Chest pain and how it may be avoided

Chest pain is one of the most common symptoms found from time to time in many healthy individuals, but also in patients with a variety of diseases, as well as cardiac patients. Most commonly, chest pain is related to muscles, tendons and joints of the chest wall, but it may also be caused by acid reflux from the stomach into the oesophagus, particularly in supine position and during sleep. Of note, it is most concerning if the seat of it is in the chest centre, radiating into the left arm or the jaw and associated with sense of strangulation and anxiety, , occurring primarily when strenuously walking or walking uphill, particularly after eating, but vanishes upon rest within a couple of moments. The English physician William Heberden described these symptoms and named it angina pectoris in 1772 and his description is still valid today.

Angina pectoris

Thus, chest pain is particularly of concern when it is related to the heart, i.e., a narrowing of the major blood vessels serving the heart muscle, causing reduced blood flow to the working myocardium during any effort or even in response to psychological stress. Stable angina vanishes at rest; if it should persist for several minutes and be resistant to the use of Nitroglycerin, a heart attack may evolve. While angina overall has a rather favourable prognosis, a myocardial infarction is a life threatening condition that requires urgent care.

Work up and Diagnosis

The diagnosis of this condition may be difficult, particularly in women who often have atypical symptoms. Therefore, a number of examinations are in use. Firstly, an exercise test on a treadmill or bicycle with monitoring of ECG changes and evolving chest pain during exercise. Unfortunately, this test is not highly specific nor sensitive for the diagnosis of angina pectoris. Therefore, several imaging modalities have been developed, among them: Echocardiography (ultrasound of the heart), cardiac Magnetic Resonance Imaging and nuclear tests employing radioactive substances to monitor blood flow to the heart during exercise.

If such a test is positive, a coronary angiogram is required, whereby an experienced interventional cardiologist enters the blood vessels of the heart with a catheter inserted, commonly in the wrist or inguina. With contrast injection and a radiograph (called coronary angiography), the arteries supplying the heart muscle (called coronary arteries) can be visualized and narrowings detected.

Management

If distinct narrowing in one or two blood vessels is detected, a stent, commonly a balloon catheter, is deployed at the site of the narrowing, while patients with narrowing of all three coronary arteries are often referred for coronary bypass surgery. Both interventions are highly effective in clearing the symptoms of angina pectoris, while long-term outcomes and life expectancy of the patient depend more on changes in lifestyle (e.g. regular exercise, a Mediterranean diet and stopping smoking) as well as medications treating high cholesterol (e.g. statins), high blood pressure medication and diabetes (e.g. sodium-glucose transport inhibitors) and Aspirin to prevent clot formation and re-infarction.

What to do?

If you have chest pain that regularly occurs during exercise, radiates to the left arm or jaw and vanishes upon rest, contact your GP or personal physician. If angina persists for quite some time even after rest and Nitroglycerin does not relieve it, you should visit an emergency room to rule out a heart attack.

London Medical would be delighted to see you and examine whether, or not, your chest pain is of a cardiac nature or related to any rheumatological or gastrointestinal condition.

Professor Thomas F. Lüscher
The Royal Brompton & Harefield Hospitals, GSTT and Kings College and National Heart and Lung Institute, Imperial College, London, U.K.