CHEST PAINS - Full extract 

Bill is a retired insurance consultant. He has been so busy helping his grown-up children that he wonders how he ever found time for work at all. He also enjoys pottering around the house, even doing some occasional gardening. 

His wife called me one morning to say that Bill had a bad pain in the chest. He was apparently quite distressed with the pain and I needed to promptly sort out over the phone whether or not it was significant. 

The pain was there when he had woken up and was felt across the top of the chest on the left side. It extended into the armpit and it hurt when he stretched or lifted his arms. It was also very painful if he coughed or sneezed. There was no shortness of breath and he was not nauseated or feeling unwell. There was no indigestion or belching, just this persistent pain on the left side of his chest. 

I felt almost certain that it was a muscular pain but I asked him to come down to the surgery straight away for a check-up. There was nothing much to find on examination, aside from some tenderness in the muscles that run between his ribs. Apparently he had been doing some heavy lifting in the garden the previous day. 

I explained to Bill that he had probably torn some intercostal muscles, and I advised him to rest for a few days. I also suggested that he take some paracetamol for pain relief. He rang later in the week to tell me that the pain had gradually settled. 

When most people get a pain in the chest they automatically think the worst. Is it my heart? Could this be the big one? Heart attack or myocardial infarction is just one of many causes of chest pain. However, it is a condition that should always be kept in mind. 

There are some clues about the nature of the pain that help distinguish whether a chest pain is coming from the heart. Any persistent heavy pain across the front of the chest should always be regarded as a heart pain until proven otherwise. The pain might be felt in the back or radiate to the neck and arms and there could be other symptoms like nausea or shortness of breath. Immediate medical assessment is necessary; the best approach is to call an ambulance and get to the nearest major casualty department. 

Heart attack is caused by a blockage of one of the coronary arteries. It is often called a coronary thrombosis or a myocardial infarction . The pain is caused by an acute shortage of blood to the heart muscle and it is often extremely severe. The person may be pale and sweating or even lose consciousness. The main concern about a heart attack is that the heart will not pump properly, or develop a rhythm disturbance and stop altogether. These risks are dramatically reduced if the person is immediately transported to hospital. 

Chest pains that come on with exercise are called angina. The pains signify narrowing of one or more coronary arteries and should be promptly sorted out with your doctor. Angina is often well-controlled with weight reduction and medication. However, if the pains become more frequent or severe, urgent referral to a cardiologist for further investigation is essential. A coronary angiogram may be necessary to establish the degree of narrowing of the coronary arteries. A decision can then be made whether an operation to improve the blood supply to the heart is required. 

There are many other causes of chest pain. Here are just a few examples... 

Muscular chest wall pains  This is probably the most common type of chest pain. It may come on after some hard physical work and is often accentuated by lifting the arms or twisting and stretching. There may also be local areas of tenderness on the back or chest. 

Indigestion or heartburn  This often feels like a burning behind the breastbone and there may be associated belching. It might have come on after a heavy meal or several drinks of alcohol. Frequently it is relieved by taking antacids. Indigestion can be a great mimic of heart pain and sometimes even the doctor will find it hard to distinguish. "It's only a bit of indigestion, dear" can be famous last words. 

Pleurisy   With some episodes of pneumonia the surface of the lung becomes inflamed and causes pain with breathing. 

Pulmonary embolus  or a "clot on the lung" usually causes a sudden severe chest pain and shortness of breath. Sometimes coughing up blood also occurs. They occur when part of a clot or thrombus in a large vein breaks off and travels up to the lungs. They are more likely after extended periods of immobilization, for instance after a long air flight or a few weeks after surgery. 

Pneumothorax  or lung puncture, usually causes a sudden chest pain, often with associated shortness of breath. Although it can follow an injury to the chest, it frequently occurs spontaneously, without any warning at all. Urgent X-ray and medical assessment is required.

Gallstones  often cause pain in the right side of the upper abdomen. Sometimes people describe the pain as being in the lower chest.

Shingles  affecting the chest wall may also produce severe chest pain on one side. The pain is usually of gradual onset and is often difficult to diagnose before the telltale shingles rash appears.

Health tips:
 * Chest pain is a symptom that should always be discussed with your doctor. If the pain is not severe and is likely to be a muscular pain or indigestion, arrange an early appointment with your doctor for a check-up.

* If the chest pain is persistent or severe and there is any possibility of it being a heart pain, go to the nearest casualty department as quickly as possible. Ringing 000 for an ambulance is the safest option.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001