Most of us think that the more severe the symptom the more serious the cause. Chest pain is a concern for adults as it can signal heart disease which remains the main cause of adult death in developed countries. However, severe chest pain does not necessarily mean that the cause is always serious. Sometimes a heart attack can present with very mild chest pain which is misleading (silent heart attack).
Similarly severe chest pain can sometimes be due to conditions that are not life threatening. One of the most common causes of chest pain reports at emergency rooms is due to acid reflux. It can be severe and painful but it is not life threatening. It is therefore important to differentiate between chest pain that is due to serious causes and chest pain that is not serious. Severe chest pain alone is not a reliable indicator.
Meaning of Severe Chest Pain
Chest pain can occur in any age group and gender. In children, chest pain is often not taken as seriously as it is with adults. Severe chest pain in adults, even with no other symptoms, always raises the concern of a heart attack and emergency medical attention is sought. However, there are various other causes of chest pain, even severe chest pain.
It is therefore important to understand that severe chest pain does not always mean a life threatening condition. Some red flags along with the pain is difficulty breathing, dizziness, confusion and referred pain to the arm. Even if these other symptoms are not present, immediate medical attention is necessary for severe chest pain in adults.
Read more on cardiac and non-cardiac chest pain.
Is Chest Pain Serious?
Pain is subjective. Therefore severe chest pain alone is not a reliable indicator of these seriousness of the underlying cause. Other symptoms should also be considered. In the absence of other symptoms, chest pain that affects sleep, daily tasks and even emotions can also be considered when assessing the seriousness of the pain.
There chest pain on its own should be considered if it has the following effects:
- Sleep. Cannot fall asleep or maintain sleep due to the intensity of the pain. Nightmares and ‘bad dreams’ may also be a result of the persistent pain.
- Daily activity. Unable to attend work, carry out routine activities or complete daily tasks efficiently due to the chest pain.
- Physical activity. Apprehensive about undertaking any physical activity due to the pain or exacerbation of the pain upon activity.
- Mental tasks. Difficulty concentrating, confusion or impairment of cognitive functions with the chest pain..
- Emotional state. Depressed and withdrawn, or agitated and irritable due to the chest pain.
The presence of other signs and symptoms, especially the following should warrant an immediate trip to the emergency room.
- Abnormal vital signs – heart rate (pulse), breathing rate, blood pressure, temperature
- Signs of shock
- Dyspnea (shortness of breath)
- Abnormal breathing sounds
- Severe fatigue
- Dizziness and/or fainting spells (‘blackouts’)
- Referred pain to the arm, neck or jaw especially on the left side.
Patients at risk of heart conditions should consider any persistent chest pain as serious and seek medical attention. This is necessary even in the absence of warning signs and other concomitant symptoms.
Causes of Severe Chest Pain
The causes of severe chest pain are the same as chest pain of any intensity. However, certain conditions tend to cause more intense pain. Here are some of the causes of severe chest pain that tends to arise suddenly, is serious and can be life threatening.
- Angina pectoris is heart muscle injury with reduced blood oxygen supply. This is temporary and does not cause death of the heart muscle.
- Heart attack is where the blood supply to a portion of the heart muscle is completely blocked. It results in death of a portion of the heart muscle tissue which can be fatal.
- Pulmonary embolism is where a blood clot blocks the circulation between the heart and lungs. It can be fatal. The blood clot usually arises in the leg vein to travel up to the chest.
- Aortic dissection is where a tear forms in the inner lining of the wall of the aorta. Blood accumulates between the layers of the aorta and sometimes the aorta can rupture.
All of these conditions are serious and require emergency medical attention. It is important to note that severe chest pain can occur with even innocuous conditions like acid reflux. Sometimes the typical heartburn of acid reflux is not present which can be misleading.
How to report severe chest pain
At the emergency room, the attending doctor will conduct a quick assessment and request specific tests to confirm or exclude possible conditions as per his/her differential diagnosis. A patient’s cooperation and accurate reporting of the following can assist the doctor with making a prompt diagnosis.
Type of chest pain
Describe the pain as accurately as possible. Severe chest pain will only tell your doctor that the pain was unbearable enough to result in a trip to the emergency room. Is the chest pain constricting, sharp/stabbing, tight, choking , burning or dull?
Is it localized to one part of the chest (center, right, left) or throughout the entire chest? Is it superficial (feels like it is on the outside) or deep (feels like it is inside)?
Radiating or Referred Pain
Is is radiating to other parts of the body (arm, jaw, back, abdomen)? Sometimes the pain may be felt in the chest an another part of the body without it extending from the chest.
What triggers the pain (food, activity, stress, change of position)? It may also be useful to provide a short but informative account of events that preceded the onset of the pain even if the chest pain did not appear to be triggered by these events.
What eased the chest pain, whether partially or completely? This could be related to rest, use of certain medication, consuming certain foods or drinks, change in position.
What other associated signs and symptoms appeared along with the chest pain? These signs and symptoms may no longer be evident but should be reported to the attending doctor.