Undiagnosed Chest Pain: Determining the Cause

Posted by Medical Board on August 12, 2015 in Heart Health Last updated on June 3, 2019

Chest Pain—Causes, Concerns, When to Call the Doctor

Every 40 seconds, a heart attack occurs in the U.S., many times without warning.[7] Fortunately for the majority of us, most complaints of chest pain are not fatal however.

Chest Pain, A common Occurrence

According to U.S. government studies, every year more than 1.2 million Americans visit emergency room facilities with a diagnosis of acute cardiac ischemia (ACI) (reduced blood flow to the heart) and more than 75% of those visits are accompanied by a leading feature of chest pain.[5]

Chest pain is a very common reason for patients to seek medical attention. It may be the primary symptom of a life threatening medical emergency, such as a heart attack, or a potentially serious medical condition, such as angina pectoris. 

Sometimes, chest pain reflects a non-urgent medical problem without any connection to the heart.

According to University of Utah ER physicians, about 95% of patients seen for chest pain test negative for a heart attack.  And while chest pain of any sort should never be ignored or taken lightly, there are many more other reasons for chest discomfort besides myocardial infarction (heart attack).[6] 

It’s never easy to differentiate chest pain caused by a heart attack or to know if you should go to the emergency room.  Sometimes a strained muscle in the chest, or heartburn can feel like a heart attack, and there is no way to know if discomfort is life threatening.

Chest Pain, Heart Attack, Angina or Angina Pectoris

The medical term for chest pain is angina.  This refers to chest pain, pressure or tightness.

Heart attack—A heart attack occurs when the flow of blood to the heart is abruptly cut off.  This is a complete shutdown of flow, many times caused by a blood clot.

Angina—Angina, also called “angina pectoris” on the other hand, occurs when blood flow to the heart is diminished in some way, causing the muscle’s demand for blood to go unmet.  This occurs when fatty plaque builds up in the arteries to the heart and is known as atherosclerosis.  At times when the heart’s demand for blood is higher, for example during physical or emotional exertion, an individual with reduced blood flow to the heart may experience pain, burning, pressure, or tightness in the chest.[3]

Angina Classification for Chest Pain

Angina is classified in one of two ways, either “stable” or “unstable”.

Stable angina occurs during periods of physical activity or emotional stress while unstable angina presents when the body and mind are at rest.  Unstable angina is considered more serious than stable angina.[4]

Though angina is an indicator of coronary artery disease, it does not mean an individual is having a heart attack (or is necessarily at risk of having a heart attack).

Angina pectoris is usually caused by insufficient delivery of blood to the heart muscle that cannot meet demands for oxygen.  The underlying problem is generally a narrowing of one or more of the coronary arteries, or their branches, which bring fresh blood and oxygen to the heart.  Patients at increased risk for this condition include smokers, diabetics and those who have a family history of heart disease in members under the age of 55 or 60.  Individuals with high blood pressure or elevated cholesterol are also at risk.

Chest Pain—What Angina Feels Like

Typically angina pain begins as discomfort, often described as crushing, squeezing or pressure behind the breast bone over an area about the size of a fist or sometimes larger.

It often travels up into the neck and jaw or down the left arm. Angina episodes begin gradually, reach a peak and then, with rest, dissipate within minutes. They are often accompanied by shortness of breath, nausea or sweating. These may be brought on by anything that increases the oxygen demands of the heart, such as physical exercise, emotional upset or a heavy meal. Many patients with angina pectoris may also have attacks at rest, particularly in the early morning hours. When patient history is suggestive of the condition, further testing is often required

This usually requires a resting electrocardiogram (ECG) and chest x-ray followed by exercise electrocardiogram or an exercise nuclear (Thallium or Sestamibi) scan of the heart.

There is a small yearly risk of a patient with angina pectoris developing a heart attack or myocardial infarction. In this event, a portion of the heart muscle is damaged due to a sudden blockage to the flow of blood and oxygen through a coronary artery. Over the ensuing weeks, the muscle is replaced by scar tissue. While many heart attacks are totally unpredictable, an accelerated occurrence of angina events, particularly at rest and at night, indicates a heightened risk of heart attack.

Differences Between Angina and Heart Attack Chest Pain

While angina may feel similar to having a heart attack it does not cause permanent damage to the heart muscle.  A heart attack does.

Angina may occur due to physical exertion, or emotional stress.  A heart attack usually comes on suddenly and is accompanied by other symptoms.  Angina can persist for years, but is generally relieved with rest. Angina may present as a more mild, squeezing or burning sensation that is uncomfortable, rather than painful.  A heart attack may feel like severe crushing chest pain although some individuals will feel no pain in the chest at all.[1]

When chest pain occurs the cause is not always clear.  In addition to common symptoms of pressure, burning, squeezing or tightness in the chest, individuals may experience other sensations including arm, neck, jaw, throat or back pressure, squeezing, burning, or tightness.

Other symptoms may also include:

  • Shortness of breath
  • Fatigue
  • Weakness
  • Back pain
  • Arm pain
  • Neck pain

Additional symptoms of angina may also include:

  • Indigestion
  • Nausea
  • Feeling Sweaty
  • Feeling faint or lightheaded

Precipitating Factors for Angina Chest Pain

Angina may present more frequently under the following conditions:

Cold weather

Physical activity such as:

  • Climbing stairs
  • Uphill walking
  • Heavy lifting
  • Sexual activity[2]

Other Causes of Chest Pain

Musculoskeletal issues cause chest pain, but are usually more localized and have a sharper quality. They also tend to be brought on by changes in posture or by the application of pressure to different parts of the chest wall. A common cause of musculoskeletal chest pain is called costochondritis. In this condition, cartilage attaching a rib to the breastbone becomes inflamed often following a respiratory tract infection. Intense localized pain that can be reproduced by applying pressure to this junction is sufficient to make the diagnosis.

Another common cause of “nonanginal” chest pain is degenerative disc disease of the spinal column in the neck. Often the pain produced by the degenerating disc compressing a nerve is referred to the front of the chest. Unlike angina pectoris, this is a long-lasting discomfort, which can be made worse by neck movement. It also tends to be associated with numbness in areas of one or both arms.

In gastroesophageal reflux disease, the acidic contents of the stomach are regurgitated back into the lower part of the swallowing tube, or esophagus. The acid-sensitive lining of the esophagus is irritated, resulting in discomfort. While this discomfort is commonly described as mild heartburn, it may frequently be experienced as a real pain underneath the breastbone.  The pain of gastroesophageal reflux disease is usually more prolonged than angina pain. It frequently occurs shortly after a meal, especially when the patient is recumbent (lying down). Caffeine-containing foods, acidic or fatty foods, or alcohol may precipitate the reflux of acid into the esophagus. Changes in posture, such as bending over, may also provoke acid reflux.

Another entity that can mimic angina pectoris is an abnormality in the muscular contraction of the esophagus called an esophageal motility disorder. Overly intense contraction of the esophagus can result in chest discomfort, which tends to be located under the breastbone. It may radiate to the neck, to the back or even into the left arm.

Usually the discomfort occurs without provocation, and unlike angina pectoris, it may last for hours. When the discomfort is associated with difficulty swallowing, an esophageal motility disorder may be strongly suspected.

Chest Pain and Mental Health

Other important causes of recurrent chest pain are psychiatric entities such as anxiety disorder, panic disorder, depression and somatization (the tendency to convert mental experiences into bodily symptoms).

The presence of additional symptoms, such as undue breathlessness, fatigue, dizziness and numbness, point away from a cardiac cause to a psychiatric disorder. Patients with panic disorder may present with recurrent angina-like chest pain. The chest pain is accompanied by an overwhelming feeling of terror and apprehension accompanied by symptoms such as shortness of breath, palpitations, faintness and sweating. Attacks commonly occur in crowded areas such as supermarkets and during crowded public transit.

Chest pain occurring in depressive illness is accompanied by such symptoms as low mood, poor appetite, poor concentration and insomnia. Fully one-third of patients presenting to the emergency room with acute chest pain can be shown to have one of these emotional disorders.

There is a group of patients who have the typical symptoms of angina pectoris that are not related to any obstruction of the major coronary arteries, but to an abnormality in the very minute vessels of the heart muscle. These tiny vessels do not appear to respond by opening to a sufficient degree under conditions of mental and physical stress. Termed microvascular angina, this condition rarely results in heart attack. While sufferers do experience chronic recurrent pain, the majority do not demonstrate any evidence of severe oxygen imbalance in the heart muscle. There is definitely a female predominance in patients with microvascular angina.

Lung conditions such as pleurisy, pneumonia or pulmonary embolism may also cause moderate chest pain in individuals.[8]

Therapy for the various chest pain syndromes is highly varied. In musculoskeletal disorders, anti-inflammatory medications, such as aspirin, may be all that is required. In angina pectoris, due to coronary artery narrowing or obstruction, drugs to reduce oxygen demand or operations to improve coronary blood supply may be required.

In gastroesophageal reflux disease, blockers of acid production by the stomach are utilized. In esophageal motility disorders or microvascular angina, drugs called calcium channel-blockers, which relax the internal muscles, may be effective. There may be a role for anti-anxiety medication or antidepressant medication when one of the psychiatric diseases is diagnosed.

Immediate Treatment for Chest Pain

At the onset of chest pain it is important to try to remain calm, stop all physical activity and sit at rest.

If you are lying down, you should sit up and begin breathing deeply to help relieve feelings of stress and anxiety.

If chest pain symptoms persist after 5 minutes and you do not have nitroglycerin, call 9-1-1 for immediate assistance. 

If your doctor prescribes nitroglycerine for sudden angina attacks, administer the tablet or spray while sitting down.  The tablet should be placed between the cheek and gum, or under the tongue.  Spray should be self administered under the tongue as well.

If pain does not resolve in 5 minutes after nitroglycerin treatment, call 9-1-1 and ask the dispatcher for further instructions.  If your doctor has instructed you to take additional doses before seeking emergency attention, follow your doctor’s orders.

You should not smoke, eat, or drink for 5-10 minutes following a dose of nitroglycerin.

Document Chest Pain

Following a chest pain event you should document details of the actual experience.

Write down:

  • Time of day
  • Activity at the time of the event
  • Length of time pain persisted
  • Description of pain
  • How pain was relieved
  • What you ate or drank prior to the episode
  • How and when you took medication for chest pain

When to Get Emergency Medical Attention for Chest Pain

It is important to get emergency medical attention if pain does not respond to nitroglycerin treatment after 5 minutes.  If pain persists or worsens, or returns after subsiding with nitroglycerin, call 9-1-1 for assistance.

Contacting Your Physician About Chest Pain

While chest pain may not warrant a trip to the ER you should contact your physician if:

  • Symptoms happen more often
  • You have angina at rest when you previously did not
  • You are more fatigued than normal
  • You are getting lightheaded often
  • Your heart rate falls below 60 beats per minute

Or

  • Your heart rate exceeds more than 120 beats per minute
  • You find it difficult to take your prescribed heart medication
  • You experience any unusual symptoms not previously reported to your doctor[2]

While chest pain can indicate serious or life-threatening medical issues, understanding the many symptoms and factors that affect a specific diagnosis can help.  Learning what to do if you or a loved one experiences chest pain is critical for future health and well-being.

References

1“6 Facts About Chest Pain.” Health and Wellness, Rush University Medical Center, www.rush.edu/health-wellness/discover-health/6-facts-about-chest-pain. 

2“Angina – When You Have Chest Pain: MedlinePlus Medical Encyclopedia.” MedlinePlus, U.S. National Library of Medicine, medlineplus.gov/ency/patientinstructions/000088.htm. 

3“Angina Pectoris.” Angina Pectoris – Health Encyclopedia – University of Rochester Medical Center, www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=85&ContentID=P00194. 

4“Angina: MedlinePlus Medical Encyclopedia.” MedlinePlus, U.S. National Library of Medicine, medlineplus.gov/ency/article/001107.htm. 

5Burt, C W. “Summary Statistics for Acute Cardiac Ischemia and Chest Pain Visits to United States EDs, 1995-1996.” The American Journal of Emergency Medicine, U.S. National Library of Medicine, Oct. 1999, www.ncbi.nlm.nih.gov/pubmed/10530533. 

6“ER or Not: Chest Pain.” U Of U Health, healthcare.utah.edu/the-scope/shows.php?shows=0_xtn3spc5. 

7“Heart Disease Fact Sheet|Data & Statistics|DHDSP|CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm. 

8Jany, B. “Pulmonary Causes of Chest Pain.” Der Internist, U.S. National Library of Medicine, Jan. 2017, www.ncbi.nlm.nih.gov/pubmed/27986981.

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4 Comments

  • Angioplasty, Smoking, and Chest Pain

    My 43-year old husband had angioplasty and a stent done on an artery that was 95% blocked. He has another one that is 60% blocked. I have read on the Internet that in 6 months about 40% of these arteries block up again. Is this true? Today he experienced some pressure on the left side of his chest and tingling in his arms that went away after 2 hours. He didn’t have any pain. Is this normal? We are from Florida and used to eat a diet high in fat. We lowered it to 40grams per day. He is trying to quit smoking. Can he wear a Nicoderm patch?

    He had angioplasty 2 weeks ago. We have HMO insurance and the providing cardiologist can’t see him for 2 more weeks. Our regular doctor prescribed Vistaril to help him quit smoking, but the description says its an antihistamine. Is this safe? He didn’t take the Vistaril today.

    He doesn’t have high blood pressure, a weight problem, or any other health problems. I’m sure the smoking and high fat diet caused this, so we really need some professional advise on how to help him to quit smoking so soon after angioplasty.

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    • It is always best to check with your own doctor about your husband’s medical condition. This being said, the rate of re-occlusion depends on the size of the vessel that was stented and the 40% figure you have found may be the occlusion rate before the use of stents, or with angioplasty alone. Stents in larger arteries tend to decrease re-occlusion rates by 50% or more.

      It is also important to take an antiplatelet drug like Ticlid for the first two weeks post stenting, usually followed by Aspirin. Vistaril is an antihistamine and sedative. Smoking is a difficult addiction. The risk of nicotine patches is probably less than the risk of smoking. You cannot smoke with the patches, however.

      It is not surprising that there is another 60% lesion, as the cholesterol builds up everywhere in the arterial system. The narrowing that you are aware of is just a warning that the disease is active. While angioplasty and stenting can relieve angina, where a patient will be in a few years depends mostly on cutting out cigarettes completely, lowering the fat content of the diet, exercising and taking lipid-lowering drugs if the serum cholesterol is higher than desired.
      Heart pain is usually not called pain but rather pressure, tightness or heaviness. It can radiate to an arm, the throat, the back, the teeth or sometimes to an old injury in the chest. If the pattern changes (more frequent, longer duration, or just plain new) it should be taken seriously. Two hours is a long duration for discomfort and can indicate a re-occlusion of the artery.

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  • Cardiac Heart Surgery and Chest Pain

    I am interested in finding out more about a post-bypass surgery syndrome I read about somewhere that involves pleurisy-like pain when deep breathing. I have CAD and try to keep on top of my treatment.

    Do you know anyone out there who has had open heart surgery and suffers from a reoccurring inflammation of the sternum and rib area? This is a very painful symptom which doctors treat with painkillers and anti-inflammatory drugs. The patient is a 20 year old girl who has suffered for the past 8 years. She is looking for someone who has had the same problem and has got some help.

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    • Chest Pain Post Open Heart Surgery

      Most patients undergoing open heart surgery for a congenital defect, valve repair or replacement or coronary artery bypass will have incisional pain that subsides gradually over the first month post-surgery. This pain is aggravated by coughing, sneezing, rotation of the chest or elevation of the arms. Due to the fact that they lie on their back for quite a while (4-5 hours in the operating room and 12-24 hours in the intensive care unit) the patients complain of thoracic and lumbar back pain that resolves within two to three weeks. Shoulder pain irradiating to the arms and fingers is not unusual. This is related to over stretching of brachial nerves while opening the sternum to perform the surgery. The incisional sternal pain is described as an ache. Many patients report a sensation of numbness on the left side of their chest which results from the dissection of the internal mammary artery. Some patients can barely wear a shirt for a few weeks following their surgery due to a hyperesthesia over their sternal skin. Fortunately, all these malaises subside within 1 or 2 months post surgery.

      In a small number of cases, the sternal pain is out of proportion or persists beyond the expected recovery period. In these patients, a wound complication such as sternal dehiscence or infection has to be ruled out. Sternal dehiscence and/or infection is rare (2-5%) but dreadful for the surgeon and patient. Dehiscence of the sternum is usually, but not necessarily, secondary to infection. The infection prevents the bone healing process and leads to mediastinitis and sternal instability. These patients are usually septic and require urgent debridement of the infected and necrotic bone and reclosure of the sternum and/or a muscle flap to cover the bone defect. Some predisposing factors leading to this complication have been identified such as obesity, diabetes, patients with chronic obstructive pulmonary disease requiring prolonged ventilation post-operatively and patients where both mammary arteries were used. In older patients with osteoporotic bone, the sternal wires may cut through the bone and lead to dehiscence without fever. These patients complain of “clicking” sternum or sternal pain while turning, coughing or elevating their upper extremities. This pain is bearable but annoying for most patients. One option for the patient is to live with this unstable sternum. The pain subsides with time but may come back while the patient is participating in strenuous exercise. However, this condition never compromises the cardiac or pulmonary function of the patient. the other option is to rewire their sternum. Occasionally, the persistent pain arise from non-union of a broken rib, dislocation of a costo-chondral junction, or a subcutaneous stitch or wire. Other causes have to be ruled out in cases of persistent chest pain post open heart surgery. A small proportion of patients (10%) have closure of a coronary artery graft with recurrent angina. This condition is usually quite well identified by the patient who experiences the same kind of pain as before surgery.

      On rare occasions, especially in-patients with atypical angina symptoms, the patient may have an unrecognized lung, gastroesophageal or psychosomatic disorder. A few weeks post surgery, some patients present post-cardiotomy syndrome (Dressler’s Syndrome) manifested by pleuretic chest pain (pain with deep breathing), fever, fatigue and pleural and/or pericardial rub on auscultation. This inflammatory process resolves spontaneously within a few weeks in most patients. On occasions, they may require anti-inflammatory drugs to relieve their symptoms.

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