Chest Pain: An Essential Guide to Unraveling Causes, Implications, and Management
▫️Written by John Keller
✅ Reviewed by Dr. Jenny Hynes on AUGUST 9, 2023
In the realm of medical symptoms, few demand our immediate attention and understanding like the enigmatic chest pain. A ubiquitous complaint with the potential to signal both benign and life-threatening conditions, its significance cannot be overstated. Acknowledging the pressing need to grasp the intricacies of chest pain, this blog explores into its causes, implications, and management, propelled by contemporary research and evidence.
Chest pain's prevalence in Australia is a formidable reminder of its impact on public health. It accounts for over 600,000 hospital visits annually in Australia, serving as a stark reminder of its ubiquity (Richards et al., 2002). Despite not all chest pain being cardiac-related, its potential association with severe conditions like heart disease, the leading cause of death globally (World Health Organization, 2021), necessitates immediate medical consultation.
Understanding the root causes of chest pain is paramount, as its origins can vary significantly, spanning from cardiac and respiratory issues to musculoskeletal and gastrointestinal factors. Failing to accurately diagnose and manage chest pain can lead to severe consequences, including delayed treatment of acute cardiovascular events or the development of chronic conditions.
In this context, physiotherapy emerges as a potential ally in the holistic management of chest pain, particularly of musculoskeletal origin (Laird et al., 2019). Contemporary research emphasizes physiotherapy as an effective, non-invasive intervention, contributing to pain reduction, cardiovascular fitness improvement, and overall wellness enhancement (Tomlinson et al., 2012). However, due to a lack of awareness, this treatment option often goes underutilized.
Promoting understanding about chest pain and its comprehensive management, inclusive of the role of physiotherapy, is an essential aspect of health literacy. This understanding can promote timely care-seeking behaviors, more appropriate use of healthcare resources and ulitmately help navigate the complex landscape of chest pain, paving the way to better patient outcomes.
What Is Chest Pain?
Chest pain refers to any discomfort or distress experienced in the area between the neck and the upper abdomen. It can take numerous forms such as sharp, stabbing, burning, squeezing, or feelings of tightness, and it might even radiate to other parts of the body including the neck, jaw, back, or arms.
Discriminating between cardiac and non-cardiac sources of chest pain is of utmost importance due to the varying severity of potential underlying conditions. Cardiac chest pain, typically termed as angina, can indicate ischemic heart disease, a condition in which the heart muscle's blood flow is reduced because of narrowed or blocked arteries (O'Connor et al., 2017). This pain is often described as a pressure or squeezing sensation and can be provoked by physical activity or emotional stress.
Non-cardiac chest pain, conversely, can have various origins such as the lungs, esophagus, muscles, ribs, or nerves. Gastroesophageal reflux disease (GERD) can cause a burning chest pain, while conditions like costochondritis (inflammation of the chest wall) may result in a sharp or stabbing pain. Moreover, musculoskeletal issues such as Tietze's syndrome, characterized by swelling of the cartilage that attaches the ribs to the breastbone, can also cause chest pain (Barbut et al., 2020).
Understanding the nature and type of chest pain can play a critical role in initial diagnosis and prompt action, underlining the necessity of medical consultation to accurately identify the cause and initiate suitable treatment strategies.
Causes and Triggers
Chest pain can arise from a variety of sources, each characterized by unique triggers, manifestations, and treatment approaches.
Cardiac conditions are a significant cause of chest pain. Angina, which stems from reduced blood flow to the heart muscle, often manifests as a sensation of pressure or squeezing in the chest, usually triggered by physical exertion or emotional stress. Pain may also radiate to the arms, neck, jaw, shoulder, or back (Sampson et al., 2014). Similarly, a myocardial infarction, or heart attack, occurs when a coronary artery becomes blocked, usually presenting with severe, persistent chest pain which can extend into the jaw, arms (with the left arm being more commonly affected) neck and back. In addition, symptoms such as shortness of breath, sweating, and nausea (Amsterdam et al., 2014) are often also present. Management strategies typically involve lifestyle modifications, medications, and in severe cases, surgical interventions.
Gastrointestinal (GI) issues, such as gastroesophageal reflux disease (GERD) and gastritis, can also lead to chest pain. GERD, a condition where stomach acid leaks into the esophagus, results in a burning sensation in the chest, often after eating or when lying down (Eslick, 2012). Gastritis, an inflammation of the stomach lining, can provoke upper abdominal or chest pain. Both conditions may be triggered by factors like specific foods, alcohol, or stress, and are typically managed with dietary modifications and medications.
Musculoskeletal issues like costochondritis and muscle strain produce chest pain that is often sharp and localized, worsening with movement or deep breathing (Proulx et al., 2009). Management commonly involves physiotherapy and pain relief medications.
Finally, anxiety or panic disorders can manifest as chest pain, frequently accompanied by symptoms such as rapid heartbeat, shortness of breath, and feelings of fear or dread. Cognitive-behavioral therapy (CBT) and medications are key to management in these cases (Bandelow et al., 2017).
Understanding the different triggers, presentations, and management strategies for chest pain across these diverse conditions is vital for effective symptom control and improved health outcomes.
Types of Chest Pain
Chest pain can be classified into three primary types: cardiac, non-cardiac, and referred pain, each possessing unique characteristics vital for diagnostic discernment.
Cardiac chest pain, often termed angina, results from diminished blood flow to the heart muscle, typically manifesting as pressure, tightness, or squeezing in the chest, potentially radiating to the arms (with the left arm more commonly affected), jaw, neck, or back (Thygesen et al., 2019). Triggered by physical exertion or emotional stress, it typically alleviates with rest or nitroglycerin spray, which is a prescribed medication. Importantly, persistent or severe cardiac chest pain may indicate a heart attack, necessitating immediate medical attention (Amsterdam et al., 2014).
Non-cardiac chest pain encompasses conditions unrelated to the heart. This includes GERD, characterized by a burning sensation often triggered by eating or lying down (Eslick et al., 2004), and musculoskeletal conditions like costochondritis, which produces localized pain that frequently worsens with movement or deep breathing (Proulx et al., 2009).
Referred chest pain is perceived in the chest but originates elsewhere in the body. Abdominal conditions, such as gallbladder or pancreatic issues, can cause upper abdominal pain that radiates to the chest. Notably, problems with the thoracic spine can also refer pain to the chest area, a key consideration for conditions like thoracic radiculopathy or intervertebral disc disease (Hegedus et al., 2008). Similarly, cervical radiculopathy, affecting the neck's nerves, may result in referred chest pain (Cleland et al., 2012).
Accurately differentiating between these types of chest pain is essential, as it informs diagnostic procedures and dictates treatment strategies. The nature, location, and associated symptoms of chest pain provide indispensable clues about its underlying cause, underlining the importance of detailed medical history taking and comprehensive physical examination.
Diagnostics and Treatment Options
The diagnostic process for chest pain is multifaceted, combining medical history, physical examination, and several advanced diagnostic tools. Clinicians perform an in-depth patient interview to understand the symptom's characteristics, onset, triggers, and associated symptoms, which provide critical preliminary information (Lee et al., 2000). Physical examination may then pinpoint specific signs related to potential underlying conditions.
Advanced diagnostic procedures include electrocardiograms (ECG), blood tests, stress tests, and imaging studies such as echocardiograms, computed tomography (CT), and magnetic resonance imaging (MRI). These tests aid in confirming or ruling out potential causes, including heart disease, gastrointestinal disorders, and musculoskeletal conditions (Amsterdam et al., 2014).
Electrocardiogram (ECG)
An ECG records the electrical signals in your heart and can detect abnormalities in these signals that can indicate a heart attack or angina. Variations in the ECG pattern can suggest ischemia (a lack of oxygen delivery to the heart muscle), or an actual myocardial infarction (heart attack) (Goodacre et al., 2005).
Blood tests
Specific enzymes and proteins are released into the blood when heart muscle is damaged. Testing for markers like troponins can help confirm a myocardial infarction. Alternatively, other blood tests may be ordered to investigate conditions such as anemia or infections that could induce chest pain (Goodacre et al., 2005).
Stress tests
Stress testing assesses the heart's response to exertion, either through physical exercise or pharmacological agents. This can uncover evidence of reduced blood flow to the heart (ischemia), thereby highlighting possible coronary artery disease (Amsterdam et al., 2014).
Imaging studies
Echocardiogram: An ultrasound of the heart, this test can visualize the heart's function and structure in real-time, providing information about its size, shape, and how well its chambers and valves are working (Russell et al., 2015).
Computed Tomography (CT) Scan: CT coronary angiogram uses dye and advanced X-ray technology to produce detailed images of the heart and coronary arteries. It can detect narrowing or blockages in these arteries (Williams et al., 2016).
Magnetic Resonance Imaging (MRI): Cardiovascular MRI offers detailed images of the heart's structure and function, and can detect conditions such as inflammation or tumors (Russell et al., 2015).
Treatment for chest pain is primarily determined by the underlying cause, and ranges from medications to lifestyle modifications and specific interventions.
Cardiac Chest Pain
Management of cardiac chest pain often necessitates a combination of medications and lifestyle modifications. In cases of acute myocardial infarction (heart attack), immediate interventions such as percutaneous coronary intervention (PCI) or thrombolytic therapy may be needed (Ibanez et al., 2018). For conditions such as angina, medications like nitrates, beta-blockers, and calcium channel blockers can help reduce the heart's workload and alleviate pain (Fihn et al., 2014). Lifestyle modifications such as regular exercise, a heart-healthy diet, and smoking cessation are also crucial (Anderson et al., 2016).
Gastroesophageal Reflux Disease (GERD)
Chest pain stemming from GERD is typically managed with antacids for immediate relief, and longer-term medications such as proton pump inhibitors or H2 blockers to reduce stomach acid production. Dietary modifications and weight loss can also help manage symptoms (Kahrilas et al., 2013).
Musculoskeletal Chest Pain
Musculoskeletal conditions such as costochondritis or chest wall muscle strain can benefit from physiotherapy, analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and local heat or cold application (Proulx et al., 2009).
Panic Disorder
Cognitive-behavioral therapy (CBT) is a well-established treatment for panic disorder, helping individuals understand and change thought patterns leading to anxiety and physical symptoms. Pharmacological treatments like selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines can also be effective (Hofmann et al., 2016).
Each treatment regimen should be individualized and tailored to the patient's specific needs, overall health, and underlying conditions, highlighting the importance of a multidisciplinary approach in the management of chest pain.
The Role of Physiotherapy in Chest Pain Management
Physiotherapy plays a crucial role in the management of chest pain, particularly for musculoskeletal and functional causes, and in the rehabilitation phase post-cardiac events. Keilor Road Physiotherapy offers tailored treatment and exercise programs aimed at reducing symptoms, enhancing physical capacity, and promoting health.
Exercise-based cardiac rehabilitation has been proven to reduce cardiovascular risk and improve quality of life (Anderson et al., 2016). Physiotherapists facilitate these programs, prescribing specific exercises that increase heart strength and improve cardiovascular health. Importantly, these programs are designed to be safe for individuals with heart conditions and are adapted to individual fitness levels and health status.
In instances of musculoskeletal chest pain, such as costochondritis or chest wall muscle strain, physiotherapists can help with pain management strategies, manual therapy, and exercises aimed at improving posture and muscular balance. Such interventions can reduce the mechanical stress on the chest wall structures, thereby reducing pain (Paatelma et al., 2018).
In addition, physiotherapy can be beneficial in managing functional and psychogenic chest pain. Certainly, there is a wide range of relaxation techniques that physiotherapists can teach patients to help manage functional and psychogenic chest pain.
1. Progressive Muscle Relaxation (PMR)
This technique involves systematically tensing and then releasing different muscle groups in the body. By becoming aware of the difference between tension and relaxation, patients can better identify and alleviate muscle tension, a common symptom of anxiety-related chest pain.
2. Guided Imagery
Here, patients are instructed to visualize calming scenes or experiences. This can promote a sense of peace and relaxation, reducing physical and psychological stress symptoms.
3. Breathing Exercises
Controlled and mindful breathing techniques, such as diaphragmatic breathing and 4-7-8 breathing, can help decrease the 'fight-or-flight' response often associated with anxiety, leading to reduced heart rate and a sense of calm.
4. Mindfulness and Meditation
Mindfulness involves focusing on the present moment, without judgment. Through mindfulness exercises and meditation, patients can learn to notice and accept their physical sensations and emotions, reducing anxiety levels and associated physical symptoms.
5. Biofeedback
This method uses electronic sensors to monitor body functions like heart rate, muscle tension, and skin temperature. Patients can see their body's stress response in real-time and learn to control it through relaxation techniques.
In each of these techniques, the aim is to elicit the body's natural relaxation response, characterized by slower breathing, lower blood pressure, and a sense of increased well-being. These methods can be very effective when performed consistently and under the guidance of trained professionals, such as the physiotherapists at Keilor Road Physiotherapy.
The role of physiotherapy in managing chest pain is multifaceted, encompassing not only symptomatic relief but also primary prevention and post-event rehabilitation, showcasing the necessity of a comprehensive, multidisciplinary approach.
Rehabilitation and Recovery
The management of chest pain extends beyond the immediate alleviation of symptoms. Rehabilitation and recovery are paramount, particularly for those recovering from cardiac events such as heart attacks or those with musculoskeletal causes of chest pain. Effective rehabilitation programs focus on restoring functional capacity, improving overall fitness, reducing risk of recurrent episodes, and enhancing quality of life.
Physiotherapy plays a pivotal role in the rehabilitation process. At Keilor Road Physiotherapy, we have expert physiotherapists to guide patients through a tailored exercise regime centred around education on the condition, the progressive restoration of cardiovascular fitness, improved muscle strength and flexibility, and enhanced functional capacity while ensuring patient safety.
For instance, following a cardiac event, knowledge about heart disease, understanding it’s symptoms, managing medications, and recognizing signs of worsening condition are important factors in the education around cardiac disease. Patients are also advised on lifestyle modifications, including a heart-healthy diet, quitting smoking, and managing stress.
Supervised exercise programs — often referred to as cardiac rehabilitation — can significantly improve long-term outcomes and reduce the risk of subsequent cardiac events (Anderson et al., 2016). These programs typically involve a combination of aerobic exercises (e.g., walking, cycling) and resistance training, adapted to the individual's current fitness level and progressively adjusted over time
Dealing with any heart condition can also be emotionally challenging. Therefore, psychological support is often provided during rehabilitation to help manage emotions, reduce stress, and improve mental health. This can include one-on-one counselling, group sessions, or referral to a mental health professional, if needed.
Ideally, a long-term management plan is developed to help maintain the gains achieved during the rehabilitation program. This includes continued exercise routines, regular medical check-ups, and sustained lifestyle changes.
In the context of musculoskeletal chest pain, physiotherapy can provide targeted exercises and manual therapy techniques to address specific muscle imbalances or postural issues contributing to pain. These interventions can include mobility exercises, strength training, and strategies for posture correction and pain management (Paatelma et al., 2018).
Overall, the value of rehabilitation and recovery in managing chest pain is undeniable. It is crucial for individuals to collaborate closely with qualified physiotherapists. At Keilor Road Physiotherapy, we develop comprehensive and personalised rehabilitation plans, catering to each individuals unique health needs and recovery goals.
Prevention and Lifestyle Tips
Prevention is often the best medicine. This is particularly true when it comes to chest pain, where lifestyle adjustments can play a significant role in reducing risk and promoting overall heart health. It's crucial to establish a regimen that supports healthy living, which includes a balanced diet, regular physical activity, stress management, and avoidance of potential triggers.
Adopting a balanced diet, rich in fruits, vegetables, whole grains, lean protein, and healthy fats, can help maintain optimal weight and control risk factors for heart disease, such as high blood pressure and cholesterol (Estruch et al., 2013).
Regular physical activity, including Pilates, enhances cardiovascular fitness and contributes to heart health. Pilates is a low-impact exercise method that focuses on core strength, flexibility, and overall body awareness and fitness. Regular Pilates sessions can improve posture, muscle tone, balance, and joint mobility, as well as relieve stress and tension and improve cardiovascular fitness (Kloubec, 2010). By promoting overall fitness and well-being, Pilates contributes to cardiac health and can be incorporated into treatment plans offered here at Keilor Road Physiotherapy.
Avoiding triggers such as smoking and excessive alcohol consumption is paramount. Both have been identified as significant risk factors for heart disease, and cessation can significantly reduce the risk of chest pain and other heart-related conditions (O'Keefe et al., 2014).
Adherence to prescribed medication regimens, particularly for conditions like hypertension, diabetes, or high cholesterol, is also key to managing these conditions and preventing potential complications, including chest pain.
Regular health check-ups and screenings are vital, especially for those at increased risk of cardiac chest pain due to factors such as age, family history, or existing heart conditions. Preventive measures, such as vaccines and regular health screenings, can help detect early signs of heart disease and provide an opportunity for early intervention.
Importantly, professional care for chest pain should not be overlooked. Always seek medical attention for chest pain and adhere to the recommended treatment plans, which may include physiotherapy interventions at clinics such as Keilor Road Physiotherapy.
Remember, prevention strategies are most effective when they are individualised and multifaceted, addressing all aspects of a person's lifestyle and overall health.
Conclusion
In conclusion, chest pain is a symptom that must not be taken lightly due to its potential association with serious conditions such as heart disease. With 20% of Australians experiencing chest pain in their lifetime, it is imperative to understand its nature, causes, and implications (AIHW, 2021). Diverse in its presentation, chest pain can vary from sharp, stabbing sensations to a feeling of pressure or tightness and can stem from various sources, including cardiac, gastrointestinal, musculoskeletal, or psychogenic causes.
Early and accurate diagnosis is pivotal, with advanced diagnostic procedures like ECGs, blood tests, stress tests, and imaging studies playing a crucial role. Treatment options are just as varied, from pharmacological interventions to lifestyle modifications and targeted interventions. Of notable significance is the role of physiotherapy, which can offer immense benefits in managing and rehabilitating chest pain, particularly from musculoskeletal and functional origins.
The importance of prevention and healthy lifestyle modifications, including balanced diet, regular physical activity (such as Pilates), stress management, and avoidance of harmful triggers, cannot be overstated. Regular check-ups, screenings, and adherence to treatment plans are essential, especially for those at risk of cardiac chest pain.
While chest pain can be concerning, with a comprehensive understanding, timely medical attention, and integrated management approaches like those offered at Keilor Road Physiotherapy, individuals can effectively address this symptom, enhance their health outcomes and improve their quality of life.
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Article by
John Keller
Clinical Director | Sports & Musculoskeletal Physiotherapist
John graduated as a Physiotherapist from the Auckland University of Technology with the John Morris memorial prize for outstanding clinical practise in 2003. John has since completed Post Graduate Diplomas in both Sports Medicine and Musculoskeletal Physiotherapy with distinction, also collecting the Searle Shield for excellence in Musculoskeletal Physiotherapy.
Reviewed by
Dr. Jenny Hynes FACP
Clinical Director | Specialist Musculoskeletal Physiotherapist
Jenny sat extensive examinations to be inducted as a fellow into the Australian College of Physiotherapy in 2009 and gain the title of Specialist Musculoskeletal Physiotherapist, one of only a few physiotherapists in the state to have done so.