HEART DISEASE SYMPTOMS : CHEST PAIN

Pain in the chest is the second most common symptom of heart disease and may be due to angina, a heart attack, dissection of the aorta, or an inflammation of the lining of the heart called pericarditis, all of which are described below. (See box, “Possible Causes of Chest Pain.”) But not all chest pain is due to heart problems. Pain in the chest may originate from a variety of other structures in the chest cavity, including the aorta, the pulmonary arteries, the pleura (the lining of the lungs), the esophagus, or even the stomach. Other superficial causes of chest pain may be a pulled muscle in the chest wall, strained cartilage, irritated joints, or pinched nerves in the thoracic spine.

 Possible Causes of Chest Pain

1. Coronary heart disease
2. Esophagitis
3. Gallbladder disease
4. Peptic ulcer
5. Hiatus hernia
6. Musculoskeletal pain
7. Cervical spine disease
8. Dissecting aneurysm
9. Pulmonary embolus and other lung disorders
10. Mitral valve prolapse
11. Pericarditis
12. Anxiety states

Chest pain may also occur when organs below the chest cavity become irritated or diseased, such as agallbladder that is blocked by stones, an ulcerated stomach, or an inflamed pancreas. Heartburn caused by stomach acid refluxing into the esophagus is also commonly confused with chest pain. Although chest pain may have many different causes, people who experience it should always let their physician decide whether it is related to heart disease. Any steady, squeezing pain in the center of the chest that lasts for more than two minutes may be a symptom of heart disease and should not be ignored. Some people who have died from heart attacks might have been saved had they not delayed seeking treatment because they misinterpreted the
pain or believed it would go away. When a physician evaluates chest pain in a patient, he or she considers the quality of the pain, its duration, the precipitating factors, where it appears to be emanating from, and where it goes. Angina pectoris, or chest pain from the heart, which was first described by the British physician William Heberden more than 200 years ago, occurs because the heart muscle is not receiving enough oxygen to function properly. The heart, like any muscle, requires a steady and adequate supply of oxygen to expand and contract. 

The heart muscle receives its primary oxygen supply from the coronary arteries. When these arteries become narrowed, usually because of cholesterol plaque formation, the blood supply, and thus the amount of oxygen, reaching the heart may be insufficient. When the heart muscle’s demand for oxygen becomes greater than the supply, which generally occurs during exertion or moments of great anxiety, pain fibers in the muscle are stimulated and angina occurs. Most people describe the quality of angina as a pressure in the chest or as if the heart were being squeezed in a vise. Common activities that increase the demand for oxygen and cause angina include jogging, carrying a suitcase while running to catch a plane, walking briskly up the stairs, and emotional engagements (such as a family argument or a dispute at work) that cause the heart to beat faster and the blood pressure to elevate. Oxygen demand also may exceed the supply after a big meal, when blood and oxygen are diverted from the heart to the stomach and intestinal tract. An easy way to remember the major causes of angina is to think of the so-called three Es: exercise, emotion, and eating. The pain during angina may be confined to the center of the chest or may also radiate from the center of the chest to the shoulders and down the inside of the left arm. At times it can radiate to the jaw and be confused with a toothache. It generally lasts for two to three minutes and usually subsides when the person stops the activity and rests. When arteries are severely narrowed, angina may occur at rest or after only minimal activity.

Depending on the degree of the narrowing in the coronary arteries, the onset of angina after exertion may be rapid or delayed. The greater the narrowing, the more rapid the onset of angina and the longer it may persist.
A heart attack occurs when one of the arteries supplying blood to the heart muscle becomes completely blocked by a combination of the long-standing cholesterol plaque and a blood clot at the site of the narrowing. In most cases, the plaque has broken through the smooth lining of the artery and attracts sticky substances in the blood, called platelets and fibrin, which accumulate and form a clot.

The pain of a heart attack often radiates to the same areas as in angina, but it will be of longer duration than angina and it does not go away with rest. Although some heart attacks can be “silent’ (occurring without pain), the nature of the pain is most often severe and may be accompanied by nausea, clamminess, sweating, and the feeling of great anxiety or dread. A heart attack may occur during heavy exertion, but it happens more frequently at rest. The most common time of day for a heart attack to occur is from 6:00 A.M. to noon. Sometimes a panic attack can mimic a heart attack. This tends to occur primarily in younger people who have an anxiety disorder. Panic attacks also are more likely to be experienced by women than by men. But whether the chest pain is of cardiac or psychological origin, any of the above symptoms in a person over 40 years of age warrants a phone call for medical care.

Dissection of the aorta is another cause of chest pain. This occurs when the major artery leading away from the heart undergoes a disruption in the inner layers of its lining. Blood enters between the layers, then is pushed along the length of the artery in a pulsing fashion that creates severe pain. Dissection most frequently occurs at the site of a ballooning out or weakening of the aorta and is called an aortic aneurysm. It is most often seen in elderly people with a history of high blood pressure, but it can occur at younger ages with rare medical conditions such as the Marfan syndrome, in which people characteristically are very tall, with long arms and legs. For example, there have been rare but unfortunate cases in which basketball or volleyball players have died suddenly from the Marfan syndrome. The pain from a dissecting aneurysm may radiate from the front of the chest to the back, or outward from between the shoulder blades. Fainting may occur when blood flow to the brain is blocked, and stroke may occur when the carotid artery is blocked. The condition should always be treated as a medical emergency. It is fatal in more than 50 percent of untreated patients. Fortunately, this is rather rare. Pericarditis can cause chest pain when the thin, smooth double membrane of the heart becomes inflamed. Both the heart and lungs are covered by this type of cellophane-like membrane. The pain is caused by friction as the two inflamed layers rub against each other with the normal movement of the heart. Pericarditis is usually the result of an infection with a virus, most commonly the Coxsackie virus Type B. In the early stages, pericarditis may be difficult to distinguish from a heart attack. The diagnosis may
be confirmed if a “rub” is heard with a stethoscope. This occurs as the two membrane layers rub together. Although it is less common, pericarditis may be caused by a chest injury, such as hitting the steering wheel of car in a traffic accident. A malignant tumor also can cause pericarditis when it invades the chest cavity. This is rare but may occur with lung or breast cancer, or with a lymphoma in the elderly. Tuberculosis, which is being seen more frequently in underprivileged populations and in people with the human immunodeficiency virus (HIV), also may cause pericarditis. Functional, or so-called psychological, chest pain is more difficult to diagnose because in some cases it may actually have a physical basis. This condition is being studied in a group of middle-aged women who experience chest pain but who are found after diagnostic tests to have normal coronary arteries. The new evidence suggests that a hormonal imbalance may contribute to the pain. Some doctors are calling this condition microvascular angina. Replacement estrogen therapy may be extremely therapeutic.