Chest pain refers to discomfort or pain felt in the chest area and can range from sharp stabbing sensations to dull aches. It is a common symptom, with millions of cases reported globally yearly. Chest pain is important because it can signal both benign conditions and life-threatening issues, such as a heart attack. Understanding the cause of chest pain is crucial in determining the appropriate treatment and care.
Am I having a heart attack?
While chest pain is the most common symptom of a heart attack, many other conditions can cause chest pain, ranging from mild issues like acid reflux to severe problems like a blood clot in the lungs. Being able to distinguish between these conditions is essential to ensure proper treatment. This article will guide patients and doctors in identifying the cause of chest pain and differentiating a heart attack from other conditions.
What is the most common cause of chest pain in adults?
Gastroesophageal reflux disease (GERD)
The most common cause of chest pain in adults is gastroesophageal reflux disease (GERD). GERD occurs when stomach acid frequently flows back into the esophagus, irritating its lining. This can cause a burning sensation known as heartburn, which may mimic the symptoms of heart-related chest pain. GERD typically affects adults aged 30 to 60 and is more common in individuals who are overweight or consume a diet high in fatty foods. The pain is usually triggered after eating or when lying down. Diagnosis is often clinical, but an upper endoscopy can confirm the condition. Treatment involves lifestyle changes and medications to reduce acid production.
Other common causes of chest pain in adults
Heart attack (myocardial infarction)
A heart attack occurs when blood flow to the heart muscle is blocked, usually due to a clot in one of the coronary arteries. This leads to the death of heart muscle cells. Common symptoms include chest pain radiating to the arm, neck, or jaw, shortness of breath, nausea, vomiting, and sweating. The pain is typically described as crushing or pressure-like. Heart attacks are most common in older adults, especially those with risk factors like high blood pressure, diabetes, or a history of smoking. Diagnosis is confirmed through electrocardiogram (ECG) changes and blood tests for heart enzymes. Immediate treatment includes medications to dissolve clots or surgery to restore blood flow.
Angina
Angina is chest pain caused by reduced blood flow to the heart muscles, often due to narrowed coronary arteries. The pain is similar to a heart attack and is typically described as pressure or tightness in the chest. However, unlike a heart attack, angina does not cause permanent heart damage. It usually occurs during physical exertion or stress and resolves with rest or medications such as nitroglycerin. Angina is a warning sign that the heart is not getting enough oxygen and may indicate an increased risk of a heart attack.
Costochondritis
Costochondritis is the inflammation of the cartilage that connects the ribs to the breastbone. The cause is often unknown but may follow trauma or physical activity. The pain is sharp, localized to the chest wall, and worsens with movement, deep breaths, or pressure on the chest. It is more common in younger adults. Costochondritis is a benign condition managed with rest, anti-inflammatory medications, and avoiding activities that worsen the pain.
Panic attack
A panic attack is a sudden episode of intense fear or anxiety that triggers severe physical reactions. Symptoms include chest pain, rapid heart rate, shortness of breath, and dizziness. The pain is typically described as tight or constricting and is often accompanied by a sense of impending doom. Panic attacks can mimic the symptoms of a heart attack, but they usually resolve with relaxation techniques and breathing exercises. Patients who experience frequent panic attacks may benefit from cognitive-behavioral therapy or medication.
Pneumonia
Pneumonia is an infection of the lungs that causes inflammation and fluid accumulation in the air spaces. It typically presents with sharp chest pain, fever, chills, cough, and shortness of breath. The pain worsens with deep breaths or coughing. Pneumonia is more common in older adults and those with weakened immune systems. A chest X-ray and blood tests confirm the diagnosis. Treatment includes antibiotics, rest, and supportive care, such as oxygen therapy.
Pulmonary embolism
A pulmonary embolism occurs when a blood clot blocks one of the arteries in the lungs, restricting blood flow and oxygen. Symptoms include sudden chest pain, shortness of breath, rapid heart rate, and coughing up blood. The pain is often sharp and worsens with deep breaths. Pulmonary embolism is a life-threatening condition typically associated with prolonged immobility, recent surgery, or a history of blood clots. Diagnosis is confirmed with imaging tests such as CT pulmonary angiography. Treatment involves blood thinners or clot-dissolving medications.
Shingles
Shingles is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. It leads to a painful rash that typically appears on one side of the chest. The pain is burning or tingling in nature and precedes the appearance of the rash by a few days. Shingles is more common in older adults and individuals with weakened immune systems. Antiviral medications can help reduce the severity of symptoms and prevent complications.
Peptic ulcer disease
Peptic ulcers are open sores that form in the lining of the stomach or the duodenum, the first part of the small intestine. They cause a burning or gnawing chest pain that often worsens after eating or when lying down. Other symptoms include nausea, bloating, and indigestion. Peptic ulcers are commonly caused by infection with Helicobacter pylori or the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Diagnosis is made through endoscopy, and treatment involves antibiotics and acid-reducing medications.
Cholecystitis
Cholecystitis is the inflammation of the gallbladder, often caused by gallstones blocking the bile ducts. It results in right-sided chest pain that may radiate to the shoulder, especially after eating fatty foods. Additional symptoms include nausea, vomiting, and fever. Diagnosis is made through imaging, such as an abdominal ultrasound. Treatment involves antibiotics and, in some cases, surgery to remove the gallbladder.
Esophageal spasm
Esophageal spasm is a condition in which the muscles of the esophagus contract abnormally, causing chest pain that mimics a heart attack. The pain is often triggered by eating or drinking and may be accompanied by difficulty swallowing. Esophageal manometry or barium swallow tests confirm the diagnosis. Treatment includes medications to relax the esophagus and dietary changes.
Less common but important causes of chest pain
Myocarditis
Myocarditis is inflammation of the heart muscle, usually due to a viral infection. It can cause chest pain, fatigue, shortness of breath, and irregular heart rhythms. Myocarditis is more common in younger adults and athletes. The condition is diagnosed through blood tests, ECG, and sometimes a heart biopsy. Treatment includes rest and medications to reduce inflammation and support heart function.
Boerhaave syndrome
Boerhaave syndrome is a rare condition where the esophagus ruptures, usually after forceful vomiting. This causes severe chest pain, difficulty swallowing, and shock. It is a medical emergency that requires immediate surgical repair. Diagnosis is confirmed with imaging studies, such as CT scans, and treatment involves stabilization and surgery.
Pulmonary hypertension
Pulmonary hypertension is high blood pressure in the arteries of the lungs. It causes chest pain, shortness of breath, and fatigue, especially during physical activity. Pulmonary hypertension is often secondary to other lung or heart diseases. Diagnosis is confirmed with an echocardiogram or right heart catheterization. Treatment includes medications to lower blood pressure in the lungs and improve heart function.
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is a genetic condition in which the heart muscle becomes abnormally thick, making it harder for the heart to pump blood. Chest pain typically occurs during physical exertion and may be accompanied by dizziness or fainting. An echocardiogram confirms the diagnosis, and treatment includes medications to relax the heart and reduce the risk of sudden cardiac arrest.
Pneumothorax
Pneumothorax occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. This results in sudden, sharp chest pain and shortness of breath. Pneumothorax can occur spontaneously or after trauma. A chest X-ray confirms the diagnosis, and treatment may involve inserting a tube to remove the air and re-expand the lung.
Mitral valve prolapse
Mitral valve prolapse occurs when the mitral valve in the heart doesn’t close properly, allowing blood to flow backward. This can cause chest pain, palpitations, and shortness of breath. An echocardiogram confirms the diagnosis. Most cases are benign, but severe cases may require medications or surgery.
Thoracic outlet syndrome
Thoracic outlet syndrome occurs when the blood vessels or nerves in the space between the collarbone and first rib are compressed. This can cause chest pain, numbness in the arms, and swelling. Imaging tests diagnose the condition, and treatment involves physical therapy or surgery to relieve pressure.
Esophageal cancer
Esophageal cancer involves abnormal cell growth in the esophagus, often causing progressive difficulty swallowing (dysphagia) and chest pain. Other symptoms include weight loss, heartburn, and regurgitation of food. The condition typically affects older adults and is associated with risk factors like smoking, heavy alcohol use, and chronic acid reflux. Diagnosis is confirmed with endoscopy and biopsy. Treatment depends on the stage and may involve surgery, chemotherapy, and radiation.
Pericarditis
Pericarditis is inflammation of the pericardium, the thin sac surrounding the heart. It often causes sharp, stabbing chest pain that worsens with deep breaths or lying down. Pericarditis can result from viral infections, surgery, or a heart attack. An ECG or echocardiogram confirms the diagnosis. Treatment typically involves anti-inflammatory medications.
Pleural effusion
Pleural effusion occurs when fluid builds up between the layers of tissue lining the lungs and chest cavity. Symptoms include chest pain, cough, and difficulty breathing, often worsening with deep breaths. It is usually caused by infections, heart failure, or cancer. Diagnosis is confirmed with imaging, and treatment involves draining the fluid and addressing the underlying cause.
Aortic dissection
Aortic dissection is a life-threatening condition where the inner layer of the aorta tears, causing blood to flow between the layers of the aortic wall. It leads to sudden, severe, tearing chest pain that radiates to the back. Diagnosis is made via CT scan or MRI; emergency surgery is required to repair the aorta.
Red flags
Red flag symptoms are warning signs that indicate a potentially serious or life-threatening cause of chest pain. These symptoms suggest that the underlying condition may require immediate medical attention to prevent severe complications or death. Recognizing these signs early can help ensure that the patient receives timely care.
Patients should seek urgent medical attention if chest pain is associated with the following symptoms:
- Shortness of breath: Difficulty breathing may indicate serious conditions like pulmonary embolism, heart failure, or a heart attack. It suggests that the lungs or heart are not functioning correctly, reducing oxygen supply to the body.
- Pain radiating to the arm, neck, or jaw: This symptom is characteristic of a heart attack. The pain often starts in the chest and moves to the left arm, neck, or jaw, indicating that the heart is deprived of oxygen.
- Sudden, severe chest pain: Conditions such as aortic dissection or pneumothorax can cause abrupt, intense pain. Aortic dissection, for example, involves a tear in the aorta, while pneumothorax involves a collapsed lung. Both are life-threatening and require immediate intervention.
- Fainting or lightheadedness: This symptom may indicate a sudden drop in blood pressure or reduced oxygen to the brain, which can result from a heart attack, arrhythmia, or aortic dissection.
- Coughing up blood: Hemoptysis, or coughing up blood, may suggest a severe lung issue, such as a pulmonary embolism, pneumonia, or lung cancer. This symptom is a sign of bleeding in the lungs, which can be life-threatening.
- Nausea and vomiting: These symptoms are common during a heart attack and can also be associated with gastrointestinal issues like peptic ulcers or gallbladder disease. When paired with chest pain, they warrant urgent evaluation for a potential cardiac event.
- Cold sweats: Sudden sweating, especially when combined with chest pain, is a classic sign of a heart attack. Cold sweats occur as the body’s stress response to the heart’s lack of oxygen, signaling a medical emergency.
- Loss of consciousness: Passing out or nearly doing so may suggest a critical problem, such as a heart attack, severe arrhythmia, or stroke. It often signals a significant drop in blood pressure or brain oxygenation and should prompt immediate emergency care.
Advice for patients
If you experience chest pain, it is crucial to seek medical advice to determine the cause. Mild or infrequent chest pain may not require urgent care, but it is still important to visit a doctor for evaluation. Severe or persistent chest pain should prompt immediate medical attention, particularly if associated with symptoms like shortness of breath, dizziness, or radiating pain. Treatment for chest pain varies depending on the underlying cause, ranging from lifestyle changes and medications to surgical interventions.
Summary
Chest pain in adults can arise from a wide range of causes, from benign conditions to life-threatening emergencies. While gastroesophageal reflux disease is a common cause, serious conditions like heart attacks, pulmonary embolism, and aortic dissection must also be considered. Recognizing red flags, such as shortness of breath, radiating pain, nausea, and cold sweats, can help patients and doctors identify when chest pain is more serious and requires urgent medical care.