Chest pain

Chest pain is the most common symptom in the community for emergency help. Every year millions of people refer to the services with such complaints.  A sudden heart attack may be the first symptom to be considered very carefully and urgently. Patients often lead to late onset by identifying chest pain with stomach afflictions and less important etiologic factors.

However, it is known that a heart attack can be transmitted without chest pain. Another common cause of chest pain is panic attacks. Therefore, many patients apply to the emergency services considering that they have had a heart attack. In these patients, it is important to direct treatment after these cardiac causes have been ruled out. Apart from these, there can be chest pain caused by musculoskeletal system, lungs, esophagus and nerves.

 

 

Causes of Chest Pain:

 

Acute myocardial infarction:

It is a clinical chart with cardiac muscle ischemia as secondary to coronary circulation disorder. A few minutes longer is characterized by severe pain. Pain can also spread to the back, neck, chin, shoulders and arms (especially the left). Electrocardiogram, cardiac enzymes, radiological examinations are used in diagnosis. Emergency treatment is necessary. Cardiopulmonary resuscitation should be performed when necessary in addition to other therapeutic approaches to thrombolytic and coronary arteries. Strong opioids, especially morphine, are effective in the treatment of pain. In addition, nitroglycerin and beta-blockers help control myocardial O2 by reducing the need for O2.

 

Angiina pectoris:

Coronary artery disease is a common symptom. Pain can be in the chest, arms, shoulders and back. Increased with exercise, and decreased with resting character. Symptoms may be hidden in diabetic patients. Other than pain, the feeling of discomfort in the head, feeling of pressure, drowning and clogging may manifest itself. Diagnose electrocardiogram, coronary arteriogram and nuclear stress tests. Nitro glycerine responds.

 

Pericarditis:

Pericardium is an inflammation. Infection can occur as a secondary to trauma, collagen tissue diseases, malignancies and renal failure. Pain in central chest, sharp and sinking feature

When patient lies, the pain is exacerbated, when patient sits or lifted on foot the pain lessens. The pain can spread to the shoulders and neck. Tachypnea and dyspnea also accompany pain. Diagnosis is made by physical examination, ECG and chest X-ray. Nonsteroidal anti-inflammatory drugs are effective in pain palliation.

 

 

 

Dissection aortic aneurysm:

Severe and sudden pain becomes life threatening. The dissection in the ascending aorta causes anterior or posterior chest pain, whereas the descending aorta dissection causes more back pain.

Nausea, vomiting and sweating are common symptoms. Medical treatment includes beta blockers for lowering heart rate and vasodilator approaches for lowering blood pressure. In necessary cases, emergency or elective surgery is planned.

 

 

 

Other heart-causing conditions leading to chest pain are:

Aortic stenosis, aortic regurgitation, mitral valve prolapses, hypertrophic cardiomyopathy.

 

Anxiety and panic attack:

In general, anxiety is the name given to the lighter of panic attacks. It is more appropriate to call it a panic attack when it is accompanied by irrational feelings such as panic, extreme fear. Panic disorder cannot be diagnosed with a single panic attack. In addition, panic attacks can occur in some anxiety disorders such as social phobia. While mental symptoms are "losing control", "losing my mind" or "going to die", physical symptoms can manifest as chest pain, shortness of breath, sweating and dizziness.

 

Escapade:

 Auspicious is acute or chronic inflammation of the middle ear. Etiological factors include gastroesophageal reflux, corrosive chemical substance, drugs and microorganisms. A painful burning sensation behind the sternum. Swallowing difficulty and swallowing may cause pain. Treatment approaches for pain relief and treatment should be planned.

 

Pneumothorax:

A clinical tablature characterized by collapsing of the lungs due to the presence of air in the pleural cavity.  It can not only occur spontaneously but also trauma and iatrogenic causes.  Sudden, unilateral chest pain is manifested by pain and shortness of breath that are reflected in the shoulder and in the abdomen.  Since only a small amount of air will resurface, monitoring may be sufficient. Aspiration of the needle, catheter or tubing may be necessary in the presence of too much air. Oxygenation and relief of pain are also important components of treatment.                              

 

Peptic ulcer:

It occurs with inflammation of the stomach and duodenum. The underlying cause is reported as Helicobacter pylori bacterial infection or some drugs used (especially nonsteroidal anti-inflammatory drugs), and the treatment approach includes intervention of antibacterial treatment and related drugs. The abdominal pain, which usually starts 2-3 hours after eating, can be on and off, and is a characteristic of being eaten or absorbed with antacids. The pain may spread to the anterior lower and middle parts of the chest as well as to the epigastrium. Make the diagnosis endoscopically and radiologically. In perforated peptic ulcers, there is severe epigastric pain that spreads to the lower chest with hypotension. The treatment is surgery.

 

Pulmonary embolism:

Pulmonary arteries and branches are usually blocked by thrombus material. The most common causes are deep vein thrombosis, surgery, trauma and fractures. More than 90% of cases have chest pain. Dyspnea, tachypnea, hemoptysis, cyanosis, tachycardia, anxiety and syncope may also accompany the clinical picture. Treatment is bed rest, anticoagulants, streptokinase and oxygenation.

 

Pancreatitis:

Chronic alcohol use or inflammation of the pancreas occurs as a secondary to biliary stones. Acute pancreatitis has severe epigastric pain with retrosternal distress. The pain spreads to the lower left part of the chest and is not affected. Severe abdominal muscle spasms, hypotension and hypoventilation may occur together. All opioids may lead to increased tonus in the Oddi sphincter and increased pressure in the biliary ducts. Therefore, nonsteroidal anti-inflammatory drugs may be preferred in the treatment of pain. 

 

Costochondritis (Tietze syndrome):

Kosta is a disease that is caused by the inflammation of the cartilages. Localization goes with pain and tenderness. A self-limiting tablature. Cold application, paracetamol and nonsteroidal anti-inflammatory drugs can be used for pain palliation.

 

 

 

Herpes zoster infection:

It is a common infectious disease, especially over the age of 50 years. Spinal roots are diagnosed according to the level of infection with varicella zoster virus. An early treatment approach may prevent the development of postherpetic neuralgia that may develop later. Pain is defined as postherpetic neuralgia when it lasts more than 3 months. This picture develops mostly in immunosuppression and in the elderly. Pain is a neuropathic characteristic. It can be in a burning, flammable or light flashing style. It also reduces the likelihood of developing postherpetic neuralgia, especially with antiviral treatment reducing pain relief within the first 72 hours. Antidepressants (amitriptyline), anticonvulsants (carbamazepine, gabapentin, pregabalin) and opioids (morphine, fentanyl) can be used in the treatment of pain.

 

 

 

Lung cancer:

It is the most common cancer. It manifests itself with symptoms such as chronic cough, hemoptysis, chest pain, fever, recurrent pneumonitis-bronchitis, weight loss, fatigue. Smoking and tobacco use are the most common factors in the etiology. Cancer-related pain may be due to invasion of the direct tumour or may develop as metastases or secondary to compression of neural tissue. Pain therapy is planned according to these factors. First of all, it is very important to apply surgery, chemo and radiotherapy for the tumour. In addition, medical and interventional pain treatment methods have a role in pain palliation. Nonsteroidal anti-inflammatory agents, weak and potent opioids may be used in the treatment of pain, as well as antidepressants and anticonvulsants in neuropathic component pain. Interventional and surgical methods that can be applied; Open or percutaneous cordotomy, spinal opioid applications, cervicothoracic sympathetic blocks, dorsal root entry lesions, stereotactic mesencephalotomy or thalamotomy, posterior spinal rhizotomy and singulotomy.

 

 

Postmastectomy and postthoracotomy syndromes:

It is neuropathic pain syndromes that occur with intercostal nerve or brachial plexus injury during breast and lung surgery. Pain is a burning and sinking character. Antidepressants, anticonvulsants, nonopioids and opioids may be used in treatment. Spinal opioid therapy may be applied in unresponsive cases.

 

 

Subphrenic abcess:

The perforation of the perforated abdominal organs leads to inflammation in the diaphragm and subdifferential abscess formation. The sinker, which spreads to the lower part of the chest and often to the shoulder, is seen with sharp pain. Together with dyspnea, fever, pleural effusion can be observed.

 

In conclusion, there are many different factors that can cause chest pain. Treatment approaches are very different. For this reason, it is a suitable approach to start the immediate treatment, especially urgency, by evaluating the character of the pain, the spread and the duration of the pain.

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Prof. Dr. Altan Şahin, 2018