The most common cause of acute chest pain in the U.S. is Acute Myocardial Infarction (also commonly known as “heart attack”). Delay in diagnosis and treatment of a “heart attack” is one of the leading causes of death. Any acute chest pain above the waist must be immediately evaluated by a qualified medical practitioner.
This post will not be focusing on the more dangerous acute causes of chest pain. My goal is to enlarge your understanding of the chronic causes of chest pain. Chronic chest pain will be defined as any pain that has lasted 3 months or longer, may be experienced on a daily basis, and has had the more immediately life threatening forms of chest pain ruled out.
Chronic Chest Pain Has Vascular Causes
I wish I could assure you that once you have had Acute Myocardial Infarction (AMI) ruled out by a licensed medical practitioner that you had no possibility for your chronic chest pain to be an AMI. No practitioner would ever totally eliminate that as a possibility. It is always on the list of diagnostic possibilities.
However, there are other vascular causes that can give chronic chest pain. You may already know that when blood flow to any organ in your chest (primarily your heart muscle and lung tissue) is severely reduced you will experience pain. That means that clots in your lung (called a Pulmonary Embolism) and chronic reduction of blood flow to your heart muscle (called Angina Pectoris) could conceivably cause a form of chronic chest pain.
Chest pain can also be caused by disorders that inflame the heart. Irritation of the sac around the heart (called Pericarditis) gives a peculiar type of chest pain that worsens with deep breathing and laying down. The heart muscle itself can become inflamed (called Myocarditis) and cause pain. Finally, the interior of the heart can become inflamed (with involvement of the valves) causing chest pain (called Endocarditis).
Chronic Chest Pain Has Infectious Causes
The most common form of infectious causes of chest pain are the pneumonias. These will usually be associated with other symptoms such as shortness of breath, fever, a cough, and sputum production. Worldwide the most common chronic infection of the lung is Tuberculosis.
Tuberculosis (TB) is also becoming more common in the U.S. as more people immigrate from parts of the world where TB is common. A chronic cough, weight loss, and malaise (general lack of energy and strength) are symptoms that often accompany TB.
There are also certain fungal lung infections that can be chronic. The same associated symptoms as in TB can be expected. Both TB and fungal lung infections are largely curable with appropriate antibiotics.
Chronic Chest Pain Has Tumor Causes
Nearly any mass that grows in the lung can cause pain. Because the lung tissue is easily compressible and the chest cavity has a large capacity, a growth can attain several inches before it can be felt. Early diagnosis of lung tumors relies upon the presence of associated symptoms and a very astute clinician.
In the U.S. more women die from Lung Cancer each year than die from Breast Cancer. Tobacco smoking remains the number one risk factor in the development of Lung Cancer. The risk of developing Lung Cancer goes up dramatically when the accumulated smoking history exceeds 10 “pack years.”
A “pack year” is 1 pack of cigarettes each day for a year, or a half a pack of cigarettes a day for 2 years, or 2 packs of cigarettes a day for 6 months, etc. It seems that the carcinogenic exposure reaches its’ threshold at 10 pack years. If you are a smoker…quit now!
Chronic Chest Pain Has Musculo-Skeletal Causes
Chronic chest pain can be caused by joint and muscle inflammation. Your chest wall has muscles that help to pull your ribs in a “bucket handle” motion. Direct trauma from a blow, vigorous exercise, and arthritic conditions can all cause chest pain. Usually chest pain of this type is worsened with deep breathing or direct pressure from examination.
A curious form of chest wall pain that occurs commonly is called Costochondritis. This chest pain condition results from inflammation of the cartilage that attaches your ribs to your sternum (the plate of bone in the middle front of your chest). Direct pressure on examination usually reveals a tender area.
Chronic Chest Pain Has Neuropathic Causes
Your chest has an abundant supply of nerves both on the inside and outside. Any disease process that irritates this network of nerves can cause pain. The pain of this type is often described as of a burning character.
A fairly common cause for this type of chest wall pain is called “Shingles” (click here to see my post on this topic). Shingles is a reactivation infection of the Chickenpox virus which has been lying dormant since the original infection as a child (especially for those born prior to vaccination for same – “baby boomers” in particular).
Chronic Chest Pain Has Auto-Immune Causes
Any disease process that inflames the lungs can cause chest pain. Many people don’t realize that Rheumatoid Arthritis can cause lung disease (as well as the devastating joint complications). There are a number of specific auto-immune lung diseases as well.
Auto-immunity is where the immune system of a person reacts against the host body. Systemic Lupus Erythematosus is another example of this process. There are excellent therapies available today to help slow down and even turn off the process.
Chronic Chest Pain Has Gastro-Intestinal Causes
Due to the anatomical proximity and neurologic connectivity, gastro-intestinal disorders can often give a sensation of chest pain. In particular, the esophagus runs through the chest and shares many neurologic connections with other major chest organs (the lungs and heart). For this reason, disorders of the esophagus can give chest pain.
To further complicate matters, spasm of the esophagus can be relieved with the administration of sublingual (under the tongue) nitroglycerin. You may know that sublingual nitroglycerin is commonly used to relieve chest pain caused by reduction in blood flow to heart muscle. Posterior chest pain can be caused by Gallbladder disease, Pancreatic disease, and Esophageal disease.
Chronic chest pain requires that gastro-intestinal causes be considered. The patterns and methods for relief may give important clues to what the underlying cause of the chest pain is due to. Esophageal irritation is often relieved by the administration of a potent oral antacid with viscous Lidocaine and an antispasmodic (such as Donnatal).
The mixture gives relief as well as a clue that the pain is originating in the esophagus. Heart pain would not be expected to be relieved with the mixture.
Chronic Chest Pain Has Psychogenic Causes
The presence of episodic chronic chest pain can be due to severe anxiety. In particular, a true“Panic Attack” can manifest with severe chest discomfort. Two simple questions are a highly sensitive screen for panic disorder:
- “In the past six months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy?”
- “In the past six months, did you ever have a spell or an attack when for no reason your heart suddenly began to race, you felt faint, or you couldn’t catch your breath.”
Though these 2 questions are highly sensitive in screening for Panic Disorder, they are not specific and do not exclude other more serious causes for chest pain. Panic Disorder generally occurs in a younger age population and in people who have major emotional conflicts.
I have reviewed for you several of the major causes of chest pain. Any chest pain must be taken seriously and evaluated by a medical practitioner. The presence of chronic chest pain does not preclude underlying heart disease. Discerning the causes of chest pain remains one of the most difficult and challenging of all clinical dilemmas for the Medical Practitioner to sort out.
Despite the challenge, most clinicians trained in the U.S. are quite good at sorting through a detailed work-up for chest pain. Most of the disorders that can cause chronic chest pain (as well as acute chest pain) are very effectively treated. The key, as in all medical disorders, is an accurate diagnosis.
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Wishing you much joy and peace,