender there when we pound on the same rib at a different spot, we worry about a non-traumatic Rib Fracture & order a Rib X-ray (not “chest”). A rib fracture without trauma could be metastatic bone cancer.
You may hear of some diagnoses like “costochondritis” & “intercostal neuralgia” that float around. I think they’re phony, because they sound so medical. The clinician didn’t want to say, “you pulled a muscle, tendon, or ligament, but it’s not your heart or lung,” so they came up with a fancy word. There is a condition called Tietze’s Syndrome, when the cartilage connecting rib to breastbone becomes red, hot & swollen. That’s obvious, dramatic, and very rare; it requires a work-up for Lupus & other such auto-immune diseases.
** Breast Disorders are sometimes perceived as “chest pain,” particularly in men and in women with small breasts. If in doubt, palpating the breast itself locates tenderness and clarifies the issue.
** Anxiety can cause chest pain. Patients with panic disorder may experience chest tightness, along with heart palpitations, sweating, sensation of suffocation, nausea, lightheadedness, tremor, and/or intense fear. Of course, a frank heart attack can also generate all of the above, including fear. Any cause of chest pain can cause anxiety.
One might consider Anxiety is if the patient has no risk factors for Coronary Artery Disease (CAD). Other clues include pain not getting worse with exertion (sometimes even feeling better with exercise), and presence of tingling in the hands and mouth [symptoms of Hyperventilation, not “true” Shortness of Breath]. Chest pain at night lying in bed is virtually always anxiety. When caring for a patient in the midst of a possible panic attack, don’t forget to inquire about stimulant use. Cocaine and Meth can cause panic, & also a heart attack.
Obviously, a person with CAD risk factors can also get a panic attack. The diagnosis then becomes harder, so we likely act as if it could be the heart, and do whatever tests necessary. Panic disorder usually begins at a younger age, so by the time the patient is “elderly,” they can tell if it’s their usual panic attack, or something different. Then there’s also an uncommon and newly-recognized condition “SCAD”, tearing of a heart artery for unknown causes (or rare diseases of the arteries) occurring in young women, and causing heart attacks.
A 25 y.o. fellow came to my ER with chest pain, which began during a poker game (aha!). Turned out that the patient’s Dad, who’d had a heart attack a month before, was losing heavily. My patient subconsciously developed symptoms, a psychological “conversion reaction” (not faking it), to get taken to the hospital. And the Dad kept on playing [& losing] for another hour before driving his son in!
Like GERD & chest wall pain, anxiety is a diagnosis of exclusion. We don’t necessarily need stress tests or cardiac catheterization, or even an EKG if the diagnosis seems obvious. But of course, a simple EKG will reassure the patient; not ordering it may increase the anxiety.
CHRONIC NON-PLEURITIC CHEST PAIN —
Chest pain that comes & goes, lasting weeks or months, is surely due to Esophageal Disease (esp. GERD), possibly a Muscle Strain, or Anxiety. None of the other Diseases last that long.
See also Non-Pleuritic Chest Pain for the clinician’s condensed thought-process when face-to-face with a patient.