Chest pain

What Is It?

Chest pain is the sensation of pain or discomfort located in the front region of the chest.

When evaluating a symptom like pain, we must define the following aspects: location, radiation, characteristics, duration, triggering factors, relieving and aggravating factors, and associated symptoms.

Location

Cardiac-origin chest pain caused by coronary artery disease (such as angina or myocardial infarction) is typically located in the central chest area (retrosternal) or may be diffuse, potentially radiating to other areas.

Cardiac pain may manifest only in its possible radiation sites. When we refer to cardiac-origin chest pain, it implies a broad area of potential radiation—from the jaw to the navel, including both arms, the back of the chest, neck, jaw, and upper abdomen. Anterior chest pain radiating to both arms is highly suggestive of a coronary origin.

Characteristics

Coronary chest pain is usually diffuse and perceived as tightness, pressure, heaviness, or burning. Pain described as sharp or stabbing is rarely of coronary origin.

Duration

Angina pain typically lasts 5 to 20 minutes. Chest pain with coronary characteristics lasting more than 20–30 minutes suggests a myocardial infarction.

Pain that lasts only seconds, several hours, or comes and goes throughout the day is rarely due to coronary artery disease.

Triggering Factors

Coronary chest pain is often triggered by physical exertion, emotional stress, or heavy meals that are hard to digest.

Relieving and Aggravating Factors

Coronary chest pain is not usually worsened by touching the chest, deep breathing, changing body position, or moving the arms.

It typically improves with rest or the use of nitrates (coronary vasodilators).

Associated Symptoms

Coronary chest pain may be accompanied by shortness of breath (dyspnea), sweating, nausea, vomiting (suggestive of myocardial infarction), palpitations, and pallor.

Symptoms like cough, fever, or heartburn may suggest other causes such as respiratory or digestive diseases.

Causes

• aortic aneurysm
• pneumothorax
• pleural effusion
• pulmonary embolism
• pneumonia
• gastroesophageal reflux
• pericarditis
• lung or mediastinal tumors
• esophagitis
• esophageal spasm
• pulmonary hypertension
• costochondritis
• rib injuries
• muscle injuries
• arthritis
• fibromyalgia
• herpes zoster
• rheumatoid arthritis

Abdominal conditions that may also cause chest pain:

• cholecystitis
• gastritis and peptic ulcer
• pancreatitis

Diagnosis and Treatment

Chest pain requires medical evaluation for proper diagnosis and treatment.

Seek immediate medical attention if you:

• feel sudden, intense pressure, tightness, or pain in the chest
• experience pain radiating to the jaw, left arm, or between the shoulder blades
• have nausea, dizziness, sweating, rapid heartbeat, or difficulty breathing
• have known angina and the pain suddenly worsens, occurs with less exertion, or lasts longer than usual
• experience angina symptoms at rest
• have sudden sharp chest pain with shortness of breath, especially after long travel, bed rest, or immobility, particularly if one leg is swollen (possible blood clot)

Key Features Suggesting Cardiac Ischemia

Often felt as pressure or tightness rather than sharp pain (commonly described by a clenched fist over the chest).

• triggered by physical effort or emotional stress
• diffuse pain on the left side or center of the chest, often radiating to the left arm, back, or neck
• accompanied by sweating, shortness of breath, pallor, or low blood pressure
• may include palpitations
• lasts several minutes
• does not improve with common painkillers
• loss of consciousness after onset is a sign of severe cardiac disease

Patient History

In addition to pain characteristics, the patient’s clinical history is crucial. The more cardiovascular risk factors a patient has, the higher the likelihood that chest pain indicates a serious condition.

Major cardiovascular risk factors:

• age over 40
• history of ischemic heart disease
• sedentary lifestyle and high-fat diet
• strong family history of heart disease
• smoking
• obesity
• diabetes mellitus
• high blood pressure
• high cholesterol
• chronic kidney disease
• cocaine use

Incidence in Brazil

It is estimated that five to eight million individuals with chest pain or other symptoms suggestive of acute myocardial ischemia are seen annually in emergency rooms in the United States.

In Brazil, there are no official numbers or estimates regarding the number of emergency room visits due to chest pain. However, based on the annual number of chest pain-related visits in the U.S., the population ratio between the two countries, and assuming a similar prevalence of coronary artery disease, it is estimated that there could be approximately 4 million emergency visits for chest pain per year in Brazil.

By the Einstein Editorial Board