Non-Cardiac Chest Pain
Background- Chest pain is one of the most common reasons people call for or visit the Emergency Room for help. Heart attack education has brought to light the urgency of seeking immediate medical treatment if one suspects they are having heart issues. However, chest pain does not always signal a heart attack, and may be totally unrelated to issues with the cardiovascular system. Often no clear reason for such pain presents itself during examination, but understanding the perception and pain experience can help medical professionals understand different experiences that lead to patient panic about chest pain (Jerlock, Gaston-Johansson, & Danielson, 2005). Typically, if chest pain is related to a cardiac issue it is usually associated with one of the following symptoms: 1) pressure, fullness or extreme tightness in the chest; 2) crushing or searing pain that radiates to the back, upward through the jaw, and especially through the left arm; 3) pain that last more than a few moments, or goes away and comes back repeatedly; or 4) pain that is combined with shortness of breath, sweating, dizziness or nausea. Chest pain that is typically unrelated to cardiovascular issues is usually described as: 1) a burning sensation behind the sternum; 2) a sour taste or a sensation of food or drink re-entering the mouth; 3) difficulty swallowing; 4) pain that changes in intensity when body position is changed; 5) pain that intensifies with deeper breaths or cough; and 6) pain or discomfort when pressure is applied to the chest (Mayo Clinic Staff, 2011).
Cardiac issues usually signal a heart attack, angina, pericarditis, a coronary spasm or an aortic dissection. All are serious, and care should be taken to either travel by ambulance or have someone drive the patient to the nearest emergency room. However, there are a number of other causes of chest pain that deal with the digestive system, musculoskeletal issues, respiratory, or other non-cardio related issues. These are called non-cardiac chest pain (NCCP) and are defined as recurring, angina like, retrosternal chest pain of a non-cardiac origin:
Digestive causes -- Typically dealing with the stomach, esophagus, or intestinal issues.
Heartburn -- Stomach acid washing up from the stomach into the esophagus can cause a painful burning sensation behind the sternum.
Esophageal spasm -- disorders of the esophagus can make swallowing difficult. One type is a spasm in which the muscles that normally move food down the esophagus into the stomach become uncoordinated, resulting in painful muscle spasms.
Hiatal hernia -- part of the stomach slides up above the diaphragm into the chest cavity causing chest pressure or pain, particularly after eating.
Achalasia -- the valve in the lower part of the esophagus does not open properly to allow food to enter the stomach, instead the food backs back up into the esophagus, causing discomfort.
Gallbladder or pancreatic problems -- gallstones or inflammation of the gallbladder or pancreas can cause acute abdominal pain that radiates up into the chest.
Musculoskeletal causes - Typically centered around the rib cage or the abdominal muscles.
Costochondritis -- also known as Tietze syndrome, the cartilage that joins the ribs to the breastbone becomes inflamed and painful.
Sore muscles -- chronic pain, strains, or even fibromyalgia can produce persistent muscle-related chest pain.
Injured ribs or pinched nerves -- bruised or broken ribs, or pinched nerves, can cause radiating chest pain.
Respiratory causes -- Centered around the lungs.
Pulmonary embolism -- a blood clot becomes logged in a pulmonary artery, thus blocking blood flow to lung tissue and causing a sharp pain.
Pleurisy -- the membrane that lines the chest cavity and covers the lungs becomes inflamed, causing a sharp, localized pain that intensifies with inhalation or coughing.
Other pulmonary issues -- collapsed lung (pheumothorax), high blood pressure (pulmonary hypertension) and asthma can produce chest pain.
Other Ancillary causes - Variable from psychological issues to viruses and other serious diseases.
Panic attacks -- periods of intense fear accompanied by chest pain, rapid heartbeat, hyperventilation, sweating and shortness of breath (very similar to cardiac conditions).
Shingles -- this nerve infection can produce a band of blisters around the back and chest wall and typically radiate pain.
Cancer -- cancers can cause pain when they localize into the chest area (Mayo Clinic Staff; Cunha, 2011; Wedro, 2011; Hershcovici, Navarro-Rodriguez,...
It is quite typical for patients with unexplained chest pain to have symptoms that are suggestive of ischamia but that, upon testing, have no evidence of coronary heart disease. In fact, many patients with chest pain symptoms have already had negative cardiac evaluations and despite reassurances that they are not having heart issues still perceive any chest pain as a "heart issue" that requires them to rush to the emergency room, contributes to severe anxiety, confusion, and further expensive and repetitive tests (Jerlock, et.al., 2005).
As part of a larger study that uses quantitative methods to find influences of psychosocial factors in patietns' experiences of chest pain, a qualitative approach was used with 19 mixed gender patients admitted to a Swedish University Hosptial Emergency Department over a 90-day period. The criteria for the study included patients under the age of 70 with chest pain symptoms, but no clinical organic causes, and who have experienced at least two incidents of chest pain in more than four weeks. These patients ranged from age 18 to 63 (median = 51 for women, 37 for men). An open-ended, unstructured interview was conductive that was narrative in form and was phrased as a conversation in which the patient was encouraged to dialog about their experience. The dialog focused on questions explaining what is like to have chest pain, describing that pain, and how the pain influences activities of everyday life. The interviews lasted from 40 to 75 minutes, with the exception of one lasting 140 minutes (Jerlock, 958).
In order to understand the meaning of these dialogs, especially since the sample size was relatively small, a content analysis was performed on the material using the following rubric:
100% of the dialogs were reviewed, transcribed, and summarized
Once a general sense of the content was extablished, the data was divided into two separate areas: pain and pain experience in everyday life
Texts were then analyzed for common themes, words and meanings
From this context, the content was formulated into four meaning units: 1) pain location, 2) pain duration, 3) pain intensity, and 4) quality of pain. This was also generalized by the intrusion this pain has into everyday life.
This analysis resulted into some interesting commonalities regarding the pain experience. These commonalities show that the experience of chest pain may be individualized, but that the overall template is shared thus:
Pain location -- pain was primarily on the left side of the chest, radiating to the left, usually described as "deep."
Pain duration -- this category varied from 8 months to 27 years, with a median of six years.
Periodic pain -- chest pain is episodic and unpredictiable; from every few hours, to weekly, 3-5 times per year, etc. Some patients are able to ascribe stress or other issues to recurring pain.
Continuous pain -- during the pain period (days to months) pain was present at all times; even in the evenings during relxation time or in bed.
Pain intensity -- descriptiors used as severe, terrible, kinfe-like, crushing.
Quality of pain -- from cutting and pressing to crushing and splitting; often causing unpleasant sensations and difficulty breathing.
Sensory aspects -- pain tended to appear suddenly and without notice; none had rational explanations for the pain, or took OTC medications prior to visiting the emergency room.
Affective aspects -- all described as varying levels of unpleasant that caused worrying, anxiety and difficulties with everyday life events (Jerlock, 958-9).
The commonalities of experience in the study shows that unexplained chest pain intrudes in a negative manner into the everyday lives of those who experience it. It is likely that the co-morbidity of the anxiety and fear elevated the blood-pressure and caused additional symptoms. When the pain increased or became so intense that the patients could not recognize it, they turned towards emergency services. Other research confirms that the stress caused by chest pain also causes a circular pattern -- more pain, more stress = elevated stress and worry, more pain = trips to the emergency room (Unexplained Chest Pain Can be Due To Stress, 2009).
Another study investigated many of the common medical reasons for chest pain and found that the most common cases of NCCP are esophageal in nature, specifically Gastroesophageal Reflux Disease (GERD). This study, more of a meta-analysis of previous research that looks at different manifestations of NCCP, shows that NCCP is more common than most think -- or about 25% in six population studies based in the midwest (Minnesota). A similar study showed that it was prevelent in about…
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