Chest pain is one of the most common symptoms, but it is also one of the most difficult to diagnose.
This is due to the fact that a range of cardiac and noncardiac illnesses can induce chest discomfort or pain. Taking history is still the most significant strategy for differentiating between the many causes. The doctor can characterize the chest discomfort with a full description of the symptom complex. Typically, five criteria are considered: quality, location, duration of pain, factors that cause pain, and factors that relieve pain.
Angina pectoris, or "heart pain," may be a precursor sign to a heart attack. It is a type of chest pain that has been characterized as "choking" or "pressing," "squeezing," "strangling," "constricting," "bursting," or "scorching."
Angina is most usually felt in the midline of the chest, although it can also occur predominantly in the jaw or neck, the left shoulder or arm, particularly the ulnar side.
The typical patient clenches his fist while reporting the ailment, which is known as the Levine sign. Angina is seldom acute or stabbing, and it rarely changes with posture or breathing. Anginal episodes often last a few minutes.
Angina seldom causes a quick discomfort or a lingering aching that lasts for hours. It is typically brought on by physical exertion or mental tension and is relieved by relaxation. The degree of effort required to create the symptom appears to vary from day to day and throughout the day in the same patient.
Because the anginal threshold is lower in the morning than at other times of the day, activities that cause angina in the morning may not trigger angina later in the day.
In rare circumstances, the back interscapular region (between the shoulder blades) or right shoulder may be involved.
Typical angina is:
Substernal (behind the breast bone) chest discomfort with a characteristic quality and duration
Provoked by exertion or emotional stress
Relieved by rest or nitrates (medicine taken under the tongue or in the form of a spray)
Atypical angina meets two of the above characteristics, while noncardiac chest pain meets one or none.
Angina can be categorized as either stable or unstable. Unstable angina is described as resting angina, severe new-onset angina, or progressive angina.
It is a condition in which the patient is more likely to have acute coronary events such as acute myocardial infarction (heart attack) or death.
The agony of a heart attack is anginal pain multiplied by several orders of magnitude. Rest does not help, and the patient commonly has symptoms such as excessive cold sweating, nausea, vomiting, dizziness, and shortness of breath. A cardiac arrest might cause the patient to lose consciousness altogether in extreme circumstances.
Although angina pectoris is the most common cause of chest discomfort, it must be separated from other causes as well. Aorta dissection (or 'tearing' of the aortic wall) is a differential diagnosis or other cause that may appear as acute chest pain that radiates to the back and migrates from its place of origin at the back down the spine to other locations, following the route of the dissecting hematoma (or blood clot).
In contrast to heart attack pain, which rises up in a crescendo once it begins, the pain is maximum at its outset and may actually reduce in severity over time.
Acute pericarditis, or 'inflammation of the heart covering,' is another prevalent cause. It is distinguished by precordial (front of the chest) discomfort, which is generally preceded by a history of viral upper respiratory tract infection.
It is more severe than anginal discomfort, usually on the left side, and is aggravated by inhaling, turning in bed, swallowing, or twisting the body. When the patient sits up and leans forward, it may lessen.
Patients who are concerned about heart disease frequently have physical chest wall discomfort.
Tietze syndrome, also known as costochondritis, is characterized by localized chest wall discomfort and point tenderness (front of ribs), which is sometimes increased by movement or coughing.
Emotional tension and worry can cause functional or psychogenic pain (Da Costa syndrome or neurocirculatory asthenia), which manifests as a dull, persistent discomfort below the left nipple that lasts for hours and is broken by short acute stabs lasting 1-2 seconds. The esophageal discomfort caused by reflux esophagitis ('heartburn') can also be mistaken for ischemic (anginal) heart pain.
The symptom, however, is mainly caused by food digestion and recumbency, and the patient may notice a sour taste in the mouth.
Distinguishing chest pain arising from the heart with other causes may be difficult and it takes an experienced doctor to make an accurate diagnosis.
The advice will be to seek immediate medical attention by calling for an ambulance service. Heart attack and some of the other causes may be easily diagnosed by performing a resting electrocardiogram for the patient.
Article contributed by Professor Tan Huay Cheem, the Chairman of the Singapore Heart Foundation’s Board of Directors. He is also the Director at the National University Heart Centre, Singapore (NUHCS).