Heart pain,Chest pain

Chest pain, often referred to as heart pain, is a common but potentially serious symptom that may indicate conditions ranging from benign musculoskeletal issues to life-threatening cardiovascular emergencies. It is essential to recognize causes, evaluation methods, and treatment strategies for chest pain in adults.

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Causes

Chest pain can be classified into cardiac, pulmonary, gastrointestinal, musculoskeletal, and other systemic/psychological origins:

• Cardiac causes

  • Angina pectoris (stable/unstable)

  • Myocardial infarction (heart attack)

  • Pericarditis (inflammation of the pericardium)

  • Myocarditis (inflammation of the heart muscle)

  • Aortic dissection (tear in the aorta – life-threatening)

• Pulmonary causes

  • Pulmonary embolism (clot in lung arteries)

  • Pneumonia

  • Pneumothorax (collapsed lung)

  • Pleurisy

• Gastrointestinal causes

  • Gastroesophageal reflux disease (GERD)

  • Peptic ulcer disease

  • Esophageal spasm or rupture (Boerhaave’s syndrome – rare but severe)

  • Gallbladder disease (cholecystitis, gallstones)

• Musculoskeletal causes

  • Costochondritis (inflammation of rib cartilage)

  • Muscle strain or injury

  • Rib fracture

• Other causes

  • Panic attacks, anxiety disorders

  • Herpes zoster (shingles) before rash appears

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Symptoms

• Cardiac chest pain (angina, heart attack) is typically described as pressure, heaviness, squeezing, or burning. It may radiate to the left arm, jaw, neck, or back, and may be accompanied by shortness of breath, nausea, or sweating.

• Pulmonary chest pain is often sharp, worsens with breathing or coughing.

• GERD-related pain often presents as burning in the chest, worse when lying down or after meals.

• Musculoskeletal pain is usually localized, reproducible by touch or movement.

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Diagnosis

• History and physical examination

• Electrocardiogram (ECG) – first-line for suspected cardiac cause

• Blood tests – troponins, D-dimer, complete blood count

• Chest X-ray / CT scan – to assess lungs, aorta, fractures

• Echocardiography – for cardiac structure and function

• Endoscopy – for suspected esophageal or gastric causes

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Treatment

Treatment depends on the underlying cause. Immediate evaluation is required for potentially life-threatening conditions.

• Cardiac causes

  • Myocardial infarction:

    • Aspirin (acetylsalicylic acid 300 mg orally, chewed)

    • Clopidogrel (300–600 mg orally loading dose)

    • Nitroglycerin (0.3–0.6 mg sublingual every 5 min, max 3 doses in 15 min) unless hypotension or PDE5 inhibitor use

    • Morphine (2–5 mg IV) for severe pain

    • Beta-blockers (e.g., Metoprolol 25–50 mg orally every 6–12 h) if stable

    • Statins (Atorvastatin 80 mg orally once daily)

    • Emergency reperfusion (PCI or thrombolysis)

  • Angina:

    • Nitroglycerin (0.3–0.6 mg sublingual as needed)

    • Beta-blockers (Metoprolol, Atenolol)

    • Calcium channel blockers (Amlodipine 5–10 mg daily, Verapamil 120–240 mg daily)

    • Antiplatelets (Aspirin 75–100 mg daily)

• Pulmonary causes

  • Pulmonary embolism: Anticoagulants (Heparin IV/SC, Warfarin, DOACs like Apixaban 10 mg BID for 7 days then 5 mg BID)

  • Pneumonia: Antibiotics (Amoxicillin 500 mg TID for 5–7 days or Azithromycin 500 mg day 1 then 250 mg daily for 4 days)

  • Pneumothorax: Needle decompression or chest tube insertion

• Gastrointestinal causes

  • GERD: Proton pump inhibitors (Omeprazole 20–40 mg daily, Esomeprazole 20–40 mg daily)

  • Peptic ulcer: PPI + H. pylori eradication therapy if positive (Clarithromycin 500 mg BID + Amoxicillin 1 g BID for 14 days)

• Musculoskeletal causes

  • NSAIDs (Ibuprofen 400–600 mg TID as needed, Naproxen 250–500 mg BID)

  • Local heat/ice, physiotherapy

• Anxiety-related chest pain

  • Benzodiazepines (short-term use; Diazepam 2–5 mg TID PRN)

  • SSRIs (e.g., Sertraline 50 mg daily) for long-term management

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Precautions

• All cases of sudden, severe, or unexplained chest pain should be treated as a medical emergency until life-threatening causes are ruled out.

• Avoid NSAIDs in patients with cardiovascular risk unless clearly musculoskeletal.

• Nitrates should not be given with sildenafil, tadalafil, or vardenafil due to risk of profound hypotension.

• Patients with known angina should be educated to seek emergency help if chest pain does not resolve after 3 nitroglycerin doses within 15 minutes.

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Drug Interactions

• Nitrates interact with PDE5 inhibitors → severe hypotension.

• Beta-blockers interact with calcium channel blockers (Verapamil, Diltiazem) → risk of bradycardia, heart block.

• Warfarin interacts with many antibiotics (e.g., Metronidazole, Macrolides, Fluoroquinolones) → increased bleeding risk.

• PPIs may reduce the efficacy of Clopidogrel (omeprazole particularly).

• NSAIDs reduce the effect of antihypertensives and increase risk of bleeding when combined with anticoagulants/antiplatelets.