Anyone who experiences chest pain often feels a sense of alarm. People have been taught to see a physician for chest pain because it may be a heart attack. There is nothing wrong with such a concern. However, it does not mean that all episodes of chest pain are from coronary artery disease. There are other causes, including non-cardiac ones.
Cardiac Causes
Cardiac chest pain that isn’t a heart attack can involve the outside of the heart. Normally, it sits within a fibrous sac called the pericardium. This sac can become inflamed (pericarditis) from various causes, including infection (e.g. virus, tuberculosis), autoimmune conditions (e.g. rheumatoid arthritis, systemic lupus erythematosus), uremia from kidney failure, certain medications, and radiation injury. The pain is usually in the center of the chest and is notably worsened when one takes a deep breath (pleuritic chest pain), swallows, or lies down. In contrast, this same pain can be lessened with sitting up and leaning forward.
A physician may hear a frictional rub when listening to the heart with a stethoscope. In some cases, the physician may order an echocardiogram, ultrasound of the heart, to see if there is fluid accumulation around the heart. It may be a small or large amount. In the worse case scenario, the amount of fluid is large enough to squeeze the heart and impair blood flow. This can be corrected with insertion of a needle through the chest wall and into the pericardium to drain the fluid (pericardiocentesis).
Other cardiac causes for chest pain include angina, myocardial infarction, and aortic dissection, all of which have already been discussed elsewhere.
Pulmonary Causes
Chest pain involving the lungs is uncommon, but it can happen. Occasionally, it can occur with pneumonia, constriction of lung airways (bronchospasm), or a blood clot or other material that travels through the veins and gets stuck in the lung (pulmonary embolism). Another cause is air within the lung cavity (pneumothorax). This can happen with trauma, like from a bullet or knife puncturing the lung, but it can also occur spontaneously, particularly in those with chronic obstructive pulmonary disease (COPD) whose lungs are susceptible to popping at fragile portions. Besides air, fluid can accumulate in the lung cavity (pleural effusion) from various causes. Other conditions involve the lining of the lung cavity (pleura), such as a respiratory infection with coxsackie virus B.
Gastrointestinal Causes
Gastroesophageal reflux disease (GERD) can cause chest pain, particularly one that is more dull and lasts a while. Spasm of the esophagus produces chest pain that feels similar to cardiac angina.
Interestingly, nitroglycerin relieves esophageal spasm pain very much like cardiac anginal pain, which is why esophageal spasm is known to mimic angina. Pancreatitis, cholecystitis, and peptic ulcer disease are rare causes of chest pain.
Musculoskeletal Causes
Muscle strain, rib fracture, and inflammation of the rib cartilage (costochondritis) cause pain from the chest wall itself. This type of pain is worsened with breathing, movement, or pressure over the pain site. However, if it occurs in someone prone to cardiac angina, the clinical picture can become confusing.
Final Words
The purpose of this overview is to clarify that not all chest pain is related to the heart. This does not mean that chest pain can be self-diagnosed. Given the risk taken with ignoring chest pain, it is recommended that a physician evaluate the symptom for a definitive determination.
References
- Goroll, Allan H. “Evaluation of Chest Pain.” Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 5th ed. Ed. Allan H. Goroll and Albert G. Mulley, Jr. Philadelphia: Lippincott, Williams, & Wilkins, 2006. 125-139.
