Recently I had a friend come to my clinic with a history of severe chest pain which started off at night and was so severe that she had to go to the hospital nearby for treatment. Apart from the pains what was most terrifying was that she was alone and she was afraid that she was having a heart attack. Luckily, her ECG at the ER was normal, her pain subsided with antacid therapy and she was sent back home. I write this article to tell you how to analyse your pain and what you must do. Of course if you are unable to analyse what you are going through or if the pain is very severe, I would advise you to go straight to the hospital and not lose time pondering as to the cause of the pain.
What are the Alarm signs in a person with a chest pain, things that would require you to go to the ER immediately?
1.Compressive chest pain with severe sweating.
2.Chest pain with severe dizziness
3.Chest pain with new onset breathlessness.
4.Chest pain followed by fainting or loss of consciousness.
5. Chest pain with a low or a very high Blood pressure or with low oximeter readings ( < 92%)or with a high pulse rate (>100bpm)
Lets look at the common causes of chest pain, see how they present typically.
1. Cardiac pain – Pain arising due to a heart attack or angina is typically central, compressive, it could radiate to the left shoulder, arm, jaw or ear and is associated with severe sweating, nausea or vomiting, dizziness and breathlessness. The key words would be pain and sweating. This pain is usually worse on exertion and could be relieved by rest. The typical patient is a middle aged to elderly man who has cardiac risk factors such as obesity, cigarette smoking, high cholesterol levels, diabetes, high blood pressure etc. Postmenopausal women are at higher risk for a heart attack compared to premenopausal women. Also women may have a heart attack with atypical symptoms and even without pain!
2.Acid reflux can also give pain behind the sternal (breast) bone. The pain could be sharp or dull, localised or diffuse. The pain could also be burning and be associated with bile/bitter water rash to the mouth. This is worse after a meal and on lying down in bed after food.
3. Chest pain due to Gas! Pain due to gas is usually sharp localised to a small area and can move quickly from one part of the chest to another or even the back. It could feel like a catch in the chest or like being stabbed and make breathing difficult. This pain usually happens after a meal and is relieved by belching/burping. The key words would be moving pain and relief by belching.
4.Pleuritic chest pain -this pain is sharp and felt on the side of the chest. It worsens on deep breathing coughing and sneezing. This is usually caused by irritation of the pleura , which is the covering of the lung and it occurs when there is a pneumonic infection of the lung. This could be associated with cough, phlegm production and breathlessness. The key words would be chest pain on deep breathing.
5. Musculoskeletal chest pain- this pain can be quite severe localised and can increase on movements, deep breathing and local pressure (which is diagnostic) If the pain increased on pressing the affected part of the chest, it is highly unlikely to be from the heart or the lung and must be from the muscles and bone of the chest. Localised pain on touch and pressure on the side of the sternal bone (2nd Costo-chondral junction is called Tietze syndrome). The key words would be localised chest pain worse on local compression. Similar pain can also happen after a rib fracture.
Other cause for chest pain:
1. Mitral valve prolapse syndrome is characterised by repeated sharp pricking anterior chest pain which may be associated with palpitations and anxiety. It affects women more often than men.
2. Sudden sharp “pleuritic” chest pain with breathlessness and low Oximeter reading could be an Acute Pulmonary Embolism. The usual patient is a woman on contraceptive pills or an elderly person who has made a long haul flight (Economy class syndrome) and has developed a Deep venous thrombosis (DVT). This could also be due to a Pneumothorax. (Punctured lung)
3. Herpes Zoster – the pain of herpes zoster can precede the typical rash by a few days. The pain is severe lancinating continuous and may have a pleuritic component i.e., it worsens on deep breathing.
So what should you do if you develop a chest pain?
1. The first thing would be to check your pulse rate, oximeter reading and your Blood pressure. These equipments are now available in nearly household. If the parameters are very abnormal, it would be sensible to go to the hospital immediately.
2. If you have any alarm signs – a hospital visit is a must urgently.