What is causing my chest pain?

Chest pain can appear in many different forms, ranging from mild discomfort to a burning sensation. While this type of pain can be due to a variety of reasons, chest pain is often the sign of a serious underlying heart problem.

Here, Professor Peter Groves, highly experienced consultant cardiologist, provides an expert insight into chest pain. The Cardiff-based specialist discusses what are the common causes of chest pain, how to recognise chest pain that is cardiac in origin, when to seek medical help from a cardiologist, and much more.

What are some common causes of chest pain?

Chest pain is actually often described by patients as something similar to a discomfort around the chest area. Thus, instead of just thinking about pain, I believe we should think about discomfort which can appear in many forms. This can be either sharp, stabbing, dull, aching, tight, pressing, or burning types of discomfort – all with different significance.

It’s important to remember that what’s contained within the chest itself is also anatomically complicated. As a cardiologist, I obviously think about the heart, but the lungs, the oesophagus, the nerves from the back and the spine, and the muscles and the bones around the chest wall are involved, as well. All these structures can give rise to symptoms of chest discomfort or chest pain when they’re not functioning normally. Thus, trying to determine the exact cause of chest pain is quite complicated because we must consider where the pain is coming from.

This can be from:

• Indigestion and acid reflux associated with spasm or inflammation of the gullet.
• Exercising, which can cause the muscles in the chest wall to ache.
• Stretching or twisting awkwardly, which can pull an intercostal muscle. This can lead to an extremely sharp and unpleasant pain.
• An infection, which can affect the muscles around the chest wall.
• A crack in the neck or spinal arthritis, which can give rise to pain that radiates down through the nerves into the chest.

What’s important to know here is that chest discomfort or chest pain doesn’t always indicate the presence of heart disease. However, it can be very difficult to make this differentiation without the help of a cardiologist who can help patients to understand when pain or discomfort in the chest is likely to be associated with heart disease and when pain or discomfort in the chest is attributable to something a bit less serious. This is why going to see a cardiologist is a very important step forward.

How can people differentiate between chest pain that is cardiac in origin and that which may be caused by other conditions, such as acid reflux or anxiety?

The most important cause of heart-related chest pain or chest discomfort is a condition called angina.

Angina occurs when there’s an imbalance between the supply of blood to the heart muscle and the demand that the heart muscle has for blood and oxygen. When the demand outstrips the supply, a referring up process then starts to occur (for example, a narrowing of arteries) that limits the amount of blood that gets to the heart muscle.

Patients who experience angina can be comfortable at rest in a relaxed situation, but if they have to exercise, climb a hill or rush for a bus, then the extra demand and the imbalance that develops causes the heart to be temporarily deprived of a good blood supply. The heart then complains by making a patient feel chest discomfort or chest pain.

Symptoms eventually become predictable. It’s thus the pattern of symptoms that’s important in patients with heart pain, which is often brought on predictably by circumstances where there’s an increase in the work that the heart is having to do (for example, physical exercise, stress or an unusual activity). Hence, the first element of chest pain is the predictability of symptoms.

The second element of chest pain is the character and the nature of the pain. The character of pain can be very confusing, but if patients feel a tightness, heaviness or constriction in their chest - as if a band is being pulled around the chest wall - then that's suggestive of heart pain. If the pain is located over the front of the chest and spreads across the chest, and if the pain moves and radiates down in to the arm (usually the left arm, but it can be the right arm as well) or up into the neck or jaw and it’s associated with a toothache, then this combination of symptoms should also raise the possibility of heart pain.

The final element of chest pain isn’t only what brings the pain on (for example, an increase in physical or emotional exercise), but also what makes the pain better. In patients who develop angina, the pain is brought on with extra stress, meaning that as soon as the stress is removed the equilibrium between supply and demand of blood is restored. The pain then quickly subsides within a few minutes, leading to the complete resolution of symptoms. Thus, heart pain - in patients who suffer from angina - is short-lived and related to bursts of increased demand, being relieved very rapidly by rest. On the other hand, patients who have a muscle strain or indigestion can experience symptoms for a long period of time (sometimes even hours).

When should someone with chest pain seek medical attention?

Patients should go an see a cardiologist if they experience a predictable onset of chest heaviness, chest tightness or chest constriction that’s particularly associated with a radiation of discomfort down into the left arm or into the neck or the jaw. The onset of these symptoms in a predictable way, on a day-to-day basis, under certain circumstances but not others, and relieved rapidly by resting or removing the stress, is enough to make a clinical diagnosis of angina. If a patient has angina, then they need to be assessed, diagnosed and treated because angina can be the warning sign of very serious underlying heart disease.

Particularly, if symptoms are progressing and getting worse form one week to the next, with the threshold of exercise at which the heaviness or the tightness in the chest appears beginning to get lower, then this is a real important red flag.

If patients are experiencing episodes of chest tightness or heaviness that are becoming longer in duration (for example, from five minutes to 10 minutes or even longer) then these are red flag symptoms that indicate the need for urgent cardiology attention.

Overall, it’s about understanding the pattern, the change in pattern, and the onset of a new pattern of symptoms. If the pain or discomfort is associated with feelings of sweating, nausea, or breathlessness, then these are additional alarm bell symptoms that may suggest heart pain.

What kind of serious cardiac conditions can be triggered by unattended chest pain?

Angina is a description of a symptom. There are different types - what I’ve described so far is called a stable, predictable angina.

Angina, however, can also become unstable and when it does, it can be a precursor to a heart attack. A transition from predictable, stable symptoms to a pattern of crescendo symptoms or to symptoms that are more prolonged in duration and more intense in severity, are symptoms that begin to raise the suspicion of an unstable angina pattern. If left untreated and attended, an unstable angina can then sadly lead to a critical life-threatening heart attack. This situation is a medical emergency that must be avoided at all costs.

Once a patient develops an unstable pattern of symptoms or prolonged severe symptoms, this can also indicate the presence of an acute coronary syndrome. This is a medical emergency that requires very careful and expert assessment, usually in hospital with urgent treatment.

Professor Peter Groves is a highly distinguished consultant cardiologist with over 35 years’ experience.

If you or a loved one is suffering from chest pain, don’t hesitate to book an appointment with Professor Groves via his Top Doctors profile today to receive expert assessment, diagnosis and treatment.