EVERY year in Britain up to one million adults see their GP about chest pain.
About six per cent of accident and emergency attendances can also be attributed to this common presentation.
The obvious concern for many when they experience chest pain is whether or not it might be related to the heart. After all, heart attacks are responsible for more than 80,000 admissions to hospital each year in England alone.
It’s worth getting the classic symptoms of a heart attack straight from the outset. Sudden, central tight or crushing chest discomfort is most often the main feature, often described as like having someone sit on one’s chest.
In addition, one should also be on the lookout for shortness of breath or radiation of the discomfort into the neck, jaw or either arm.
Interestingly, in a recent survey, only 41 per cent of people knew that sweating, in conjunction with chest pain, could be a symptom of a heart attack and only 27 per cent knew that feeling weak, lightheaded or nauseous could also be a symptom.
People also sometimes describe feeling an impending sense of doom at the outset as well. If all this goes off quite quickly, it’s still worth seeing a doctor but if it continues any longer than 15 minutes, it’s certainly time to call 999.
We are lucky that the survival rate from heart attacks is much higher than it was. In the Sixties, seven out of 10 were fatal. Nowadays seven out of 10 patients survive.
Still, cardiovascular disease remains one of our biggest killers so it is always worth being on the lookout.
It’s also worth being aware that during a heart attack around 21 per cent of people may experience no chest discomfort at all (26 per cent in women), which can make things a bit more awkward to diagnose.
This is more likely in people who are diabetic, so it is worth being aware of the other symptoms just in case.
There are lots of other causes of chest pain, the majority of which are harmless.
If I’m being picky, “chest” is not actually a medical word as such. Its closest equivalent in anatomical terms is the thorax, which is the section of our bodies between the neck and the abdomen.
Because much of this is enclosed within the ribs, the old English word “cest”, meaning box or casket, was long ago employed as a colloquial term and this then stuck.
In this region, there are various sites which can be a source of pain. Having already mentioned the heart, the chest also contains the oesophagus, the lungs, the ribs, the intercostal and chest muscles, the sternum (breast bone), breast tissue in women and various blood vessels, including the aorta.
Probably the most common non-life threatening cause of chest pain that we see in general practice is gastro-oesophageal reflux, otherwise known as GORD, or indigestion.
This can be a central burning pain, often worse in the mornings or after eating or drinking, particularly if it’s spicy, acidic or alcoholic.
It’s a good sign if this is relieved by things like Gaviscon or drinking a bit of milk — something that will certainly not settle the symptoms of a heart attack.
The lungs, too, can generate the sensation of chest pain. A pneumonia (lung infection) will often trigger discomfort and pain in the front or in the back depending on where in the lung the infection is.
If a clot travels into the blood vessels within the lung and lodges there (pulmonary embolism) one might experience a severe, sharp and stabbing pain which catches when taking a big deep breath (something referred to as pleuritic chest pain as it can also be caused by inflammation of the outer pleura of the lungs, which can just be down to a virus).
If there is a clot, one is likely to feel short of breath and the heart rate will be higher than usual.
One of the big flags here is if you cough up some blood.
Another very common presentation to us in general practice is pain that is caused by strains or inflammation of muscles. The intercostal muscles are the ones in between each rib so expand and contract as we breathe in and out.
This can be sometimes confused with pleuritic chest pain, although you are unlikely to experience shortness of breath or blood in the phlegm if that is the case.
A long coughing illness often triggers this and even a particularly hard workout in the gym can give the same outcome.
Time is the best healer in this case while ensuring that you are taking the occasional deep breath to keep the air moving and prevent infections developing in the lung.
A cricket ball to the ribs, bruising or even fracturing them will have a similar effect, although this is likely to be more painful for longer.
Pain relief and time are the best options here (and even if a rib fracture is suspected, this is not routinely X-rayed as it makes no difference to the management).
In simple diagrams and skeletons in cartoons, ribs always cover the entire circumference of our bodies, connecting to the sternum in the centre.
In reality, the bony parts of the ribs stop just short of the sternum at which point they turn to cartilage. At this cartilage joint, there is a degree of give to allow for expansion of the chest.
Unfortunately, sometimes this costal cartilage can become inflamed and cause pain, tender to the touch (heart pain will never be tender to the touch) in a condition known as costochondritis. A more severe form of this is known as Tietze’s syndrome after the German physician who discovered it.
While this can be mild and overcome with rest and anti-inflammatories, it can advance to really quite severe levels which can occasionally require the intervention of pain specialists.
Another big cause of pain in the chest is anxiety. Typically this is a sensation of tightness, mimicking the symptoms of a heart attack and generally making things worse as a result.
While a heart attack or angina might come on after exerting oneself, however, tightness with anxiety occurs either in moments of high anxiety and panic (unsurprisingly) or while lying in bed at night.
People who are then fine during their workouts the next day are almost certainly suffering from anxiety-related chest tightness rather than anything cardiac.
Deep breathing exercises can be used to alleviate the symptoms which, as with Gaviscon in the case of GORD, would not make heart pain go away.
As you may therefore appreciate, chest pain can be a difficult symptom to navigate and often requires a bit of detective work.
An electrocardiogram can be useful to rule out heart attacks but these are not 100 per cent accurate. A blood test (troponin) to check for heart muscle damage is another way but, if the index of suspicion is that high, you should probably be in hospital by then anyway.
To make matters even more complicated there are always the rarer and unusual conditions that throw their hat in the ring of differentials as well.
Angina is partial blockage of a coronary artery (the arteries that supply the heart muscle with blood), causing chest pain on exertion which settles when one rests. It needs to be borne in mind that angina is sometimes a precursor to a heart attack so should not be ignored.
Printzmetal’s angina, on the other hand, refers to similar pain that occurs due to spasming of these vessels — common in people who use cocaine.
You may also have heard of a condition called Broken Heart syndrome which presents to all intents and purposes exactly like a heart attack but is actually a mostly transient enlargement of one of the ventricles of the heart.
This condition is most common in people who have been through a traumatic experience or bereavement. It is otherwise known as Takotsubo cardiomyopathy, so named because the heart, when scanned, resembles the shape of the takutsubo pots used by Japanese fishermen to trap octopuses.
So if you get a twinge in the chest, it might be one of the more benign causes.
However, if there is any doubt at all about it having a more serious cause, make sure you get it checked out.
All too commonly, I have seen people presenting with heart attacks who have been experiencing similar pains for weeks leading up to the bigger event which, if checked out earlier, could have been averted.
