Chest pain: Why it is not always about the heart

Chest pain can present differently, depending on what is triggering the symptoms. It can appear in many forms, ranging from a sharp stab to a dull ache to a burning or crushing feeling. Sometimes, the pain moves up the neck and into the jaw before it spreads to the back or down one or both arms.

Dr Isaac Ssinabulya, a consultant cardiologist at Uganda Heart Institute (UHI), says although most life-threatening causes of chest pain can involve the heart or lungs, different complications can cause chest pain. So, in most cases, chest pain can be due to a serious problem or have nothing to do with the heart. However, without seeking medical help, it is hard to know what is causing the pain.

“Many times, chest pain is associated with heart disease but even with heart disease, there is just a mild discomfort that may be accompanied by pressure or tightness in the chest, shortness of breath, dizziness, racing heartbeat, cold sweats, nausea and vomiting,” he says.

Causes

Chest pain has many possible causes all of which need medical attention and care, Dr Ssinabulya says. They may be heart or digestive related as well as muscle and bone causes. 

A heart attack results from blocked blood flow to the heart muscles, often from a blood clot and can cause chest pain. Others include coronary artery disease (blockage of blood vessel that feeds the heart), inflammation of the sac that covers the heart (pericarditis) usually causes sharp pain that gets worse when breathing in or lying down, aortic dissection (life threatening rupture of the aorta, a main blood vessel in the heart), very thick heart muscle which causes limited blood flow to entire muscle.

Dr Suzan Tusiime, a cardiologist, says some chest pain can be caused by digestive disorders such as a heartburn which causes a painful, burning feeling behind the breastbone. Also, gallstones or inflammation of the gallbladder or pancreas can cause stomach pain that spreads to the chest.

“Some types of chest pain are associated with injuries and other problems affecting the structures that make up the chest wall. These include costochondritis, a condition in which the cartilage of the rib cage that joins the ribs to the breastbone becomes inflamed and painful, sore muscles especially chronic pain syndromes, such as fibromyalgia, may cause long-term pain that affects the chest muscles. Also a bruised or broken rib can cause chest pain,” she says.

Lung-related issues

Lung-related problems such as inflammation of the membrane covering the lungs, a blood clot in the lungs (pulmonary embolism) can also cause chest pain.

“Chest pain due a collapsed lung typically begins suddenly but lasts for hours and causes shortness of breath. A collapsed lung occurs when air leaks into the space between the lung and the ribs. High blood pressure in the lung arteries affects the arteries carrying blood to the lungs causing chest pain,” Dr Tusiime says.

As mentioned earlier, one has to worry because the pain can mean a life-threatening condition and one has limited time to reverse the damage. They can result in severe heart damage, heart failure and death.

How to get proper diagnosis

First and foremost, one has to provide a clear description of the pain and understanding of the other prevailing circumstances and background medical history. This will help narrow down the possibilities and, therefore, guide on what tests to do. This saves time and resources given that not many are privileged to have all the resources at hand.

The Electrocadiogram (ECG) is a very useful test in chest pain as it can reveal the problem and also guide on next steps. 

“This test shows electric activity of the heart in the various parts. Your doctor is then able to see these electrical changes (signs of heart attack, strain on what part of the heart, evidence suggestive of heart muscle thickening, how fast or slow the heart is, its regularity and any other complications like heart blocks). A normal ECG does not mean the heart is normal, early on the ECG might be normal. So in case of typical symptoms do additional tests,” Dr Ssinabulya says.

Heart scan

The echocardiogram (heart scan) allows the healthcare provider to see the heart structures and how they function. Provides direct visualisation and, therefore, able to see extent of the problem. Examples include poor heart muscle movement in case of heart attack, muscle thickness, covering of the heart, valves and blood flow, one can also see the major vessels and pick any abnormalities with them.

Cardiac catheterisation, a procedure which involves using a needle-stick to introduce small tubes through blood vessels and reach the vessels that supply the heart. A special dye is then injected in the vessels and with use of special X-rays one can see blood flow through the vessel assessing degree of narrowing or blockage. These can then be opened up by using special stents and balloons.

Laboratory tests such as cardiac enzymes (troponin I being the most sensitive) help in diagnosing a heart attack. Other lab tests include: Full blood count to assess for infections, level of blood among others, blood sugar and lipid profile to look out for risk factors for heart disease. Kidney and liver function tests to assess organ function or complication but also guide for next steps of management.

How to manage these conditions?

For heart attacks Dr Ssinabulya recommends antiplatelets (drugs that prevent blood cells from adhering to each other).

He says, “We then unblock the vessel with medicine that dissolves the clot or directly in the cardiac catheterization lab by sucking out the clot and or put a stent. We also give medicine that support the heart depending on extent of damage and heart failure, give cholesterol lowering drugs, control blood sugar in case it is high and blood pressure.”

He adds that, “Coronary artery disease has stages but main guiding principle is to control what is causing the disease and reverse or slow down progression. This is managed by aspirin, control blood pressure, cholesterol and blood sugar as well as lifestyle changes such as weight loss and dietary modification.”

Pericarditis is treated with medication to reduce the inflammation, aortic dissection is managed by controlling blood pressure and heart rate and prepare for surgery to replace the damaged vessel. 

Thickened heart muscle: if due to narrowing of the heart valve (aortic valve) – prepare for surgery and replace the valve. 

For cardiomyopathy, plan for heart muscle reduction surgery, especially if thickness is causing blood flow obstruction.

Frequently asked questions

How is non-cardiac chest pain treated?

The treatment for non-cardiac chest pain depends on the underlying cause. Some common treatments for non-cardiac chest pain include:
● Medications, such as proton pump inhibitors (PPIs) for GERD or anxiety medications for anxiety
● Lifestyle changes, such as losing weight, eating a healthy diet, and exercising regularly
● Surgery, in some cases, such as for a hiatal hernia

What are the risks of non-cardiac chest pain?

The risks of non-cardiac chest pain depend on the underlying cause. However, some common risks of non-cardiac chest pain include:
● Anxiety
● Depression
● Sleep problems
● Reduced quality of life

What should I do if I have non-cardiac chest pain?

If you have non-cardiac chest pain, it is important to see a doctor to get a diagnosis and treatment. Do not ignore chest pain, even if you think it is not caused by a heart problem. Untreated non-cardiac chest pain can lead to serious complications, such as anxiety and depression.