Navigating chest pain

In his latest online article, Dr Dwayne Conway gives us his insights into chest pain. He talks about the common causes, when to be concerned, treatment options and lifestyle changes to help prevent chest pain.

What are the common causes of chest pain

Chest pain has a multitude of causes, with some being serious and others less so. While most of these discomforts in the chest, shoulder, neck, or upper back are benign, some may signal severe conditions like a heart attack, pulmonary embolism, pneumonia, aortic dissection, or problems with the stomach or oesophagus (gullet), such as oesophagitis or peptic ulceration.

The chest area includes various structures like skin, muscles, bones, nerves, heart, lungs, blood vessels, oesophagus and more, each capable of generating pain. Pinpointing the exact cause of pain can be complex, but an individual’s own description of the pain can play a vital role in determining the cause. This highlights the significance of a conversation with a healthcare professional in assessing chest pain.

Pain, fundamentally, is a perception in our brains, transmitted through our nervous system. Any alteration in this system can modify how we perceive pain, sometimes reducing our awareness of it or, conversely, causing pain without any physical issue.

When should I be concerned about chest pain?

Considering the multitude of potential causes for chest pain, ranging from benign to life-threatening, it's often challenging for an individual to discern the level of concern needed for their symptoms. While the majority of chest pains are typically not serious, it's crucial to consult a doctor, nurse, or pharmacist to ensure an accurate understanding of the pain's likely cause, thereby not overlooking any critical issue.

Let's examine chest pain originating from the heart, which is my own area of expertise. Cardiac pain, being ‘visceral’ (deep organ-related), tends to manifest as a dull or aching discomfort over a wider area, often described as pressure or constriction on or around the chest. Identifying the precise source of this pain is complicated because deep organs share sensory nerve connections with other areas, resulting in what we term "referred pain." Cardiac discomfort might therefore be felt in the jaw, neck, shoulder, left arm, back or even the upper abdomen. The localisation of cardiac pain varies between individuals, but tends not to change position. This type of pain typically emerges during physical exertion, known as exertional angina, and subsides shortly after ceasing the activity. Pains that deviate from this pattern are less likely to be heart-related. For instance, sharp, stabbing pain localised to a specific area on one side of the chest, or pain unrelated to physical activity, lasting a few seconds, linked to specific postures or movements, or tender to touch, is less likely to stem from the heart. However, there might be less clear characteristics, necessitating professional medical advice for chest pain of uncertain cause.

In cases where the pain is accompanied by 'warning signs' like severe dizziness, extreme breathlessness, or loss of consciousness, seeking immediate medical assistance by calling the emergency services is strongly recommended.

What are the treatment options for chest pain?

Treatment options depend upon the cause of the pain. I mentioned earlier the very long list of potential causes of chest pain. Therefore, the list of potential treatments is also long.

If the pain has features of a heart attack, I would recommend taking aspirin 300mg immediately as this can be a simple life-saver. At the same time, call 999 for immediate medical attention and the paramedics may provide additional pain-relieving treatments depending upon their assessment. Cardiac pain (heart attack or angina pain) can respond to GTN spray or GTN tablets. Painkillers can also be effective. However, to fully treat the underlying cause of the cardiac pain may require hospital-based investigations such as an invasive coronary angiogram. Certain types of heart attack require immediate angiography and coronary intervention (angioplasty) in order to unblock a blocked artery, which can help to relieve the pain and reduce risk from the heart attack.

Stable angina on exertion does not usually require hospital admission but may require outpatient investigations. Medications that can reduce angina pain include: GTN, beta blockers, calcium antagonists, isosorbide mononitrate, nicorandil and ivabradine.

In the more common situation of chest pain from a non-cardiac cause, it is again important to treat the underlying cause in order to settle the pain. For example, inflammatory causes of chest pain such as pleurisy, pericarditis or musculoskeletal pain can respond well to non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. In contrast, NSAIDs can worsen pain from the stomach and oesophagus (gullet) as they make the stomach lining more prone to ulceration. Medications such as lansoprazole that reduce acid production in the stomach may be more helpful in reducing gastro-oesophageal pain.

If in doubt as to the cause of your chest pain, or the best treatment options, please seek advice from your GP, practice nurse or pharmacist.

Are there any lifestyle changes that can help prevent chest pain?

Once again this would depend upon the cause of the chest pain. In almost all cases it helps to remain fit and active and to eat healthily. Relaxation techniques, yoga and physiotherapy can help many causes of chest pain including musculoskeletal pain, anxiety and even cardiac pain.

If you are experiencing chest pains, I would recommend keeping a record of your chest pain episodes in a diary: When does the pain occur? Is it at any particular time of day? Is it related to eating or drinking? Is it precipitated by physical activity such as walking or carrying objects or housework? Is it affected by taking deep breaths in? Is it precipitated by moving the neck, arm or shoulders? How long does each episode last? Does anything help to ease the pain? How would you describe the character of the pain? What do you think is causing the pain? Is there anything that worries you about this pain? Does it affect your ability to live a normal life?

This information can be extremely helpful for a health professional to assess the likely cause of your pain, and guide you to the most suitable investigations and or treatments for your chest pain.

Dr Dwayne Conway is a distinguished consultant interventional and general cardiologist with over 25 years of experience. You can schedule an appointment with Dr Conway on his Top Doctors profile.