A variety of disorders involving the lung may be associated with chest pain. Pneumonia is one of the most common, particularly when it involves the lining of the surface of the lung known as the pleura. Inflammation of the pleura is called pleurisy. Pleuritic pain tend to be sharp, and of brief duration when it is present. Typically it may come and go over a period of hours, and tends to occur only during inspiration. When associated with pneumonia, it is usually accompanied by a cough and fever. It also may be a symptom of a pulmonary embolism (see below), the site of metastasis of a malignant tumor, or a sign of one of the autoimmune diseases such as lupus erythematosus. Although pleurisy tends to be localized to a relatively small area of the chest, at times, with the more infectious type, the chest pain may be generalized and cause shortness of breath.
Pulmonary Embolism:
Another major cause of chest pain is a pulmonary embolism. An embolism is a mobile blood clot that usually occurs after a surgical procedure, particularly if the patient has been lying immobile in bed for several days. Immobility and the stress of surgery are associated with stasis of blood in the lower extremities and pelvis. This encourages the formation of blood clots in these areas. An injury to the lower extremities also may result in the formation of a clot, days or even weeks later. Whatever the origin, portions of the clot may break off and migrate to the lungs. This is most likely to occur when attempts are made to ambulate a patient in the post-operative period. Usually such a clot lodges in the small blood vessels in the lung. If the clot is a large one, it may be associated with coughing up of blood, shortness of breath, pain intensified by deep breathing, and even sudden death. The pain associated with a pulmonary embolism may be indistinguishable from both cardiac ischemia and the pain of an acute heart attack. Chest pain may be the first clue that a clot is present in the legs or thighs. In general, prolonged bed rest for any reason encourages the formation of blood clots in the lower half of the body followed by a pulmonary embolus. Usually the diagnosis of an embolism can be made by chest x-ray, however, special tests and procedures may be required in more obscure cases.
Pneumothorax:
A pneumothorax is an important cause of chest pain. It occurs when air perforates the outer surface of the lung forcing ambient air into the chest cavity. When this happens, the victim suffers chest pain followed by collapse of the perforated lung and shortness of breath. Usually the pain is in the lateral chest rather than the center of the chest, and it may be aggravated by breathing. The diagnosis of pneumothorax can readily be made with a chest x-ray. It also may be identified on physical examination, if the doctor takes the trouble to listen to both lungs.
Mediastinal emphysema
refers to the presence of air in the central portion of the chest cavity that contains the heart. Because the air may create pressure and stretching of the structures and nerves within the mediastinum, severe chest pain may result. In addition, because the stretched nerves involve the same nerve roots as the nerves coming from the heart, it may be very similar to cardiac pain. Usually the pain is more superficial and tends to be modified by respiration and body position. This disorder can be diagnosed by a chest x-ray.
Pulmonary Hypertension
is a rare cause of chest pain. As you might infer, this is an elevation of the pressure in the pulmonary arteries. The pulmonary artery is the artery that exits from the right ventricle. Before it enters the lungs and branches into tiny blood vessels, it contains unoxygenated, venous blood. A number of diseases may cause the pressure in the pulmonary artery to become elevated including various forms of congenital heart disease, mitral stenosis (obstruction of the mitral valve), chronic lung disease, and primary pulmonary hypertension. Although primary pulmonary hypertension is an extremely rare disease, it has recently been found to be a side effect of certain medications used for weight loss. The chest pain associated with pulmonary hypertension occurs with exertion and is relieved by rest, and may be indistinguishable from the chest pain associated with cardiac ischemia. Indeed, it is thought that the pain seen in this condition is due to ischemia of the right ventricle. Except for chronic lung disease, the various conditions giving rise to pulmonary hypertension occur in a much younger group of people, and the chest pain that develops does not respond to the usual cardiac medications. The diagnosis of all these disorders can be made from a careful physical examination, chest x-ray, and even the electrocardiogram.
Aortic Valve Disease:
The aortic valve is the exit valve of the heart and all blood must leave the heart through this opening. Immediately after the aorta exits from the heart, the coronary arteries arise and supply the heart muscle with blood. If the aortic valve is diseased and obstructed, the blood flow exiting from the heart eventually will be reduced, even though the pressure within the left ventricular chamber becomes markedly elevated. At the same time, the pressure within the aorta beyond the valve will be reduced, and the amount it is reduced depends upon how obstructed the aortic valve becomes. If pre-existing coronary artery disease is present, a previously insignificant degree of narrowing in a coronary artery may now become very significant. The result will be a reduction in blood flow and chest pain. Usually, if significant aortic stenosis is present, the murmur associated with it is readily heard. Unfortunately, the modern cardiologist has become so technology oriented that frequently he does not even bother to listen to a patient's heart with a low technology instrument such as the stethoscope. Even if he does so conscientiously, the blood flow through the valve may be so reduced that no murmur can be heard.
Mitral Valve Prolapse
has been claimed to cause chest pain. There is no anatomical reason why mitral valve prolapse should cause chest pain. Because both this disorder and recurring chest patient pain are so common, mitral valve prolapse is often discovered coincidentally in the evaluation of a patient with chest pain symptoms. Also, mitral valve prolapse may accompany obstructive coronary artery disease; however it is the coronary artery disease that produces the chest pain and not the mitral valve prolapse.
Pericarditis:
This is due to an inflammation of the membrane surrounding the heart called the pericardium, and is accompanied by unique changes in the electrocardiogram. Viral and bacterial infections may sometimes involve the pericardium and will produce chest pain very similar to that seen with cardiac pain. The pain of pericarditis, however, is aggravated by deep breathing and influenced by changes in body position. It may cease when the breath is held or if the victim leans forward. Pericarditis is not a common disorder. Because of its similarity to cardiac pain, and the unique changes seen on the electrocardiogram, it easily can be mistaken for an impending heart attack. If coincidental coronary artery disease is found on an angiogram, and if the doctor seeing the patient is an aggressive cardiologist, potentially dangerous coronary artery bypass surgery may be performed that not only is unnecessary, but possibly harmful to the patient.
Dissecting aneurysm of the aorta
is enlargement and separation of the wall of the aorta, the main artery exiting from the heart. When present, it may cause chest pain and be mistaken for an acute heart attack. When chest pain is present, it usually is severe, may involve the back and even the abdomen, and is a medical emergency. If the artery ruptures through the weakened portion of the aortic wall, death is immediate. Milder forms of dissection may be confused with a heart attack but can usually be diagnosed by a simple chest x-ray. However, if an x-ray is not taken, and the patient is made to undergo angiograms, there will be prolonged delay during which the aneurysm may rupture.
Syphilis:
While syphilis is rarely seen today, it occasionally does occur, particularly in individuals who spent their earlier years in undeveloped countries where this disease is still prevalent. The lesions of syphilis have a predilection for the ostia of the coronary arteries; that is, where the coronary arteries exit from the aorta just above the aortic valves. By causing marked narrowing of the ostia, blood flow is markedly reduced in the coronary arteries. This will cause chest pain that is identical to that caused by obstructive coronary artery disease. Surgical intervention as well as antibiotic treatment of the syphilis are the recommended forms of therapy.
Premature Beats
may be accompanied by a sharp, stabbing pain over the heart area, and occasionally may be associated with a fleeting choking sensation. Usually such symptoms occur at rest and decrease during physical activity, but may reoccur when activity ceases.
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