Noncardiac Chest Pain
“The good news: It’s not your heart. The bad news: I don’t have a clue what it is.”
The first half of this statement is heard every day in emergency rooms and doctors’ offices across the country. The second half may involve a little more honesty than most doctors want to admit.
You come to the ER with chest pain (CP) worried that it might be your heart. They hang on to you for a few hours, do several tests, and conclude that your worst fears—that you’re in the throes of a massive heart attack or something similar—are not founded.
The job of the ER doctor in this scenario is really two-fold. First, determine if you have a life-threatening emergency and, if so, initiate treatment. Second, if your symptoms aren’t the harbinger of certain doom the ER doctor has to come up with a diagnosis to give you and to put on the chart. The first part of this equation is actually pretty easy in most situations—we have well-established algorithms to guide the evaluation and exclusion of a relatively short list of dangerous things that can cause CP.
It’s the second part—if it’s not your heart, then what is it?—that is the real challenge. Most doctors will offer a diagnosis but in many cases it’s their best effort at a blind guess. You can’t really blame them for trying. No doctor wants an unsatisfied patient and, of course, no patient wants to go home without a diagnosis, especially after seeing how much they owe in co-pay. It’d be like taking your car to auto mechanic who charges you a thousand dollars only to tell you “Well, it ain’t your transmission.”
So, if the CP isn’t coming from a blocked artery, what exactly is it? We first rule out other potentially life-threatening or immediately reversible ailments. Most of these are fairly easy to detect with simple screening tests or discernible based on the patient’s account of their symptoms:
Aortic dissection. A tearing or rupture of the aorta that comes spontaneously (most often in patients with a history of high blood pressure) and is lethal in about 50% of cases.
Pulmonary embolism. A blood clot, generally arising in the veins of the legs, lodges in the arteries of the lungs. CP, shortness of breath, and cough are clues to this problem. It is fatal (if untreated) in about a quarter of patients.
Spontaneous pneumothorax. This is a relatively rare problem where the lung deflates without apparent cause. It is easily detected on chest x-ray and, while not as deadly as other problems, needs to be treated relatively quickly.
Pneumonia. This one doesn’t really fall into the “urgent” category like the others, but it is serious and the diagnosis needs to be entertained in patients with CP.
After that, you’re left with a long list of benign problems that can lead to CP. Here is a partial list of the more common causes of benign noncardiac CP and a brief descriptor of each:
Esophageal pain. This is a broad category of painful problems relating to a structure that sits right behind the heart and is served by the same pain nerves as the cardiac muscle. Esophageal reflux, spasm, hiatal hernia, achalasia, and functional dyspepsia can mimic with protean precision all the symptoms of a heart attack. Spasm, in particular, can be challenging since it also responds quite quickly to administration of nitroglycerin (this is partially why a positive response to nitroglycerin is utterly useless in helping us isolate the cause of discomfort). About 60% of patients with CP will have an esophageal problem as the source.
Costochondritis. The costochondral junction is where the ribs attach to the sternum (breastbone) and can be afflicted with inflammation and joint aches just like the knee, hip, and any other skeletal junction of the body. Pain can mimic angina, but can also be tender to touch and worse with movement or deep breathing. Costochondritis is a somewhat unglamorous cause of pain and leads to no dangerous problems. As you muse over health problems with acquaintances at cocktail parties you may wish to invoke the more exotic moniker of Tietze Syndrome when referring to your ills. Your friends will be more impressed as they take a step back from you and wipe their hands on their pants.
Pleurisy. Inflammation of the lining of the lung can lead to severe, stabbing pain anywhere in the chest, most often exacerbated by deep breaths and body movement. There’s no test to pinpoint this (the diagnosis is made based on the description of pain and the absence of other problems) and treatment consists of antiinflammatory medications such as ibuprofen and indomethacin. Pleurisy’s cousin is inflammation of the lining of the heart (pericarditis) and can present with similar symptoms.
Herpes zoster (shingles). Early in the course of this demonic ailment a patient will have severe focal pain and tenderness days before the characteristic rash appears. Successful treatment depends on early suspicion and administration of antiviral drugs. Clinicians need to keep this disease in mind when seeing older patients with CP limited to one side.
Fibromyalgia. This is an entity nearly everyone has heard of but no one really understands. Chronic CP is a common feature.
Radiculopathy. Strain your cervical spine and you could pinch or compress one of the nerves that serve the chest wall, shoulders and neck. The pain’s not terribly similar to pain from the heart, but since it frequently travels down the arm or into the jaw it can be confusing for patients and clinicians.
Muscle strain. At some point in their lives virtually every person will pull a muscle and suffer pain for a few days or longer. There are dozens of muscles that attach to the chest wall (including layers of muscles that bind the ribs together) and any one of them could serve as the source of significant discomfort.
Somatic causes. Somatic is a polite, professional way of saying it’s all in your head. It’s well known that depression, anxiety, and panic attacks can cause a patient to quite literally experience all the symptoms of a heart attack. This was first described as a cause of CP among veterans of the American Civil War by a doctor named Jacob Mendes Da Costa who observed these symptoms in patients whose psyche had been ravaged by the stress of war (Da Costa syndrome is also termed “soldier’s heart”). In my experience this sort of thing can affect even the most balanced, sane, calm individuals and is not limited to crazy people. Personally, I resist the urge to make the diagnosis of “stress-related” pain since I don’t remotely consider myself an expert in psychiatry or stress disorders (despite my use of the highly technical term “crazy people”).
One thing that all these benign causes of CP have in common is that they are extremely difficult to diagnose with any degree of certainty. Most often we arrive at these conclusions by excluding other, more easily diagnosed problems. Modern medicine is very good at telling you what you don’t have and not so good at pinning down what you’ve got, especially if it doesn’t lead to death or permanent impairment.
So, breath easy (that is, if it doesn’t hurt to take a deep breath) if the doctor tells you it isn’t your heart—that is indeed good news. Just be prepared for a little frustration if you want to find someone who can definitively tell you what it is rather than just what it isn’t.