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7Jun

There are numerous causes for chest pain and fortunately most chest pain is harmless.
However it is important to be aware of the more serious causes of chest pain and if you have any worries at all you should seek urgent medical advice from either your GP or from the Emergency Services.

The likely causes of your chest pain can usually be distinguished by a few useful tips around the nature of the pain, your age, what makes it worse or better, the timing of the pain and how long you have had it.

By far the commonest cause of chest pain is what we call musculoskeletal, in other words pain affecting the muscles, and tissues of your chest and sometimes the nerves. Typical causes of musculoskeletal chest pain include;

  • Local injury or bruising
  • ‘Pulled’ intercostal muscles
  • Viral infections affecting the intercostal muscles (the classic one is Bornholm disease caused by the Coxsackie B virus)
  • Shingles (before the rash has developed)

This type of pain has only usually been present for a day or 2 and is normally sharp and stabbing (like a knife), is worse when taking a deep breath, is frequently tender to touch or press and is often worse with movement or stretching (doing up your bra in females) and by lying on that side in bed. It often comes on after undertaking some physical activity such as gardening, carrying heavy shopping bags, lifting children or moving furniture around. In shingles it may have more unusual qualities such as burning and tingling. It is perfectly harmless and settles nicely with straight-forward pain-killers and anti-inflammatories such as ibuprofen or naproxen.

Acid reflux is another frequently seen cause for chest pain. This usually causes;

  • burning discomfort right behind the breastbone which might radiate up into the throat
  • mild nausea
  • feelings of hunger
  • a bilious feeling in the top of the stomach.

It is usually worse with lying flat or bending and stooping. If you lie flat and get your partner or friend to press in the pit (top) of the stomach it is often very tender. It frequently follows bouts of binge drinking or eating. Again it is relatively harmless and should settle with antacid treatment (eg Gaviscon) but if it persists for more than a week or so or you feel unwell with it you should seek medical advice.

‘Pleuritic’ chest pain occurs when the lining of the lungs (pleura) are inflamed and the two most common causes are infection or a blood clot in the lungs. Pleuritic pain can be very similar to musculoskeletal pain in that it is locally very sharp and worse with taking a deep breath. However it is not usually worse with moving or stretching and is not usually tender to touch over the area affected.

If infection is the cause then frequently there may be an underlying pneumonia giving rise to old fashioned ‘pleurisy’. You may feel hot and sweaty and mildly breathless, with an underlying temperature. You should arrange to see your GP pretty promptly for some antibiotics.

Doctor StethoscopeBlood clot or Pulmonary Embolus is a very serious cause of ‘pleuritic’ chest pain. It occurs when blood clots have developed in the back of the calves of the legs and break off, shooting up to the lungs. They cause part of the lung to infarct or ‘die’ leading to pleuritic chest pain. It can occur spontaneously with no obvious cause, but more commonly occurs after a long haul flight (or bus or car journey), following surgery (particularly on the lower limb), after a prolonged illness or in patients with underlying cancer. The back of one side of the lower leg is often swollen or tender too, which gives it away. If you think you may have had a pulmonary embolus then you should seek urgent medical advice.

Finally we get to cardiac causes for chest pain. This kind of pain is usually fairly easily distinguishable from other causes of chest pain but unfortunately can mimic all of them and vice versa!

Angina is the commonest cause of cardiac chest pain and many people suffer from this. Angina is short for angina pectoris which literally means, chest pain! Angina is typically felt across the left side of the chest, has a tight and squeezing quality and may radiate to the left arm (or right arm or both!) as well as the throat and occasionally through to the back or upper stomach. It is usually worse with exertion such as climbing stairs or hills and in cold weather. It settles with stopping the exertion or going into the warm. Most people who have angina recognise the symptoms well and frequently take a ‘puffer’ (GTN spray) to abort the attacks.

Angina is caused by the heart muscle having a reduced oxygen supply. The heart is a very effective pump and made out of a certain type of specialised cardiac muscle. Like all other living tissues, the cardiac muscle needs an adequate blood supply of its own to provide it with oxygen and nutrients. It the heart is working harder and the blood supply isn’t sufficient (such as in hardening of the arteries or blocked and narrowed arteries) then the muscle starts to protest and that causes angina.

There are rare variants of normal angina such as Prinzmetal’s angina (which is caused by coronary artery spasm and not necessarily brought on by exertion) and syndrome X, in which patients (often women) experience typical angina but have normal coronary arteries when examined with angiography. Both have a good prognosis.

If you think you have new symptoms of angina then you should arrange to see your GP. If your angina is different, more severe, or doesn’t settle when it normally should then you should seek urgent medical advice.

Heart attacks are very serious and should be treated urgently. The symptoms of a heart attack are similar to angina but are more severe and last longer.

Typically patients feel severe chest pain across the chest (often left sided) which is gripping and squeezing and often likened to ‘somebody sitting on my chest’, it radiates to all the places that angina does (anywhere above the middle of the abdomen!) and may be accompanied by;

  • sweating
  • breathlessness
  • dizziness
  • nausea and vomiting

The pain usually lasts for several minutes to several hours.

If you have any of these symptoms then you should seek urgent medical advice and not tomorrow, now!!

The NHS poster of a man with a belt pulled tightly around his chest sums it up very well but be aware that some heart attacks are silent (no pain at all, you just feel terrible) and atypical.

  

Dr Helen Webberley

Dr Helen Webberley is an NHS GP with a practice in South Wales, and an experienced online doctor providing healthcare advice and treatment via the Internet. She is a talkhealth expert in the Online Clinics. If anyone has any queries about their health then feel free to contact her.

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