The presence of chest pain, especially if it is severe, often raises the concern about cardiac conditions like a heart attack (myocardial infarction). However this is not the only cause of severe chest pain and a number of factors have to be taken into consideration in order to discern cardiac chest pain from non-cardiac chest pain.
Cardiac Chest Pain
Cardiac chest pain in this context is considered as any pain attributed to ischemia – oxygen deprivation to the heart muscle. This must be taken very seriously as it can progress to an infarct (death of heart muscle tissue) without prompt and appropriate treatment. Example : heart attack (myocardial infarction).
Non-cardiac Chest Pain
Non-cardiac chest pain refers to pain due to other structures within the thoracic cavity. However, it must be remembered that certain conditions affecting the heart may not always result in ischemia and may therefore not present in a manner resembling ischemic cardiac pain. Example : GERD (heartburn), pleuritis or even pericarditis (inflammation of the lining around the heart).
Distinguishing between Cardiac and Non-Cardiac Chest Pain
There is no conclusive way to differentiate between cardiac and non-cardiac chest pain in the home environment. There are many cases where severe heartburn causes chest pain that resembles cardiac disease and only the use of nitrates may allow a person to differentiate between cardiac and non-cardiac chest pain in this instance. Severe chest pain should always be taken seriously and a trip to the emergency room is often warranted to exclude more serious underlying disorders. This can only be done under the supervision of a medical professional in conjunction with the relevant tests and investigations. Refer to Chest Pain Tests and Chest Pain Diagnosis for more information.
- Pain is dull, constricting, choking and/or crushing.
- Other terms to describe ischemic cardiac chest pain includes squeezing, burning or heavy.
- Sometimes it may just feel like discomfort which is why the character of cardiac chest pain can be so misleading.
- A common but inconclusive presentation in cardiac chest pain is a patient clutching the chest (picture below).
- The pain may vary from burning to sharp, stabbing and prickling.
- Chest pain due to anxiety may also result in pain that is similar to cardiac chest pain.
- The pain is usually central (towards the center of the chest) and fanning outwards (diffuse).
- Pain may be away from the center of the chest where a patient can clearly identify it as a right-sided or left-sided chest pain.
- Pain is usually localized – located at only one spot which can be clearly pinpointed by the patient.
- Pain to the jaw, neck, shoulder, arms (either one or even both) or back.
- Sometimes there pain may be radiated to the upper abdomen.
- There may not often be any radiation of the pain or it may radiate to other sites apart from those mentioned above.
- Gastritis with accompanying GERD may cause a burning chest pain as well as upper abdominal pain and this may be confused for radiation.
- Triggered or exacerbated by exertion or emotion.
- At times a large meal or even extremes of temperature, particularly cold, can trigger or exacerbate the pain.
- Unstable angina may not be triggered by any specific factors.
- Spontaneous although it may be exacerbated by exertion (usually after rather than during activity).
- Changes in posture, deep or rapid breathing or pressure may also exacerbate the pain.
- Pain is relieved by rest and responds quickly to nitrates.
- Not relieved significantly by rest, if at all.
- Does not respond to nitrates or there may be a slow response.
- Pain relived by antacids may be related to gastrointestinal disorders. Pain that improves upon leaning forward may be related to the pericarditis (inflammation of the lining around the heart).
Concomitant/Associated Signs and Symptoms
- Severe shortness of breath – patient may report a feeling of suffocation.
- Fainting spells (‘blackouts’)
- Other signs and symptom may be present that is helpful in identifying the cause of the pain.
- Gastrointestinal – bloating, belching, nausea, vomiting and/or regurgitation. Refer to Gastric Chest Pain.
- Respiratory – shallow breathing, persistent cough, abnormal breathing sounds, difficulty breathing when lying flat, expectorating mucus or coughing up blood. Refer to Lung Chest Pain.
- Musculoskeletal – limited range of motion, cannot tolerate pressure on the affected area. Refer to Muscle Chest Pain and Bone Chest Pain.
- Psychological – weepy, depressed, excited, agitated, fearful. Refer to Nerve Chest Pain.