Patients sometimes come to the urgent care or go to their family medicine clinic when they have chest pain. Usually, they should be evaluated in the hospital emergency department where more advanced testing can be performed and quick treatments can be delivered in the event the pain is related to the heart.
The cause of the pain is sometimes difficult to determine but it generally originates from an organ in the chest area such as the heart, lung, esophagus or from the chest wall (skin, muscle or bone). Sometimes the gallbladder or stomach may cause referred pain that radiates to the chest.
Angina: pain related to the heart not getting enough oxygen. In people with clogged arteries of the heart, there are deposits that are called plaques deposited into these vessels that narrow them and prevent a normal amount of oxygen-rich blood to reach the heart muscle. Angina is the term used to describe this phenomenon of chest pain that is related to the decrease in blood flow to the heart (called ischemia).
Heart attack: pain due to cardiac ischemia is more serious when a blockage in a cardiac vessel occurs as a result of the surface covering of a fatty plaque rupturing. If a blood clot (also called a thrombus) forms on the plaque, it can partially or completely block the artery of the heart and slow or block the flow of blood to the heart. If that occurs for more than 15 minutes the muscle may become damaged or cause death of that area of the heart that the blood vessel supports. During a heart attack (also called a myocardial infarction) the patient may experience a sensation of chest pain that may be a sharp, dull or burning pain that is usually located in either the middle or upper chest (possibly the left side), and sometimes this pain may radiate to the back, arms, jaw or neck. The pain may get better or worse with activity or rest and there may be other symptoms such as sweating, nausea, rapid heart rate or shortness of breath.
Risk factors for heart attack: We know that there are some factors that may increase the risk of a person having chest pain that may be related to the heart. Some of those can be: previous heart attack, previously diagnosed stroke, history of smoking (especially recent), high blood pressure, diabetes, high cholesterol or family history of heart attacks.
Other heart related reasons of chest pain: Even though a heart attack is the diagnosis that is most classic to think about when we think about heart related chest pain, there are other heart related problems that can cause chest pain, such as:
1) Angina variants – caused by temporary spasms of the arteries of the heart.
2) Pericarditis – or inflammation of the membranes of the heart
3) Mycocarditis – which is inflammation of the heart muscle itself. This is most commonly causes by a viral infection
4) Hypertrophic cardiomyopathy – problems related to the heart valves
5) Aortic dissection: the aorta is a main artery of the body that supplies blood to the body and lungs and is composed of layers of muscle cells similar to the layers of an onion. Rarely, there can be separation of these layers of muscle in the aorta which can cause breakage of the blood vessel and that can cause severe pain that comes on suddenly and is often felt in the chest or back between the shoulder blades. It is a serious life threatening condition and needs to be corrected by surgery right away.
Chest pain related to the chest wall: There are various conditions that can cause the muscles, bones, skin and soft tissues of the chest wall to become painful.
1) Physical activity that is more strenuous than usual can cause muscle soreness. This type of pain is usually made better or worse by a particular position. Taking a deep breath or pressing on the chest wall may also worsen the pain
2) Costochondritis is pain coming from the cartilage that connect the ribs to the breastbone
3) Shingles, a viral infection of the skin (that may occur on the chest) can be very painful but is usually present with even light touch to the skin on the chest or even clothes moving against the skin. There may be a rash present at the time of the pain or it can actually occur before a rash is present
4) Trauma or injury to the chest from sports or even from a recent surgery can product pain in the chest wall
Chest pain related to the esophagus: The tube that connects the mouth and throat to the stomach is called the esophagus. A group of the same nerves connect to the heart and also to the esophagus so pain coming from the esophagus can be confused with heart related chest pain. To be even more confusing, in some patients nitroglycerine (often used to treat heart related chest pain) can also relieve the pain from esophageal spasms.
Chest pain related to the gastrointestinal tract: Problems related to the stomach, intestines, gallbladder, or pancreas can spread or even begin with pain in the chest.
Chest pain related to the lungs: Problems related to the lungs may also cause chest pain and usually the pain gets worse with breathing:
1) Pulmonary embolism: A blood vessel of the lung can become plugged from a blood clot. These are more common in people who have had recent surgery, are pregnant or had a long airplane flight or been in bed for a long time. Pulmonary embolisms (PEs) can be life threatening and need immediate attention
2) Pneumonia: An infection or inflammation of the lungs is usually associated with fever, and cough. Chest pain related to pneumonia is common
3) Pleurisy or pleuritis: results from inflammation of the lining of the lungs and can happen as a result of injury or viral illness but is also seen with a pulmonary embolism (blood clot in the lung)
4) Pneumothorax: this is also called a collapsed lung and happens when air gets between the chest wall and the lung. This can be due to trauma or even occur spontaneously
As you have learned, there are many possible causes of chest pain and many of these could be life threatening and need immediate attention. Rapid attention and treatment is most efficient in the hospital, and therefore we recommend that patients who experience chest pain be evaluated in the emergency department of the hospital rather than an outpatient urgent care center.
In the event that you go to the urgent care or to your local primary care provider with chest pain, it might very well be recommended that you be urgently rushed to the hospital for evaluation of the pain because of the serious life threatening conditions that can cause chest pain related symptoms and the more advanced testing options available at the hospital. In the event that you should need surgery or cardiac catheterization to treat the pain related to heart attack or heart muscle injury you will have rapid access to these treatments at the hospital.
If you or someone that you know is experiencing chest pain, please have them evaluated by a medical provider. If you are concerned about the possibility of pain related to your heart, you should get to your nearest hospital immediately. Please don’t try to drive yourself to the hospital in this case – call 911 and have your local ambulance company bring you for evaluation.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO