WHAT IS NONCARDIAC CHEST PAIN?
ACUTE CHEST PAIN
CHEST PAIN DUE TO LUNG DISEASES
MUSCULOSKELETAL CHEST PAIN
ESOPHAGEAL CHEST PAIN
CHEST PAIN DUE TO UPPER ABDOMINAL DISEASES
PSYCHOSOMATIC CHEST PAIN
FUNCTIONAL CHEST PAIN
MORE THAN ONE CAUSE OF CHEST PAIN IS OFTEN PRESENT CONCURRENTLY
INTRODUCTION
Chest pain may arise from any of the organs present in the chest cavity, namely, the heart, the lungs, the blood vessels, the esophagus, or the chest wall itself. Nerve endings (sensors) that are involved in the experience of pain are present in the internal organs as well as in the chest wall. Although the sensors in the internal organs are insensitive to painful stimuli such as cutting and pricking, they are activated when the organ loses blood supply or is stretched. Nerve sensors in the chest wall, including the outer lining of the pleural cavity, the musculoskeletal wall, and the skin are sensitive to cutting, pin prick, pressure and heat. The branches of nerves that carry sensory information from the internal organs and the chest wall intermingle in the spinal cord on their way to the brain. Therefore, pain arising from the internal organs can be felt (often termed “referred to”), and may be confused with that arising in the chest wall.
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PSYCHOSOMATIC CHEST PAIN FUNCTIONAL CHEST PAIN |
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| WHAT IS NONCARDIAC CHEST PAIN? |
Simply stated the term noncardiac chest pain means that the chest pain is not due to heart disease. However, indiscriminate usage of the term noncardiac chest pain has led to confusion about its meaning and therefore it requires qualification when used. Cardiologists often use this term narrowly to describe those patients who present with chest pain suggestive of coronary artery disease, but in whom coronary artery disease has been excluded. Accordingly, this diagnosis includes cases of functional cardiac chest pain (discussed below). It also includes highly selected cases of chest pain arising from other organs that resemble cardiac chest pain and whose actual diagnosis was missed by the referring physician. Noncardiac chest pain is a diagnosis made by the exclusion of a cardiac cause of chest pain. The gold standard test for excluding the diagnosis of coronary artery disease is coronary angiography.
Most physicians do not include cases that have a well defined source of chest pain in organs other thanheart under the umbrella term of noncardiac chest pain, while others use the term noncardiac chest pain very broadly to include all cases of chest pain due to organs other than the heart, such as the lungs, esophagus, musculoskeletal structures, and psychosomatic causes. This confusion has led to reports of widely varying rate of prevalence of noncardiac chest pain.
Noncardic chest pain is a common condition. More than half of the patients who present to emergency room with chest pain suggestive of acute coronary ischemia have noncardiac problems. Almost one third to one half of cases evaluated for chest pain with coronary angiograms is found to have normal coronary arteries.
Acute chest pain may signify a life threatening emergency and these usually present in the Emergency Department. The causes of acute, sudden onset chest pain include acute myocardial infarction, unstable angina, acute angina, acute aortic dissection, pulmonary thromboembolism, pericarditis or pleuritis, or pneumothorax. These conditions require prompt diagnosis and treatment which should be initiated as soon as possible. Cases that are found to have no life threatening disease may have chronic cardiac, pulmonary, musculoskeletal, gastrointestinal, or psychosomatic and functional disorders. In a number of cases the diagnosis remains elusive. It has been estimated that a cardiac cause of chest pain is excluded in almost 80% of the cases.
Chest pain due to lung diseases or pulmonary chest pain is usually due to pleuritis or inflammation of the membranes that line the chest cavity. Pleuritic chest pain is characterized by sharp, well localized pain that is made worse on breathing and coughing or sneezing. Pleural inflammation may occur in pneumonia, pulmonary embolism, lung cancer or as an isolated phenomenon. Other symptoms of lung disease such as cough, sputum, coughing of blood, shortness of breath, rapid heartbeat, anxiety, and faintness may be present. Pneumothorax, or rupture of the parietal pleura with spillage of air into the pleural space, can present with acute chest pain and shortness of breath.Sickle cell disease may cause acute pleuritic chest pain. Pulmonary chest pain is usually acute and often diagnosed by x-ray of the chest. D-dimer testing and computed tomography (CT) pulmonary angiography is often needed for diagnosing pulmonary embolism. Pulmonary chest pain may be present in 5% to 12% of all cases of chest pain presenting in the primary care setting, or the Emergency Department.
Musculoskeletal chest pain includes all causes of chest pain that arise from lesions in the chest wall, including the muscles, ribs, and costal cartilages, and the spine, including the intercostal nerves. The diagnosis of musculoskeletal chest pain can usually be made easily by careful history and physical examination. Musculoskeletal causes may be responsible for chest pain in up to one third of cases of chest pain in primary care centers. Some of the musculoskeletal diseases that cause chest pain are described briefly below:
Tietz syndrome is a rare, self-limited disorder that is characterized by tender swelling of one or more upper costochondral cartilages.
Costochondritis is a common, but poorly understood disorder that involves upper (2nd to the 5th) costal cartilages that are tender without swelling.
Precordial catch syndrome is a common, self-limited disorder that is characterized by sudden onset of localized sharp stabbing pain that lasts 30 seconds to 3 minutes. It is not associated with any physical signs. Diagnosis of these conditions is mainly clinical and treatment is by reassurance. Costochondritis may benefit by local heat and non-steroidal anti-inflammatory drugs (NSAIDs).
Pectoral muscle girdle fatigue due to drag on the arm by a bra strap, a baby carried on the forearm, and from carrying heavy shoulder bags can lead to cervicothoracic pain. Treatment is avoidance of the offending stress.
Slipping rib syndrome is a common disorder that is characterized by subluxation of tips of the lower (8-10) cartilages. The subluxated tips may impinge on the intercostal nerves and cause pain. History of previous chest trauma may be obtained. Treatment is by reassurance or local nerve block. Surgery is sometime required.
Thoracic disc herniation may cause band like chest pain. Other conditions such as ankylosing spodylitis, intercostal neuralgia, spinal stenosis, and diffuse idiopathic skeletal hyperostosismay cause chest pain. These patients with musculoskeletal chest pain are treated with reassurance, local heat application, and nonsteroidal anti-inflammatory agents (NSAIDs). Corticosteroid-lidocaine injections may be helpful in some cases. Lesions of ribs and thoracic spine such as fractures, inflammatory disorders, and tumor infiltration are common causes that should be carefully looked for.
Fibromyalgia is a common functional disorder causing chronic chest pain that has the following suggestive features: 1) symptoms over 3 months; 2) widespread aching pain and stiffness involving chest, neck, shoulder, and periscapular wall; 3) pain affected by weather, physical activity, and psychological stress; 4) impaired sleep; fatigue and morning stiffness; associated anxiety, depression, chronic fatigue; 5) multiple discrete tender points on physical examination; and 6) normal lab tests and exclusion of common clinical conditions. Patients with fibromyalgia also frequently have associated functional cardiac and esophageal pain and psychosomatic disorders. Drugs that suppress nociception such as antidepressants (duloxitine, milnacipran) tricyclics, anticonvulsants (pregabalin), and aerobic exercises and cognitive behavioral therapy may be useful.
Acute esophageal chest pain may be due to esophageal perforation, bolus obstruction, or hiatal hernia strangulation. These conditions require immediate evaluation in the Emergency Department. They may be suspected on careful history and examination and diagnosed by imaging or other specialized studies. The well established causes of chronic chest pain of esophageal origin are mucosal inflammation and specific esophageal motility disorders.
Esophageal inflammatory disorders
Reflux esophagitis
Reflux esophagitis is chemical esophagitis secondary to gastroesophageal reflux disease GERD (see knol on Gastroesophageal Reflux Disease) is a very common cause of chest discomfort or pain. Chest pain in reflux esophagitis is characterized by the sensation of heartburn. Heartburn is precipitated by bending forward and is relieved by ingestion of milk or antacids. Heartburn may also be precipitated by exertion and particularly after a large meal. These features may mimic those of angina. Heartburn is often associated with regurgitation.
Reflux esophagitis may cause erosions of esophageal mucosa, a condition that is called erosive reflux disease (ERD). Erosive reflux disease requires aggressive treatment with proton pump inhibitors (See knol on Gastroesophageal Reflux Disease [GERD]). Untreated erosive esophagitis may develop complications of esophageal peptic ulcer, esophageal stricture, or intestinal metaplasia (Barrett’s esophagus) that may progress to carcinoma. Esophageal ulcer may cause chest pain and pain on swallowing. Esophageal stricture may cause food sticking during swallowing. Development of Barrett’s esophagus occurs silently. In fact when Barrett’s esophagus develops, symptom of heartburn may ameliorate. Chest pain with progressive dysphagia and weight loss in a patient with long history of heartburn is suggestive of Barrett’s carcinoma.
Non-erosive reflux disease (NERD) is a name given to cases of reflux esophagitis that have near normal endoscopy. It has been estimated that up to 70% of cases with heartburn and reflux esophagitis may have NERD. These patients are clinically indistinguishable from patients with ERD as far as symptoms of heartburn reflux and response to proton pump inhibitors, H2 receptor blockers or antacids (See knol on Gastroesophageal Reflux Disease [GERD]). Although endoscopy is unremarkable, subtle microscopic changes may be seen on mucosal biopsies. Moreover, esophageal pH recording test shows abnormal acid reflux. NERD cases are treated for the symptoms and untreated NERD cases uncommonly develop complications associated with esophagitis.
Esophagitis due to infective agents
The esophagus may be a site of invasion by a variety of organisms leading to conditions including viral esophagitis and Candida esophagitis, particularly in immuno-compromised hosts. These patients usually present with painful swallowing and chest pain. These conditions are diagnosed by careful history and examination and endoscopy, biopsy and histological evaluation.
Esophageal Motility Disorders
Two well defined esophageal motility disorders that may cause chest pain are achalasia and diffuse esophageal spasm (DES). Achalasia is characterized by loss of esophageal peristalsis and loss of relaxation of the lower esophageal sphincter (LES) in response to a swallow, whereas DES is characterized only by loss of peristalsis but preserved LES relaxation. These patients usually present with sticking of both liquid and solid foods and regurgitation of nonacid mucous. They may also present with chest pain. In many cases the pain resembles heartburn and this condition may be confused with GERD.
Functional chest pain attributed to the esophagus
These include cases of functional chest pain that on investigation are found to have esophageal function abnormalities of unclear clinical significance or normal esophageal function except for esophageal hypersensitivity.
The esophageal motility abnormalities of questionable significance include hypertensive esophageal peristalsis (nutcracker esophagus), hypertensive or hyper-contracting LES and so-called nonspecific motor abnormalities. The causal relationship between these manometric diagnoses and chest pain has not been established. Moreover, a temporal association between these conditions and chest pain has not been documented. Finally, treatment of the hyper-contractile states with smooth muscle relaxants has not proved to be effective in the relief of chest pain.
Dynamic high resolution endoscopic ultrasound in these patients has shown that episodes of chest pain are associated with sustained contraction of esophageal longitudinal muscle. The longitudinal muscle contraction remains undetected by intraluminal manometry. Therefore, sustained esophageal longitudinal muscle contraction has been proposed as a cause of chest pain in patients with normal esophageal manometry. Further studies are needed to fully establish sustained longitudinal muscle contraction as the cause of unexplained chest pain.
Several recent studies have suggested that the esophagus may develop sensory hypersensitivity so that stimuli that do not normally produce pain may be perceived as painful. Esophageal hypersensitivity is demonstrated by showing reduced threshold to esophageal distension in eliciting pain sensation. Esophageal mucosal hypersensitivity has been tested by the esophageal acid perfusion test (Bernstein test).
Esophageal hypersensitivity may be a part of generalized visceral hypersensitivity. The pathophysiology of visceral hypersensitivity is not fully understood, but may occur peripherally in the esophageal afferent nerves or in the central nervous system.
Cases of functional esophageal chest pain, like those of functional cardiac chest pain, are frequently associated with psychosomatic symptoms. It has been suggested that esophageal motility and functional abnormalities may be secondary to the underlying psychosomatic abnormalities. These patients may respond to antidepressants such as trazodone.
Disorders of stomach, gall bladder, biliary tract, and pancreas usually produce epigastric pain. However, some times they cause lower chest pain. This may be true for gastritis, gastric ulcers, gastric volvulous, and gastric banding for obesity. Biliary tract pain may be radiated to the right shoulder. Pancreatitis and other abdominal diseases may cause epigastric and retrosternal pain. These conditions can be diagnosed by careful history and examination and appropriate blood tests, imaging studies, and esophago-gastro-duodenoscopy (EGD).
Psychosomatic disorders are important and common causes of chest pain. Chest pain is an important component of panic disorder, anxiety state, and depression. In some studies up to 75% of patients with chest pain and near normal coronary arteries reportedly have some psychiatric diagnosis.
Panic disorder, which affects approximately 5% of the US population, is an important cause of chest pain. Criteria for chest pain associated with panic attack (DSM-IV) are chest pain or discomfort associated with intense fear or discomfort in which three or more of the following symptoms develop abruptly and peak within 10 minutes: 1) palpitation; 2) sweating; 3) trembling; 4) sensation of shortness of breath or smothering; 5) sense of choking; 6) nausea and abdominal distress; 7) dizziness, light headedness, and fainting; 8) feeling of unreality or detachment from self; 9) fear of losing control or going crazy; 10) fear of dying; 11) numbness or tingling ; 12) chills or hot flushes.
Recurrent chest pain is also associated with acute or chronic anxiety, personality disorder, depression, hysteria, phobic disorder, obsessive compulsive disorder and somatization. These patients should be referred to a psychiatric clinic for help in diagnostic evaluation and treatment. Many of these patients require education about the disease, gentle persuasion, and reassurance that effective treatments for these disorders exist, before they accept these recommendations. The effective treatment for these disorders includes antidepressants, anxiolytics, or behavioral cognitive therapy. Attributing a chest pain syndrome to this source can be difficult and often requires very careful history and physical examination, and depending on the case, appropriate diagnostic testing to exclude other etiologies of chest pain.
Functional chest pain may be ascribed by the patient to one of the organs such as the heart or the esophagus. Often these patients have a more generalized disorder of pain perception, which are associated with psychosomatic abnormalities. There is considerable overlap between functional cardiac, esophageal, musculoskeletal, and psychosomatic causes of chest pain. For example, a group of patients with unexplained chest pain were diagnosed according to the following distribution: esophageal motility disorders (41%), panic disorder (43%), and microvascular angina (22%). Eighty-seven percent of these patients developed characteristic chest pain during catheterization with right ventricular stimulation or intracoronary adenosine infusion, suggesting heightened visceral nociception.
Patients with functional chest pain have normal survival; however, their quality of life and functional status are markedly impaired. They over-utilize health care resources. Most patients continue to experience chest pain and functional impairment even after a diagnosis has been made.
Various diseases that cause chest pain are very common clinical entities such as coronary artery disease, pneumonia, esophagitis, musculoskeletal, and psychosomatic disorders. Therefore, more than one cause of chest pain may coexist, making a proper evaluation difficult. Moreover, one disease causing chest pain may be associated with another disease causing chest pain with increased frequency. Thus, reflux esophagitis may aggravate coronary ischemia because of connections of nerves between the esophagus and the heart. Also, risk for reflux esophagitis is increased in patients with coronary artery disease. Furthermore, patients with organic disease causing chest pain may develop anxiety and stress that may make a proper diagnosis difficult.
TREATMENT OF CHRONIC RECURRENT CHEST PAIN
Chronic and recurrent chest pain may be an indicator of a serious disease. Therefore, self diagnosis of the cause of chest pain should only be made in case of obvious minor injury or muscle strain. Otherwise, medical help should always be sought. The primary care provider obtains a careful history and physical examination narrows the cause of chest pain to cardiac ischemia, cardiac or pulmonary diseases, esophageal disease, upper abdominal disorders, musculoskeletal disorders and psychosomatic causes.
If chest pain is thought to be cardiac in origin, the patient may be referred to a cardiologist for evaluation. (See knol on cardiac chest pain) These patients often receive investigation with exercise or pharmacological stress testing with EKG, with or without myocardial perfusion nuclear SPECT and echocardiography (ECHO) to determine severity and extent of ischemia, left ventricular function, and functional capacity. Coronary angiography is the gold standard for excluding coronary artery disease. If ischemic heart disease is excluded, a diagnosis of noncardiac chest pain is made by the cardiologist. It has been estimated that out of all cases of chest pain undergoing cardiac catheterization for suspected coronary artery disease, 30% to 50% are found to have near normal coronary arteries that practically excludes a diagnosis of ischemic heart disease. These cases should be reevaluated for other cardiac, pulmonary, esophageal, upper abdominal and musculoskeletal and psychosomatic causes of chest pain by careful history, physical examination and tests.
Pulmonary and musculoskeletal causes are investigated by careful history and physical examination. X-ray of the chest, spine, and ribs are often helpful. Persistent and difficult to diagnose or treat cases are referred to rheumatologist for further evaluation. Treatment depends on specific diagnosis.
If the chest pain suggests uncomplicated heartburn of recent onset, empiric acid suppression therapy may be tried. Reflux esophagitis is the commonest cause of unexplained chest pain. A gastroenterologist is consulted when patient has persistent heartburn that is not responsive to therapy or when alarm symptoms, such as dysphagia, odynophagia, unintentional weight loss, or loss of appetite are present. A gastroenterologist after a careful history and examination arrives at a provisional diagnosis of esophagitis or significant esophageal motility disorder and proceeds with investigations. If there are no alarm symptoms a PPI therapeutic trial may be initiated, if it has not already been properly done by the primary care physician. If there is no satisfactory response, the patient usually undergoes endoscopic examination or esophago-gastro-duodenoscopy (EGD). EGD is often required in longstanding and complicated cases and when alarm symptoms are present. EGD may show erosive esophagitis or complications of ulcer, stricture or Barrett’s esophagus.Mucosal biopsy is performed to confirm the diagnosis. EGD with mucosal biopsies also helps in establishing diagnosis of infective esophagitis as well as eosinophilic esophagitis. These conditions are appropriately treated.
If the esophageal mucosa is found to be normal and the mucosal biopsy is also reported to be normal, a 24-houresophageal pH monitoring study is performed. Normal mucosal biopsy with abnormal esophageal pH suggests a diagnosis of non-erosive reflux disease (NERD). Acid perfusion test ("Bernstein" test) in which 0.1 % hydrochloric acid is perfused by catheter into the distal esophagus is usually abnormal in these cases. Cases diagnosed as NERD are aggressively treated with PPI. If a 24-hour pH study is normal, possibilities of nonacid reflux disease is considered. This possibility is investigated by esophageal impedance testing in which nonacid reflux into the esophagus can be documented.
If patient does not have esophagitis, possibility of significant esophageal motility disorders should be reevaluated using esophageal manometry. Achalasia and diffuse esophageal spasm (DES) are found in only a small number of the cases of unexplained chest pain. They usually have associated dysphagia and when diagnosed are appropriately treated. Most of these patients are found to have either normal esophageal motility or abnormalities that are of uncertain clinical significance. Such patients may undergo esophageal hypersensitivity testing using esophageal balloon distension test.
Cases diagnosed as having increased esophageal sensitivity are treated by reassurance and should receive psychiatric evaluation.
Psychiatric evaluation is very helpful in patients with chronic persistent chest pain who provide a history of panic reactions, anxiety, and depression. Patients are often resistant to a psychiatric evaluation. However, education and gentle persuasion can overcome such a resistance. This is particularly important after serious organic cardiac, esophageal, upper abdominal and musculoskeletal causes of chest pain have been excluded. Cases referred for psychosomaticinclude cases diagnosed as functional cardiac and esophageal chest pain, fibromyalgia. This is because these diagnoses overlap and they may represent a common functional chest pain syndrome.
Chest pain is also common in children. It has been reported to be the second most common symptom for referral to a pediatric cardiologist. As expected, true cardiac chest pain is almost nonexistent. A small number were found to have supra-ventricular tachycardia of mitral valve prolapse. Majority (32% to 76%) had musculoskeletal chest pain. Gastrointestinal, particularly GERD was the second most common cause. In many cases no cause was found. The remaining patients are found to have various causes of chest pain.
FURTHER READING about PSYCHOSOMATIC CHEST PAIN
FUNCTIONAL CHEST PAIN
1) Fass R, Eslick GD. Editors. Noncardiac Chest Pain. A Growing Medical Problem. Pleural Publishing Inc. San Diego 2007.
2) Kocis KC. Chest pain in pediatrics. Pediatric Clin North Amer 1999; 46: 189-203.
3) Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994 Apr;38(4):345-52.
4) Pope JH. Missed diagnosis of acute cardiac ischemia in the emergency department. NEJM 2003;342: 1163-1170.
5) Wong W-M. Attitude and referral patterns of primary care physicians when evaluating subjects with noncardiac chest pain – A survey. Dig Dis Sci 2005; 50: 656-661.
6) Eslick GD, Jones MP, Talley NJ. Non-cardiac chest pain: prevalence, risk factors, impact and consulting—a population-based study. Aliment Pharmacol Ther. 2003 May 1;17(9):1115-24.
7) Eslick GD, Coulshed DS, Talley NJ. Diagnosis and treatment of noncardiac chest pain. Nat Clin Pract Gastroenterol Hepatol. 2005 Oct;2(10):463-72.
8) Ruigomez A. Chest pain in general practice. Fam Pract 2006; 23: 167-174.
9) Fenster PE. Evaluation of chest pain: a cardiology perspective for gastroenterologists. Gastroenterol Clin North Am. 2004 Mar;33(1):35-40.
10) Achem SR, DeVault KR. Noncardiac nonesophageal causes of chest pain of esophageal origin. Curr Treat Options Gastroenterol. 1998 Dec;1(1):49-55.
11) Faybush EM, Fass R. Gastroesophageal reflux disease in noncardiac chest pain. Gastroenterol Clin North Am. 2004 Mar;33(1):41-54.
12) Sengupta, JN. Esophageal sensory physiology. GI Motility online (2006) doi:10.1038/gimo 16.
13) Lee R. Mittal R. Heartburn and esophageal pain. GI Motility online (2006) doi:10.1038/gimo 75.
14) Fass R, Dickman R. Nonerosive reflux disease. GI Motility on line (2006) doi: 10.1038/ gimo 42.Womens Health and Medical Care; It's a Free Info at your own risque about : Medical, Health, Nutrition, Alcoholism, Allergy, Anxiety, Asthma, Beauty, Cholesterol, Diabetes, Fitness, Heart Disease, Massage, Smoking, Weight Loss. But Nothing in this site web should be construed as individual medical advice. Patients should consult with their own physician regarding the diagnosis and treatment of their disease. Not all of the medications discussed are FDA-approved for the treatment of disease, and some side-effects and contraindications have not been listed.
