a 35 year old woman developed sudden excruciating chest pain which occurred while going for a run
and then it resolved with rest she's never had this chest pain before and the first thing she
wants to know is am i having a heart attack with chest pain you can usually figure out what's
causing it by asking the right questions but sometimes further testing is needed
of course whatever you see on the internet including this video is no substitute for seeking
medical attention in real life with that said by the end of this video you'll know my approach
to diagnosing chest pain especially since there are many clues that can give away the diagnosis
so let's get at it chest pain can originate from all the organs in the chest
heart lungs esophagus as well as nerves muscles bones and joints the three most serious lung
diseases that cause chest pain include pulmonary embolism meaning blood clots in the lungs
pneumothorax where the lung deflates like a flat tire and pneumonia and with the gastrointestinal
tract the esophagus can cause chest pain when you have acid reflux aka gerd or gastroesophageal
reflux disease and this is actually the most common cause of non-cardiac chest pain
then you have the very common musculoskeletal causes of chest pain like costochondritis
chest pain often induces anxiety but the reverse is also true anxiety and emotions
are often the causes of chest pain so is it the chicken or the egg in order to sort out the
cause we have to answer some key questions and understand the context like age of the patient
past medical history we need to know things about the specifics of the chest pain like its character
its duration and the exact location what makes the pain worse what makes it better for example
is it better or worse when sitting up or lying flat how about when you take in deep breaths
and of course what are the associated symptoms like shortness of breath cough back pain fever
all very important chest pain that originates from the heart can almost always be boiled down to one
of five things a heart attack angina arrhythmias aortic stenosis and pericarditis angina refers to
chest pain that occurs when the heart muscle isn't getting enough blood flow it's a feeling often
described as a chest heaviness tightness squeezing crushing constricting or sometimes burning
in the center of the chest or a little bit left of the breastbone the pain sometimes radiates to
the shoulder and arms typically on the left side and it can also radiate to the neck and jaw and
the upper abdomen stable angina lasts less than 5 minutes unstable angina which is the worst angina
that lasts about 5-10 minutes sometimes longer when it comes to a heart attack or myocardial
infarction this is caused by a plaque in a coronary artery that breaks off travels downstream
and lodges somewhere causing a sudden blockage of blood flow to a particular area of the heart
it's overall similar to the chest pain with angina but usually it's a more intense pain
and more likely to feel short of breath nauseous have profuse sweating the pain builds up over
minutes and it lasts about 30 minutes when it comes to a heart attack do women have different
symptoms for men not really women might be less likely to have chest pain when they have a heart
attack and they're slightly more likely to have severe fatigue as a presenting symptom
pericarditis is inflammation of the pericardium which is the sac that engulfs the heart that can
be caused by many things including viruses including covid pericarditis causes a severe
sharp stabbing kind of chest pain that's worse with taking in deep breaths as well as coughing
and sneezing the other unique feature about this chest pain is that it's worse when lying down and
better when leaning forward the pain doesn't really go away until it gets properly treated
aortic stenosis refers to the aortic valve of the heart hardening with age and subsequent narrowing
of the diameter where blood is pumped from the left ventricle of the heart going to the aorta
so it's a tighter narrower space there when this happens there's also less blood flow that goes to
the coronary arteries since the coronary arteries stem from the base of the aorta
ultimately this can translate into less blood flow going to the heart this doesn't make for
a happy heart and this myocardial ischemia can cause chest pain similar to angina and like
with angina the more you exert yourself the more likely you are to elicit that myocardial ischemia
and hence chest pain so giving things a rest will make the pain go away
there's many different types of arrhythmias some are more concerning than others but regardless of
the kind of arrhythmia the heart becomes less efficient with its ability to pump blood this
can lead to myocardial ischemia and associated chest pain in aortic dissection it's a serious
condition in which a tear occurs in the inner layer of the aorta the biggest artery in your body
which stems from the left ventricle of the heart with an aortic dissection blood rushes through
the tear causing the inner and the middle layers of the aorta to split hence the term dissection
depending on its severity it can be fatal an aortic dissection will present with abrupt
chest pain that is excruciating like a ripping or a tearing sensation which almost always radiates
to the upper part of your back between the shoulder blades with a pulmonary embolism
meaning a blood clot that travels to the arteries of the lungs that can cause a
heaviness sensation in the chest and often people feel short of breath with a typical abrupt onset
sometimes a pulmonary embolism can result in a section of the lung not getting enough blood flow
and that part of that lung tissue can die off and this is called a pulmonary infarction which is the
lungs equivalent of a myocardial infarction when this happens patients will often have pleuritic
chest pain meaning it hurts more when taking a deep breath hurts more if you're having coughing
hurts more if you sneeze the lung that has the pulmonary infarct is where that pleuritic chest
pain is going to be located also pulmonary infarcts can cause people to cough up blood
speaking of pleuritic chest pain something else that can cause it is pleuritis inflammation of
the lining of the lung inflammation of the pleura which is most often due to pneumonia so if you
have a left side of pneumonia or a right side of pneumonia that's where your pain is going to be if
you have pleuritis that's going to be a pleuritic type of chest pain meaning it's worse with deep
breaths and coughing and sneezing and also with an ammonia you're more likely to have other symptoms
like shortness of breath cough fever coughing up stuff and so forth pneumothorax is when the lung
deflates like a flat tire and it can happen for a number of reasons but this is almost always
going to cause someone to have a sudden sharp stabbing type of chest pain that is going to
be a polarity type of chest pain where it's worse with deep breaths most people with a pneumothorax
are also going to feel shorter breath and have a fast heart rate now to the esophagus let's say you
do a dangerous tick-tock trend like eat pureed ghost peppers like this guy did in california
which led to severe wretching and vomiting to the point of tearing a hole in his esophagus
well this is a life-threatening condition called borhoff syndrome and that's going to present with
excruciating sharp chest pain that radiates to the back and then you go into septic shock which
is sometimes fatal borehole syndrome can also happen if you have an endoscopy but thankfully
that's pretty rare much more common is acid reflux which can cause a burning dull tightening pain
sort of mimicking angina which lasts minutes to hours and is provoked by bending straining
or lying down this chest pain can also happen with other issues with the esophagus such as esophageal
spasm and esophagitis meaning inflammation of the esophagus what about musculoskeletal causes
of course chest pain is obvious when someone has trauma and breaks ribs and so forth but one of
the most common causes of chest pain is something called costochondritis where you have inflammation
of the cartilage where the ribs are meeting the breastbone it's usually caused by sudden heavy
exertion like lifting heavy objects or performing a movement that puts a lot of sudden force in the
chest this chest pain is usually worse with taking a deep breath and coughing and sneezing
and unlike the other things that cause chest pain this chest pain is usually reproducible
meaning you can reproduce the pain by pressing on it or it'll feel worse when you press on it and to
our final type of chest pain it's issues that are brought on by the nerves that go there so
for example things like thoracic outlet syndrome intercostal neuralgia and spinal cord compression
this type of pain is a tearing or a burning sensation or an electrifying pain and it's
usually associated with numbness and tingling what if you get varicella zoster the virus that
causes shingles well sometimes that's going to affect the these nerves that go to the chest and
if it does so then this pain often precedes the shingles rash and that skin is very sensitive to
touch also you can have psychological origins of chest pain for example when it's brought on
by anxiety or panic attacks so what about our 35 year old woman who's developed sudden excruciating
chest pain while running we know that it resolved with rest and no she did not eat a bunch of ghost
peppers beforehand it turns out her pain lasted five minutes and was a crushing type of pain
in the center of her chest which did not radiate anywhere other than resting nothing made the pain
worse or better she also had nausea and profuse sweating associated with her pain now she's had
several previous episodes of chest pain with activity but those episodes were much milder
but now she's very concerned about this pain to the point of coming to the er her initial vital
signs were normal except for her heart rate which was kind of fast going at 110 beats per minute
oxygen saturation 100 with physical exam there's nothing abnormal whether breath sounds or heart
tones she's in a sinus rhythm there's no skin rash and she does not have any chest wall tenderness
she's otherwise a healthy person she doesn't smoke or drink alcohol or vape or do any drugs
she doesn't take any medications she doesn't have any close relatives with any major medical
problems her parents they're in good health so what's causing her chest pain well it seems like
she's having angina especially because it occurred while exerting herself when she was running
and it was a crushing type of chest pain that lasted five minutes and went away with rest so
she gets an ekg which other than sinus tachycardia was normal chest x-ray as expected was normal a
cardiologist sees her where they take her to the cath lab and they do a cardiac catheterization
where they inject contrast dye to get a close look at her coronary arteries her
coronary arteries look normal so she's not having a heart attack they even gave her intracoronary
nitroglycerin during the cardiac cath which shows no change in the coronary artery diameter
so this indicates that there's no spasm of the coronary arteries which is something that could
cause angina she has a cardiac mri done which shows something peculiar diffuse perfusion
abnormalities the cause of this patient's chest pain is something called microvascular dysfunction
in women with typical angina symptoms when they have a cardiac catheterization
more than half of them end up having abnormal narrowing of their coronary arteries usually
due to something called microvascular dysfunction the very small arteries that deliver blood to the
heart the ones that are usually too small to see during the cardiac catheterization these arteries
are less than 0.5 millimeters in diameter but they can be problematic and not deliver enough blood to
the heart muscle if someone has microvascular dysfunction and that's a whole other topic
including its prevention and treatment but the main takeaway is to pay attention to the different
clues of chest pain by asking the right questions in order to get to the heart of the matter