Chest Pain

Chest pain can be classified as follows:

Based on severity:

• Mild pain is the pain that typically comes and goes and is usually tolerable in nature.
• Moderate pain is when the pain that begins to interfere with and distract you from conducting daily activities.
• Severe pain is when the pain becomes unbearable and needs immediate medical attention.

Based on character

• Sharp pain - A sudden spike of pain which is of a high intensity is called sharp pain.
• Dull pain - A dull pain is usually mild to moderate in severity. However, it can exaggerate by pressing the body part where the pain is experienced.
• Stabbing pain- A stabbing pain feels as if a knife has been pierced through your body. It is of high intensity and is unbearable.
• Boring pain-Boring pain is a piercing type of pain which you feel in deeper parts of your body.
• Throbbing pain-The pain which is of beating type or which comes with the pulse is known as a throbbing pain.
• Burning pain-A pain which causes a burning sensation in the affected body part is known as burning pain.
• Tingling pain-Tingling pain is felt as a needle-prick-like or sting-like pain.
• Pressure pain-If the affected part of your body feels tightness or fullness along with pain, it is called pressure pain.

Based on location

The chest area can be divided into left, right, and centre. Pain could be felt in any of these areas.

A radiating pain is the one where the pain spreads from the chest to other parts of the body such as the neck, jaw, or arm.

Based on duration

• Acute pain is when you are experiencing a pain which develops in a short duration of time. A sudden and severe pain in the chest requires urgent medical attention.
• Chronic pain is when you have been experiencing the pain for a long period of time (more than 3 months, either continuously or intermittently).
• Recurrent or episodic pain is when the pain is experienced every once in a while. The time period between two successive episodes may be regular or irregular. In between the episodes, the person does not feel the pain.
• Breakthrough pain is when you experience a dull pain for a long period of time and it has intermittent episodes of sudden sharp pain. This sudden sharp pain is known as breakthrough pain.

Based on the kind of damage

• Nociceptive pain
  Nociceptive pain is the pain which occurs due to a damage inside the tissues. When the damage is of the surface tissues of the chest such as the skin, dermis, etc, it is called somatic pain. When the damage occurs in the internal organs in the chest, such as lungs, gallbladder, pancreas, heart, etc, it is called visceral pain.

• Neuropathic pain
  When the damage occurs in a nerve that supplies to the chest area, the pain is known to have a neuropathic origin.

• Psychogenic pain
  When you are under great stress or facing emotional problems, pain is often experienced in the chest area. This pain is most commonly associated with anxiety and panic attacks. It is known as psychogenic pain.

• Musculoskeletal
  If the muscles of the chest and the ribs are damaged, or when a rib is broken, the pain is said to be of musculoskeletal origin.

A pain in the area between your neck and the lower end of the ribs is known as chest pain. It might be felt as a fullness, tightness, squeezing, burning, or pressure sensation in the chest. There are various symptoms associated with chest pain such as breathlessness, fatigue, sweating, nausea, fever, chills, and in extreme cases, it can also lead to death. There are many reasons for experiencing a chest pain, but only a doctor can give you a definitive answer to what’s causing it.

As we have mentioned above, chest pain that you experience can be of various types. Along with the chest pain, you may also experience the following symptoms:

• Tightness or crushing sensation in the chest area
• Fullness in the chest
• Pain radiating to the neck, jaw or arm
• A feeling of pressure in the chest region
• Increased heartbeat or heart rate
• Shoulder pain
• Palpitations in which the heartbeat becomes faster, louder, and irregular.
• Nausea
• Vomiting
• Fever or chills
• A cough with yellowish-green sputum or mucus
• Breathlessness
• Low or high blood pressure
• Diaphoresis which is an unexplained excessive or profuse sweating
• Dizziness may also be experienced. In certain cases, the person may also faint.
• Fatigue without or with minimum physical activity

When to see a doctor?

If you experience any of the following symptoms, immediately go and see a doctor. If your condition is severe, tell one of your family members or a friend to take you to a doctor or call a doctor.

• Pain with tightness or crushing sensation in the chest.
• The pain radiates to your neck, jaw or left arm.
• Difficulty in breathing or breathlessness.
• Pain is sudden, severe and does not go away even after taking medications which were previously prescribed by your doctor.
• Dizziness, anxiety, profuse unexplained sweating, confusion, etc.
• Continuous chest pain which does not go away.
• Chest pain which is not relieved by lying down or bending forward.
• Very low or very high blood pressure.
• Fever or chills with yellowish-green mucus in your cough.

Why does chest pain happen?

The chest area has many structures such as the lungs, heart, pancreas, stomach, gallbladder, ribs, muscles, nerves, etc. Hence, a chest pain may be experienced if there is an underlying condition, damage, injury, infection, tumour, or abnormality in any of the above-mentioned organs.

Heart Problems

Angina is a term used to define a pain characterized by a feeling of pressure or squeezing which occurs in the chest due to an underlying heart problem. Angina and heart attack are two different things. Angina is a warning sign of a heart disease, however, heart attack (myocardial infarction) is a serious disease which can also be fatal if emergency treatment is not given.

• Inflammation
  In inflammation, a part or organ of the body swells up due to the accumulation of fluid, immune system cells, or foreign body toxins. Inflammation can occur in the sac which surrounds the heart. This is known as pericarditis. It results in a sharp pain in the chest which may spread to your neck or shoulder muscles.

• Infection
  In some people, infectious bacteria can reach the heart muscles and cause infection. One of such conditions is known is acute bacterial endocarditis. This causes pain in the chest when you breathe, sneeze or cough.

• Blockage
  When the level of your blood cholesterol is high, it can get accumulated on the walls of one of the arteries which supply blood to the heart (coronary artery). Over a period of time, this plaque can lead to blockage of your coronary artery. This is known as coronary artery disease. In this disease, chest pain occurs because the availability of oxygen to your heart muscles is reduced and in return, the heart has to work harder which causes pain. The pain causes a tightening or pressure sensation in your chest. The pain may also radiate to your neck, jaw, shoulder, or arm. (Read more: High cholesterol)

• Heart muscle damage
  When the heart muscles do not receive enough oxygen, it leads to heart muscle damage. When this happens, a pain similar to that of angina is experienced in the centre or on the left side of the chest. Although, this pain is severe than that in angina and is the crushing type.

• Genetic disorder
  In some genetic disorders, the muscle in one part of the heart may become excessively thick. This causes pain in the chest which may also be associated with breathlessness after exercise or intense physical activity. If the muscle keeps thickening over a period of time, it will make the heart work harder to pump blood. As a result, in later stages, you may also experience dizziness, fatigue, fainting, etc. In severe cases, heart failure can also occur.

• Malfunction of the heart structures
  Sometimes, one or more structures of the heart may not work properly. For example, our heart has valves between the upper and lower chambers as well in the major blood vessels which take blood to and away from the heart. These valves prevent backflow of the blood and make sure that it flows in one direction. If a valve is malfunctioned, such as in mitral valve prolapse, it does not close completely, there won’t be enough pressure generated in the heart chamber to pump the blood. If the prolapse is mild, the disease may not show any symptoms. In moderate to severe cases, the person experiences chest pain which is also associated with other symptoms such as palpitations, dizziness, etc.

• Tear of an artery
  In a few instances, the wall of an artery of the heart (coronary artery) may tear. This is known as coronary artery dissection. If the aorta (a major blood vessel which carries blood from the heart to be supplied to the rest of the body), it is called an aortic dissection. This leads to filling up of the blood in the chest cavity. This leaking blood accumulates and causes sudden and severe pain in the chest along with a tearing sensation which may be felt in the neck, back or abdomen (the area between the ribs and pelvis).

Lung Problems

• Inflammation
  A layer of tissue which covers our lungs is known as the pleura. Any irritation in the pleura may result in its inflammation which is known as pleuritis. The pleuritic pain is characterized by a sharp pain in the chest which occurs while breathing, coughing or sneezing.

• Infection
  Sometimes, our lungs may get infected with bacteria or viruses. In such conditions, you may experience chest pain which is similar to that of pleuritis and occurs while sneezing, coughing or breathing. In pneumonia, the chest pain is dull, aching type which is associated with other symptoms such as fever, cough, chills, etc. Sometimes, pus may also come with the mucus while coughing.

• Blood clot or blockage
  A blood clot can travel from the bloodstream to your lungs and get itself lodged in there. This clot may result in the development of an acute, sharp pain as seen in pleuritis. It may also cause fever, and in severe cases, the person may go in a state of shock (a life-threatening situation in which enough oxygen doesn’t reach the body and may damage various organs). The blood clot most commonly occurs after a major surgery such as a surgery to remove a tumour or a blood clot or coagulation (thrombosis) in a deep vein.

• Injury
  In cases of injury due to accidental trauma or a sudden blow to the chest, air may be released into the chest cavity. This is known as pneumothorax. This may cause a sudden and sharp pain which is often associated with a low blood pressure.

• High blood pressure
  The right side of the heart receives blood from the lungs. Hence, high blood pressure in the arteries of the lungs increases the workload on the right side of the heart. This is known as pulmonary hyperventilation. The chest pain experienced in this condition is similar to that of angina.

• Disease or allergy
  You may also experience chest pain if you have a disease or an allergy in the airway system such as asthma. The pain is often associated with symptoms like wheezing, shortness of breath, and discomfort while breathing.

Problems of the Digestive system

• Ulcers
  Ulcers or sores in the lining of the stomach are known as peptic ulcers. You may experience pain and discomfort in the chest area because of them. The pain is often severe and burning type.

• Gastroesophageal reflux disease
  When the contents of your stomach start flowing back into your food pipe, it is known as gastroesophageal reflux disease (GERD). The stomach acid causes a burning pain or heartburn in the lower central region of your chest.

• A problem in the muscles of the oesophagus
  When the muscles of your oesophagus do not contract in a synchronized manner or contract too much, it causes pain in the centre of your chest. The pain is usually felt while eating food when it travels down your throat.

• Inflammation
  If your pancreas or gallbladder have inflammation, it can cause chest pain too. Pain associated with the pancreas is felt on the left side, while that of the gallbladder is experienced on the right side. It may also be felt in the centre of the chest and may also radiate to other areas of the body. The pain is sharp and severe in nature. Pancreatic pain is often relieved on bending forward.

• Hypersensitivity
  Sometimes, your oesophagus may become painful on the slightest of changes in pressure or acidic contents. This is known as oesophagal hypersensitivity.

• Rupture of oesophagus
  In severe cases of vomiting or after undergoing a surgery, your oesophagus might rupture. It causes a sudden and sharp pain in the chest.

• Hernia
  A hiatal hernia is a term which used to describe the condition in which your stomach pushes itself into the lower chest region after eating food. Because of this, you may experience fullness, pain, and discomfort in the chest.

• Epiglottitis
  It is an emergency condition which may obstruct the airway or your baby. The symptoms include shortness of breath, high fever, chest pain, extremely sore throat which may also cause difficulty in swallowing.,

Musculoskeletal Problems

Chest pain may also be felt if you get a muscle sprain or fracture in your ribs. This type of pain is sharp, severe and is felt in the area of the injury.

Costochondritis is one such condition which occurs in babies when the tissue which connects the ribs is inflamed and causes severe chest pain. It may also be associated with a dry cough.

Nerve problems

Conditions in which injury or infection of the nerves which are associated with the chest area occurs such as trauma to the spine, shingles, etc, chest pain is common. In shingles, an infection by varicella-zoster virus occurs along the nerve. This may cause severe pain in the chest, shoulder, and back area. It is often associated with the development of a rash in the area where the nerve lies.

Risk factors
following are a few factors which make you more prone to chest pain:

• Smoking.
• Excessive alcohol intake.
• Obesity (overweight)
• Immune system disorders which make you prone to infections.
• High cholesterol in the blood serum increases the risk of coronary artery blockage.
• High blood pressure increases the workload on our heart.
• Minimum to no physical activity has a negative effect on your heart and your body as a whole.
• Eating unhealthy and junk food increases the risk of developing heart and digestive system related problems.

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Most causes of chest pain are preventable except for those which are genetic, or allergic.

Following is a list of things that you can do to prevent chest pain:

• Maintain personal hygiene
  When you maintain personal hygiene effectively, you prevent a number of diseases like pneumonia, tuberculosis, etc.

• Eat a healthy nutritious diet
  Eating right is the key to a healthy body. Strong immunity is not built in a day. It is developed by always nourishing your body with the required vital nutrients such as vitamins, minerals, carbohydrates, and proteins. A low-fat diet will keep your cholesterol under control and prevent the development of heart diseases and the diseases of the blood vessels like high blood pressure, coronary artery blockage, thrombosis, etc.

• Limit alcohol intake and stop smoking
  This will prevent the development of high blood pressure, lung, heart and liver diseases and cancer associated with alcohol consumption and smoking.

• Take ample rest at home if you are suspecting infectious disease
  Resting and taking medications on time will help in healing your body faster.

• Exercise daily
  Regular exercise improves your blood circulation, keeps your heart and lungs healthy, and strengthens your immune system. This will help not only help you in preventing diseases but will also help in fighting against them.

• Maintain a healthy weight
  A healthy weight is very important in preventing the diseases of the heart, digestive system, pancreas and gallbladder.  

• Get a routine blood test done every 6 months to rule out any abnormalities or diseases.

• Get a full body check up once in a year to make sure you are healthy and free of diseases.

• See a doctor whenever you feel discomfort or have any abnormal symptoms.

As we have mentioned above, only a doctor would be able to correctly diagnose the cause of your chest pain. Hence, we urge you not to ignore your chest pain because it has chances of having an underlying serious medical condition.

The diagnosis of your chest pain is highly dependent on your detailed history and physical examination more than the investigatory or diagnostic tests. The diagnosis of your chest pain involves the following steps:

Medical history 
Since it is the most important step in diagnosing the cause of your chest pain, your doctor will ask several questions and conduct a physical examination of your chest area before advising any diagnostic test.

Following are the questions that your doctors may ask to get a clear idea of your condition:

• Describe your pain?
• When did the pain occur?
• In which area did you feet it?
• For how long did you feel it?
• Does it go to other parts of your body?
• Do you feel it after physical activity?
• Did you also experience other symptoms like fever, chills, nausea, dizziness, sweating, cough with blood or pus, bitter taste in mouth, etc?
• Do you experience it while breathing, coughing, or sneezing?
• Does it become severe on pressing the chest area?
• How is the pain after eating or on empty stomach?
• How does your pain become severe?
• Is it relieved by taking medication, resting, lying down, etc?
• Do you have a rash in the area of pain?
• Have you been injured recently or in the past?
• Are you suffering from any medical condition such as high blood pressure diabetes, tuberculosis, liver disease, gallstones, heart disease, kidney disease lung disease, etc
• Did you undergo any surgery in the chest area?

Physical examination

• After taking a detailed history, your physician will conduct your physical examination as follows:
• Measuring the Vital Signs or Vitals: Vitals signs are those clinical measurements which indicate the state of a person’s essential body functions. These include the heart rate or pulse rate, blood pressure, breathing rate, and body temperature.
• Your physician will measure your blood pressure in both the arms to rule out aortic dissection.
• Your heart and breathing sounds may also be checked by your doctor using a stethoscope.
• Following this, your doctor will examine your chest area to check for the presence of a skin rash, an injury or trauma, pain or crackling sound on pressing the affected area, whether your chest expands normally on breathing, or if you have pain on coughing or sneezing.

Diagnostic tests

Following are the tests which may be performed to diagnose your chest pain:

• Blood Test
  In this test, a sample of blood is drawn from your body. It is examined to estimate the number of blood cells, cardiac (heart) enzymes and proteins, etc. An increase in the number of white blood cells indicates the presence of an infection. Presence of cardiac enzymes and cardiac proteins in the bloodstream indicates a damage to the heart causing their release into the blood circulation. These enzymes and proteins may also indicate a risk of heart attack in future.

• Sputum test
  If your chest pain was accompanied by a wet cough (a cough with mucus), a sample of the same may be collected to check for the type of infection and its severity. This mucus or sputum sample is put on a plate where bacteria can grow. These bacteria are then tested under a microscope (a device which enlarges the image of small bacteria and substances which cannot be seen with the naked eye) to know if there is a serious infection like pneumonia, tuberculosis, etc.

• Bronchoscopy
  In this test, a thin tube with a camera and light source attached to it is used which is known as a bronchoscope. Your physician will slide it into your airway through your mouth or nose to reach your lungs. Bronchoscopy gives a clear picture of your airway system and helps in detecting the abnormalities, tumours, bleeding in your windpipe (trachea), bronchus (part of airway system which is present between the trachea and lungs), and lungs.  It is also used to collect the mucus in deeper parts of your airways, especially in babies.

• Chest X-ray
  A chest X-ray is useful in determining if there is an abnormal enlargement of chest organs such as lungs or heart, deviation of your windpipe, fracture of your ribs, any suspicious area where infection might be present, etc.

• CT (computed tomography) scan
  A CT scan of your chest area will give a clearer picture of the internal organs. It is useful in determining an abnormal enlargement of the stomach, gallbladder, liver, and pancreas, the presence of gallstones, any changes in the lungs, etc  

• ECG
  In this procedure, a gel is applied to the skin of your chest and sometimes your arms or legs and sensors (also known as electrodes) are attached to record the electrical activity of your heart. ECG is a test which is done to check if the rhythm and rate of your heart are normal. It is also able to record any damage to the heart.

• Echocardiography
  Echocardiography is a procedure which is done to check whether your heart, its structures, and blood pumping are normal.

• Catheterization
  Using a catheter to examine the heart is known as cardiac catheterization. In this procedure, a catheter is inserted in one of your blood vessels in your arm or leg to reach the heart. A dye is then inserted in the catheter which enters the heart and X-rays are taken. This is useful in identifying any blockages in the arteries and in deciding the right surgical procedure which should be done.

• Angiography
  Coronary angiography or arteriography is a procedure in which a dye is inserted in the blood. When it reaches the heart, X-rays are taken which show a clear picture of the arteries of the heart (coronary arteries). This will help in identifying the presence of blockages.

• Nuclear Scan
  This procedure uses a radioactive (substances which emit mild radiation) material which is inserted in the bloodstream. This imaging procedure is done to monitor the flow of blood through the heart.

Treatment of chest pain depends on the underlying cause and may involve medications, surgery, and lifestyle changes.

Medications

• Painkillers and anti-inflammatory drugs
  If the underlying cause is an inflammation of the internal structures such as the stomach, gallbladder, pancreas, rib cartilages, etc, your physician may prescribe some medications to relieve your pain and reduce the inflammation.

• Antibiotics and antivirals
  Antibiotics and antivirals are given if the underlying cause of your chest pain is an infection. This will relieve your chest pain as soon as the infection resolves. Antibiotics are usually prescribed with painkillers and anti-inflammatory drugs to reduce the swelling and pain. It is helpful in treating diseases like pneumonia, pancreatitis, shingles, peptic ulcers, cholecystitis (inflammation of the gallbladder), etc.

• Antiplatelet drugs
  These drugs are used if the underlying cause is a blockage due to clot formation in the blood vessels. This will prevent the clot from forming and will help to reduce the chances of a blockage. For example, aspirin.

• Blood-thinning medicines
  These are also known as anticoagulants which prevent the formation of a clot. If a clot has already been formed, they prevent an increase in its size.

• Clot-dissolving medicines
  They are also known as thrombolytic agents. They dissolve the clots in the coronary arteries. Example heparin, warfarin, etc.

• Medicines for heart muscles
  Digitalis is a drug which is used to improve the function of the heart muscles and help the heart to pump blood harder. It also helps in improving the heart rhythm.

• ACE (Angiotensin Converting Enzyme) inhibitors
  These drugs block the action of ACE and prevent the production of angiotensinogen which is a hormone responsible for narrowing the blood vessels. Inhibiting this hormone will reduce the blood pressure (BP) in persons who have high BP. They also help the heart in pumping the blood efficiently.

• Beta-blockers
  These drugs reduce the blood pressure and workload on the heart.

• Nitroglycerine or Nitrates
  These are helpful in relaxing the muscles in blood vessel walls and provide relief from chest pain.

• Calcium channel blockers
  These medicines act in a way similar to that of nitroglycerine and are used to treat blood pressure and chest pain.

• Diuretics
  These medicines help in reducing the blood pressure by removing fluids and salts from the body. Hence, they are also known as “water pills”. They reduce the workload on the heart and prevent the risk of a heart attack.

• Cholesterol-controlling medicines
  These drugs reduce the level of low-density lipoprotein (LDL), also known as bad cholesterol. This will reduce the chances of blockage in the coronary arteries.

​​Surgery

If the underlying cause of your chest pain is a blockage, clot, gallstones, or damage of the organs, you may need to undergo a surgery, such as cholecystectomy, pancreatectomy, rib fracture repair, coronary angioplasty and stenting, coronary artery bypass grafting (CABG), heart valve replacement, heart transplant, surgery for putting pacemaker, etc.

• Cholecystectomy
  Removal of your diseased gallbladder.

• Pancreatectomy
  Removal of a diseased part or whole of your pancreas.

• Rib fracture repair
  Joining the fractured parts of the rib.

• Surgery to treat pneumothorax
  It includes pleurodesis (sticking back the pleura together), pleural abrasion (rubbing the pleura to help it stick to the lung), pleurectomy (removal of the pleura so that the lung sticks to the chest wall), etc. All these surgeries prevent the build-up of air or fluid between the pleural membranes.

• Coronary angioplasty and stenting
  A stent is inserted in an artery of the arm or leg to reach the heart and a small balloon is used to break the plaque which blocked the artery initially.

• Coronary artery bypass grafting
  A healthy blood vessel is connected or grafted to the blocked artery. Hence, it bypasses the blocked area of the coronary artery and provides a new path for the blood to flow and reach the heart.

• Heart valve repair or replacement
  This is done to repair or replace the faulty or dysfunctioning heart valve with a new valve.

• Heart transplant
  In case of a severely damaged heart, a transplant may be done to replace the diseased heart with a new heart from a donor.

• Pacemaker
  A pacemaker is placed below the chest skin with wires connected to the heart. It helps in maintaining the rhythm of your heart.

• Surgeries for VAD (Ventricular Assist Device) and TAH (Total Artificial Heart)
  VAD assists the heart to pump blood more efficiently in people with weak hearts. TAH replaces the lower two chambers of the heart to replace failed lower chambers of the heart.

Although, there are various causes of chest pain which are not very serious, ignoring a chest pain which is continuous, or severe, or comes every once in a while might indicate an underlying serious medical problem. If it is not treated, it may lead to complications that may bring damage to different parts of your body. These complications are as follows:

• Damage to internal organs
  If the underlying cause is an infection, blockage, malfunction of a heart valve, gallstones, blood clot, ulcers, etc and is not treated on time, it may lead to severe damage of the organs like lungs, pancreas, gallbladder, heart, etc.

• Sepsis
  If there is an underlying infection, it may cause damage to the involved organ leading to sepsis.

• Septic shock
  If the infection spreads from its site of origin to other parts of the body through the bloodstream, it is known as a septic shock.

• Death
  Septic shock can lead to multisystem failure (failure of the major systems of the body) and sometimes death. If the heart muscles are damaged, it may lead to a heart attack, which if not treated immediately may lead to the death of the person.