Chest pain – Dr. Angela Georgescu, primary care cardiologist at Monza Hospital

„Chest pain is one of the most common causes of going to the cardiologist or the emergency room. It is often a harmless pain, with no life risk and no heart cause, but in some cases it can have a fatal outcome. Chest pain is one of the main causes of emergency department overload, but at the same time it is very often not taken seriously by patients, leading to the omission of an early diagnosis of acute myocardial infarction (many patients consider it a simple „cold” and end up to the doctor only after a few days). It is often difficult even for a doctor to immediately determine the cause of chest pain.

Any part of the chest can cause this pain. Of the chest pains, most have noncardiac causes : parietal (related to the chest wall), pleural (pleurisy), pulmonary (pneumothorax or pneumonia), digestive (reflux esophagitis), etc. Due to the complex distribution of the nervous system in the body, chest pain can also originate in other areas of the body (for example in the abdomen: perforated ulcer, cholecystitis, etc.). But there is also chest pain caused by cardiovascular disease , which is potentially life-threatening. These are the first ones we think of because they are very serious and require emergency treatment.

The leading cause of heart painis ischemia: angina pectoris, acute myocardial infarction. Ischemic heart pain has certain characteristics: it appears and disappears progressively (not suddenly), it appears especially on exertion, lasts ~ 10-20 minutes and gives way quickly to the administration of sublingual nitroglycerin. It is located in the center of the chest (near the sternum), sometimes radiating to the left upper limb, to the mandible or to both arms. It is not usually accompanied by other symptoms, but can sometimes be associated with nausea, vomiting, shortness of breath (shortness of breath), dizziness, fatigue (tiredness). This type of pain does not vary with breathing movements or changing position. But none of these characteristics are pathognomonic (no definite diagnosis), but only indicative. The exact diagnosis is made by associating this information with that provided by the EKG. Sometimes additional investigations are needed (cardiac ultrasound, coronary angiography, physical or pharmacological stress tests, chest CT scan, cardiopulmonary radiography, blood tests, etc.). When the ischemia is not very severe, the EKG may not show changes in the intervals between painful episodes (but only during pain). If the ischemia is more advanced, then changes may occur during periods without pain. When the ischemia is not very severe, the EKG may not show changes in the intervals between painful episodes (but only during pain). If the ischemia is more advanced, then changes may occur during periods without pain. When the ischemia is not very severe, the EKG may not show changes in the intervals between painful episodes (but only during pain). If the ischemia is more advanced, then changes may occur during periods without pain.

However, ischemic pain is not the only cause of heart pain. These may be other life-threatening cardiovascular conditions that manifest as chest pain: pericarditis (inflammation of the pericardium – the sheet that envelops the heart, accompanied or not by the accumulation of fluid in the space between it and the heart), aortic dissection ( rupture of the wall of the largest vessel in the body), pulmonary embolism (the presence of a blood clot in the pulmonary arteries). In these cases the pain is no longer typically ischemic, but is generally continuous, of varying intensity. The intensity of the pain is not directly proportional to the severity of the condition.

However, the highest proportion of cases of chest pain is noncardiac pain, especially parietal and psychogenic pain. Parietal pain can be traumatic or, in most cases, inflammatory. Parietal pain can be caused by: cervico-thoracic spondylosis (a disease of the thoracic spine with anterior irradiation, often accompanied by irradiation on the left upper limb), left scapulohumeral periarthritis, Tietze syndrome (inflammation of the joints between the anterior and coastal ), shingles. These pains usually appear after exposure to cold, current or after great physical exertion, sudden movements or awkward positions maintained for a longer period (at the office, at the wheel, etc.). In general,

Psychogenic chest pain is part of the category of cenestopathies (pain without an organic cause) and is a diagnosis of exclusion, and must first refute the possible objective causes. Psychogenic chest pain occurs especially in patients who have gone through long periods of stress, conflict or in patients with depression. Patients with this type of pain often go to many doctors, do a lot of investigations, receive multiple treatments, without being convinced that they do not have a heart condition and often refuse psychological or psychiatric care. Psychogenic chest pain can sometimes occur in the context of panic attacks and is accompanied by fear, dyspnea, sweating, palpitations.

Given the multitude of possible causes of chest pain and the risk of death of certain conditions, it is recommended that the patient seek specialist advice as soon as possible from the onset of chest pain, even if it later proves that the condition is not serious. Thus, it is useful for family doctors to have an electrocardiograph in the office, so that they can quickly diagnose an acute coronary syndrome and refer the patient to the emergency departments. Patients with known heart disease or hypertension who experience an episode of chest pain should go directly to a cardiologist. „

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