Chest Pain (Intra & Extra Cardiac Causes)

Chest Pain (Intra & Extra Cardiac Causes)

1. Definition
   Chest pain is any discomfort or painful sensation felt in the region of the chest. It may arise from the heart itself (intra‑cardiac) or from structures outside the heart (extra‑cardiac).

2. Causes / Etiology
   Intra‑cardiac: myocardial infarction, unstable angina, pericarditis, myocarditis, valvular disease.
   Extra‑cardiac: lung disease (pneumonia, pneumothorax, pleurisy), musculoskeletal problems (costochondritis, rib fracture), gastrointestinal disorders (GERD, peptic ulcer), esophageal spasm, anxiety or panic attack.

3. Types or Classification
   a. Cardiac chest pain – pain due to heart disease, usually pressure‑like and may radiate to arm or jaw.
   b. Pulmonary chest pain – pain from lung or pleura, often sharp and worsens on deep breathing.
   c. Musculoskeletal chest pain – pain from muscles, ribs or sternum, aggravated by movement or palpation.
   d. Gastro‑esophageal chest pain – burning or discomfort related to reflux or ulcer disease.
   e. Psychogenic chest pain – pain linked to anxiety, panic or stress without organic pathology.

4. Pathology (stepwise)
   step 1 → nociceptors in chest wall, heart or adjacent organs are stimulated by ischemia, inflammation or mechanical stretch.
   step 2 → afferent nerve fibres carry the impulse to the dorsal root ganglion and then to the spinal cord.
   step 3 → the signal ascends via the spinothalamic tract to the thalamus and finally the cerebral cortex where it is perceived as pain.
   (step 4 – if the stimulus is severe, reflex sympathetic activation may cause tachycardia, sweating and shortness of breath.)

5. Clinical Features

General:
‑ discomfort or pain in the anterior chest, may be central or left‑sided
‑ radiation to neck, jaw, left arm or back
‑ shortness of breath, sweating, nausea, light‑headedness

Specific:
‑ Cardiac pain – pressure, heaviness, often at rest or on exertion, may be relieved by rest or nitroglycerin.
‑ Pulmonary pain – pleuritic, sharp, worsens on inspiration or coughing.
‑ Musculoskeletal pain – localized, tender on palpation, increases with movement of the chest wall.
‑ Gastro‑esophageal pain – burning, related to meals, relieved by antacids.
‑ Psychogenic pain – variable intensity, associated with anxiety, may improve with reassurance.

6. Complications

Acute:
‑ Myocardial infarction → arrhythmia, cardiac arrest, death.
‑ Pulmonary embolism or pneumothorax → respiratory failure.

Chronic:
‑ Chronic angina → reduced exercise tolerance, heart failure.
‑ Post‑infarction scar → ventricular aneurysm, heart failure.
‑ Persistent musculoskeletal pain → chronic pain syndrome, depression.

7. Diagnosis / Investigations

Routine:
‑ ECG – looks for ST changes, Q‑waves, arrhythmias.
‑ Chest X‑ray – assesses lung fields, mediastinum, pleural space.
‑ Blood tests – cardiac enzymes (troponin, CK‑MB), CBC, electrolytes.

Special:
‑ Stress test – evaluates inducible ischemia when baseline ECG is non‑diagnostic.
‑ Echocardiography – visualises wall motion, valve function, pericardial effusion.
‑ CT or MRI chest – detailed view of aorta, pulmonary emboli, mediastinal masses.

8. Management

General:
‑ Give oxygen if SpO₂ < 94 %.
‑ Provide analgesia (paracetamol or mild opioid) and calm the patient.

Modern treatment:
‑ Acute coronary syndrome – aspirin, clopidogrel, heparin, followed by thrombolysis or primary angioplasty.
‑ Unstable angina – nitrates, beta‑blockers, statins, ACE‑inhibitors.
‑ Pneumothorax – needle decompression or chest tube.
‑ GERD – proton‑pump inhibitor, lifestyle modification.

Dietary advice:
‑ Low‑saturated‑fat diet, plenty of fruits and vegetables.
‑ Limit caffeine, alcohol and spicy foods if reflux is present.
‑ Maintain healthy weight and regular moderate exercise.

9. Homeopathic Therapeutics

Aconitum napellus
‑ sudden sharp chest pain with anxiety or fear
‑ pain radiates to arm or jaw
‑ worse from cold air, cold drinks or exposure
‑ better with warmth, hot applications
‑ associated palpitations, rapid pulse
‑ patient is restless, sensitive to noise

Bryonia alba
‑ pressing, bruised feeling in chest
‑ pain worsens on movement, deep breathing or coughing
‑ better when lying still, pressing the area
‑ dry cough may be present
‑ patient feels irritable, wants to be left alone

Kali carbonicum
‑ heavy, constricting pain in the centre of chest
‑ worse in cold weather or after cold drinks
‑ better with warmth, hot water bottles
‑ accompanied by irregular heart rhythm, palpitations
‑ patient may be anxious, depressed, feels “heavy” in the head

Lycopodium clavatum
‑ tight, band‑like pain, especially after a big meal
‑ worse on exertion, stress or when lying on left side
‑ better with rest, warm drinks, gentle walking
‑ shortness of breath, occasional wheeze
‑ patient is shy, fearful of criticism, seeks reassurance

Spigelia anthelmia
‑ sharp, stabbing pain that may feel like a knife in the chest
‑ aggravated by movement or deep inhalation
‑ better with pressure on the painful spot or lying still
‑ may have rapid pulse, feeling of “fluttering” in chest
‑ patient is nervous, irritable, often restless.