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  Chest pain

Proper evaluation of the chest pain is important particularly identifying immediately if it is a life threatening condition to prevent sudden cardiac death. Ominous symptoms that necessitate you to seek emergency medical attention are: severe crushing, squeezing, or pressure in your chest that lasts more than a few minutes or more than half an hour not relieved with rest, or if the pain moves into your neck, left shoulder, arm, or jaw.

Chest pain
Chest pain

Causes of life-threatening chest pain are as follows:

1. Heart attack (also called acute myocardial infarction or AMI). This is a condition wherein blood flow to the coronary arteries that supply the heart becomes blocked and deprived of oxygen. Because of this, eventually the heart muscle deteriorates and damaged. The most common cause of coronary artery blockage is cholesterol buildup (atherosclerosis), blood clots, or spasm of the vessels. Risk factors include: high blood pressure, smoking, diabetes, hypercholesterolemia, family history of heart attacks at a young age usually less than 60 year of age, male gender, obesity and one or more previous heart attacks.

2. Angina. This chest pain is associated with inequality between the oxygen needs of the heart and the amount of oxygen delivered by the bloodstream. This imbalance is due to partial blockage or narrowing of the coronary arteries. There are two types: Stable angina which occurs upon exertion and relieved with rest. Unstable angina which occurs even at rest.

3. Aortic dissection. This is a tear in the inner lining of the aorta, the biggest artery in the body causing massive internal bleeding thus, blood flow is interrupted.

4. Pulmonary embolus. This is a thrombus or blood clot that has been dislodged, travels and eventually settled in one of the major blood vessels supplying the lungs.

5. Pneumothorax. A condition wherein air enters the pleural sac, a space between the chest wall and the lung parenchyma. Eventually, pressure balance is lost and the lung is unable to expand also called as atelectasis or collapsed lung.

6. Perforated viscus. This is a hole in the wall of any area of the gastrointestinal tract which allows air to enter the abdominal cavity. Chest pain is felt because of the presence of air in the abdominal cavity that irritates the diaphragm.

7. Cocaine-induced chest pain. Cocaine accelerates cholesterol plaque formation within the inner lining of the blood vessels which is a risk factor for acute myocardial infarction. It also causes vasoconstriction hence, decreasing blood flow to the heart, which causes chest pain.

The following are non-life threatening causes of chest pain:

1. Acute pericarditis. The inflammation of the sac that surrounds the heart called pericardium.
2. Mitral valve prolapse(MVP). This is an abnormality of the mitral valve, one of the heart valves located between the left atrium and left ventricle. One of the leaflets of the valve bulge into the heart chamber during contraction causing backward flow of blood within the heart chambers.
3. Pneumonia/Pneumonitis. A lung parenchyma infection. Chest pain occurs because of inflammation of the membrane surrounding the lungs.
4. Esophageal disorders. The chest pain felt in this condition is alarming because it often mimics chest pain of a heart attack. These include: gastroesophageal reflux disease (GERD) when digestive juices which is acidic flow backward from the stomach into the esophagus causing the symptom known as heartburn; esophagitis and esophageal spasm which is an excessive and non-rhythmic contractions of the smooth esophageal muscles.
5. Costochondritis. An inflammatory condition of the cartilage between the ribs. The pain is characterized as dull and sharp, on and off and aggravated with deep breathing, chest movement, and deep touch.
6. Herpes zoster or shingles. This is a reactivation of chickenpox characterized by painful vesicular rash which is dermatomal in distribution. Risk factors are: immunocompromised state like advanced age, HIV, or malignancy.

Diagnosis of heart attack is according to these three basic procedures:

1. The presenting typical clinical symptoms.
2. Electrocardiogram (ECG) findings which is an electrical tracing of the activity of the heart.
3. Elevation of the cardiac enzymes which is given off by the heart when it does not receive sufficient oxygen. (e.g. CPK-MB , Troponin I)

Other diagnostic tests that will help in excluding other causes of chest pain are: Chest X-ray, Transesophageal echocardiography (a specialized ultrasound), Chest CT scan or angiography and 2D-echocardiogram.

Self-care at home is you suspect having a heart attack is to chew 2 tablets of aspirin (total of at least 160 mg) for faster effect. While in the early stages of heart attack, chewing aspirin can reduce the risk of death by 23%. If nitroglycerin tablets available, place one tablet sublingually to help increase blood flow to the blocked arteries. Place another tablet of nitroglycerin sublingually if chest pain continues in the next 5 minutes. If the chest pain persists even after 3 nitroglycerin tablets then call an ambulance. Supplemental oxygen is also needed to prevent further decrease of oxygen flow. If the problem is due to an acid reflux then this may be relieved with antacids. In patients with spontaneous pneumothorax, a chest tube is inserted to correct the negative pressure in the pleural sac. Viral pericarditis and costochondritis is usually treated with analgesics like nonsteroidal anti-inflammatory drugs (NSAIDs). Conservative treatment is the approach for mitral valve prolapse. In pneumonia, antibiotics and analgesics can be given for the chest wall tenderness. Surgery is reserved for unsuccessful medical treatment and this includes angioplasty or coronary bypass graft (CABG). By far, the most important thing to do is regular follow-up visits with the attending physician regardless of what the cause of the chest pain is. In this way, the medical condition can be properly monitored and managed appropriately.

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