What is Chest Pain? Chest pain raises concern for both patients and doctors. Foremost is concern about discomfort that arises from the heart which may warn of ongoing or impending heart attack. When heart muscle is injured due to obstruction in arteries that deliver oxygen to the heart, chest pain usually occurs. When muscle is deprived of oxygen but not injured, the pain that results is called angina. Angina can be stable and occur predictably –for example with exercise—or it can be unstable and occur without warning and with increasing frequency at rest. Another cause of heart derived discomfort is inflammation of the sac or pericardium around the heart. This is called ‘pericarditis’. The aorta, the main artery into which the heart pumps blood, can cause pain if it tears (aortic dissection) or weakens and bulges (aneurysm). Places in the chest other than the heart may cause chest discomfort. Inflammation or ulcer in the lining of the stomach (gastritis, gastric ulcer), reflux of gastric contents into the esophagus (hiatus hernia), and spasm of the esophagus (esophageal spasm) produce symptoms as do distention and irritation of the gallbladder or ducts leading to the gallbladder (cholecystitis, choledocolithiasis). Problems in the lung may cause chest pain. These include inflammation of the lining around the lung (pleuritis), inflammation of the lung itself (pneumonitis) or inflammation of the bronchial tubes (bronchitis). If a blood clot travels to the lung obstructing flow in a pulmonary artery (pulmonary embolus) chest discomfort may occur as it can when a lung collapses (pneumothorax). Frequently chest discomfort arises from tendons, muscles and ligaments in the chest wall. Often we do not connect discomfort from muscle or ligament strain to an injury that may have occurred at an earlier time. Arm, shoulder and chest discomfort may occur as a result of nerve irritation or compression arising from the spinal cord or from nerve injury from viral infections (herpes zoster). Quality and Intensity of Chest Discomfort Chest discomfort may be slow or sudden in onset and it may be mild, moderate or severe. It may occur in the front, middle, back or side of the chest and may change with body movement, breathing or eating. It may wax and wane, progress or remit. All of us experience symptoms differently. Common descriptions of chest discomfort include (1) pressure, (2) fullness, (3) constriction (4) burning, (5) searing, (6) tearing, (7) sharp, (8) dull, (9) heavy or (10) gassy discomfort. Other Important Symptoms Associated with Chest Discomfort Serious causes of chest discomfort may trigger a response in our nervous system. When this happens we may experience nausea, sweating, diarrhea or loose stools. Others may remark that we look pale or our skin feels clammy. If fluid builds up in our lungs, a clot develops in a lung artery, a lung collapses or we are simply anxious we may feel short of breath. What You Should Do If You Have Chest Discomfort Do not try to diagnose yourself, family or friends! Do not hesitate!! Doctors with years of experience often have trouble figuring out what causes chest discomfort and whether it is serious. One of the most common mistakes that we make is denying the possibility that chest discomfort is serious and that prompt evaluation is needed. New onset symptoms should be evaluated quickly and assumed to be serous till proven otherwise—even more so if one feels ill or if symptoms are accompanied by nausea, difficulty breathing, sweating, lightheadedness, or palpitations (see above). New symptoms should be reported to your doctor. If he or she is not available, if you feel ill, or if you experience nausea, sweating, lightheadedness or difficulty breathing it is advisable to go to a local hospital emergency room. It is advisable to call 911 to bring you there. What You May Expect In An Emergency Room The protocol for evaluating chest discomfort in an emergency room is fairly standard. It involves a history and exam given by a doctor and nurse, physical examination, blood pressure, oxygen level measurement, electrocardiogram, chest x-ray and blood work. If there is any suspicion that you are at risk for a serious cause of chest discomfort further tests may be ordered such as a CAT scan of the chest, lung scan or echocardiogram. An exercise test is occasionally performed at this time. Depending on what is found you may be discharged home, observed for a longer period of time or admitted to the hospital for further evaluation and treatment.