DR. JAYARAM LINGAMANAICKER

MBBS, LRCP (Edin), LRCS (Edin),
LRCP&S (Glas), MRCP (UK),
FRCP (London), FACA (USA),
FAMS (Cardiology), FACC (USA)

Lifeline Heart Centre
#11-10 Mount Elizabeth
Medical Centre
3 Mount Elizabeth
Singapore 228510

Tel: (65) 6836 2611 /
  (65) 6836 9038 /
  (65) 6836 1990

Fax: (65) 6836 9037

E-mail:    

lifelineheart@gmail.com /
lifelineheart@singnet.com.sg



Patient Guide > Angina
Patient Guide > Angina


Introduction

Chest pain is one of the most common reasons people call for emergency medical help. Doctors evaluate and treat millions of people for chest pain every year around the world. Fortunately, chest pain doesn't always signal a heart attack. Often chest pain may be unrelated to any heart problem. However it is wise to have it checked; better to be safe than sorry.

Causes

Chest pain has many possible causes, all of which deserve medical attention. The causes of chest pain fall into two major categories cardiac and non-cardiac causes.
  • Cardiac causes

    • Heart attack
      A heart attack is due to a blood clot that's blocking blood flow to the coronary arteries and eventually your heart muscle. It can cause pressure, fullness or a crushing pain in your chest that lasts more than a few minutes. The pain may radiate to your back, neck, jaw, shoulders and arms, especially your left arm. Other signs and symptoms may include shortness of breath, sweating, dizziness and nausea. All, some or none of these may accompany your chest pain.

    • Angina
      Fatty deposits that build up in the arteries can cause narrowing and temporarily restricting blood flow to your heart, especially during times of exertion. Reduced blood flow to your heart can cause recurrent episodes of chest pain angina pectoris, or angina. Angina is usually brought on by physical or emotional stress. The pain is usually relieved by rest.

    • Other cardiac causes:

      • Pericarditis
        Inflammation of the sac surrounding your heart (pericardium), often related to a viral infection produces chest pain called pericarditis. Pericarditis causes sharp, centralized chest pain. You may also have a fever and feel sick.

      • Aortic Dissection
        A rare, life-threatening cause of chest pain called aortic dissection involves the main artery leading from your heart your aorta. If the inner layers of this blood vessel separate, forcing blood flow between them, the result is sudden and tearing chest and back pain. Aortic dissection can as a complication of uncontrolled high blood pressure.

      • Prinzmetal's Angina
        Coronary artery spasm, also known as Prinzmetal's angina, can cause chest pain. The coronary arteries go into spasm, temporarily closing down blood flow to the heart. Spasm of the coronary arteries may occur spontaneously or be triggered by a stimulant, such as nicotine or caffeine. Coronary artery spasm, which tends to cause episodes of chest pain, can occur with activity or at rest. The condition may coexist with coronary artery disease.

  • Non-cardiac causes

    Many conditions unrelated to your heart can cause chest pain. These include:

    • Heartburn
      Stomach acid that goes up from your stomach into the tube (oesophagus) that runs from your mouth to your stomach can cause heartburn a painful, burning sensation behind your breastbone. Often this feeling is accompanied by a sour taste and the sensation of food re-entering your mouth. Heartburn-related chest pain usually follows a meal and may last for hours. Signs and symptoms occur more frequently when you bend forward at the waist or lie down.

    • Panic attack
      If you experience episodes of intense fear accompanied by chest pain, rapid heartbeat, rapid breathing (hyperventilation), profuse sweating and shortness of breath, you may be experiencing a panic attack a form of anxiety state.

    • Pleurisy
      Sharp, localized chest pain that's made worse when you inhale or cough may be caused by pleurisy. This condition occurs when the membrane that lines your chest cavity and covers your lungs becomes inflamed. Pleurisy may result from a wide variety of underlying conditions, including pneumonia and, rarely, autoimmune conditions such as SLE.

    • Costochondritis
      This condition also known as Tietze's syndrome the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed. The pain from costochondritis may be intense, leading you to assume you're having a heart attack. Yet the location of the pain is different. Costochondritis causes tenderness, it hurts when you push on your sternum or on the ribs near your sternum.

    • Pulmonary embolism
      This condition occurs when a blood clot becomes lodged in a lung artery. This is a life-threatening condition and the symptom includes sudden, sharp chest pain that begins or worsens with a deep breath or cough. Other signs and symptoms can include shortness of breath, palpitation and faintness. Pulmonary embolism may occur after a recent surgery or prolonged immobilization.

    • Other Lung Conditions
      A collapsed lung (pneumothorax), high blood pressure in the arteries carrying blood to the lungs (pulmonary hypertension) and asthma also can produce chest pain.

    • Muscle Pain
      Muscle-related chest pain tends to come on when you twist side to side or when you raise your arms. Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain.

    • Injured ribs or pinched nerves
      A bruised or broken rib, as well as a pinched nerve, can cause chest pain that tends to be localized and sharp.

    • Swallowing disorders Several disorders of the oesophagus, the tube that runs from your mouth to your stomach, can make swallowing difficult and even painful. One type is oesophageal spasm, a condition that affects a small group of people with chest pain. This results in painful muscle spasms. Another swallowing disorder achalasia, in this condition the valve in the lower oesophagus doesn't open properly to allow food to enter your stomach. Instead, food backs up into the oesophagus, causing pain.

    • Shingles
      Infection of nerves caused by the chickenpox virus can produce pain and crop of blisters on your chest wall.

    • Gallbladder or pancreas problems
      Gallstones or inflammation of your gallbladder (Cholecystitis) or pancreas (Pancreatitis) can cause acute abdominal pain that radiates to your chest.
Seek medical advice when...

Seek medical advice when:

Pain in your chest can be difficult to interpret. The cause of the pain could be something as simple as indigestion or as serious as a heart attack. If you experience persistent chest pain or a feeling of pressure or tightness in your chest particularly if it's accompanied by other signs and symptoms, such as shortness of breath, sweating, nausea, dizziness or pain that radiates to your arms or your neck seek emergency medical help.

In the Emergency room

On arrival at the emergency room you'll probably have your blood pressure, pulse and temperature checked. The doctor will get a detailed history of the chest pain - Where is the pain located? How would you describe the pain? Do you have other signs and symptoms along with the pain? A detailed physical examination is carried out. Chest pain doesn't always signal a heart attack. But that's what emergency room doctors will test for first because it's potentially the most immediate threat to your life. They may also check for life-threatening lung conditions, such as pulmonary embolism, aortic dissection or a collapsed lung (pneumothorax) that can cause chest pain.

Tests for chest pain:
  • Electrocardiogram (ECG)
    It records the electrical activity of your heart through electrodes attached to your skin. Heart rate and rhythm and the electric impulses going through your heart are recorded as waves displayed printed on paper. The ECG may show that a heart attack has occurred or is in progress.

  • Stress tests
    This is carried out usually electively when patient is stable. There are many kinds of stress tests. You may be asked to walk on a treadmill or pedal a stationary bike while hooked up to an ECG. Or you may be given a drug intravenously to stimulate your heart in a way similar to exercise. Stress tests may be combined with imaging of the heart using ultrasound (echocardiography) or radioactive material (nuclear scan).

  • Blood tests
    Blood tests are ordered to check for increased levels of certain enzymes normally found in heart muscle. Damage to heart cells from a heart attack may allow these enzymes to leak, over a period of hours, into your blood.

  • Chest X-ray
    An X-ray of your chest allows checking the condition of your lungs and the size and shape of your heart and major blood vessels. Other lung conditions like pneumonia and pneumothorax may be detected.

  • Nuclear scan
    This elective test helps diagnose cardiac causes of chest pain, such as a narrowed heart artery. Trace amounts of radioactive material, such as Thallium or Sestamibi, are injected into your bloodstream. X ray cameras can detect the radioactive material as it flows through your heart and lungs.

  • Coronary Angiogram
    This test identifies individual arteries to your heart that may be narrowed or blocked. A contrast medium (dye) is injected into the arteries of your heart through a catheter a long, thin tube that's fed through an artery, usually in your groin, to arteries in your heart. As the dye fills your arteries, they become visible on X-ray and video. The procedure is called coronary angiography.

  • 64 Slice CT Angiogram
    This procedure, also called an ultra fast CT scan, scans your arteries for signs of narrowing and blockage. It also gives the amount of calcium deposited in your arteries (calcium score).

  • Magnetic resonance imaging (MRI)
    MRI is an imaging technique that uses magnetic fields and radio waves to create cross-sectional images of your body.

  • Echocardiogram
    An echocardiogram uses sound waves to produce a video image of your heart. This image can helps to identify valvular, heart muscle and blood flow pattern abnormalities.
Treatment

Treatment

Cardiac causes

If heart problems are the cause of your chest pain, your doctor may prescribe medications such as:
  • Aspirin
    Aspirin is a blood thinner, helping to maintain blood flow through narrowed heart arteries. When taken during a heart attack, aspirin can significantly decrease death rates. It may be chewed to hasten its absorption. Aspirin is advised for most people who have had a heart attack for an indefinite period.

  • GTN
    This medication is used to treat angina temporarily, usually it is put under the tongue. It widens narrowed blood vessels, improving blood flow to your heart relieving the angina.

  • Beta blockers
    These drugs help slow your heart rate and decrease your blood pressure, which decreases the demand on your heart. These medications help limit the amount of damage during a heart attack and prevent a second heart attack occurring.

  • Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin receptor blockers (ARBs)
    These drugs help the heart to pump blood from your heart more easily. ACE inhibitors or ARBs is given if you've had a moderate to severe heart attack that has reduced your heart's pumping capacity. These drugs also lower blood pressure and may prevent a second heart attack.

  • Calcium channel blockers
    Coronary artery spasm is treated using heart medications such as calcium channel blockers to relax the coronary arteries and prevent the spasm. It is also used to treat angina and high blood pressure.
Heart Attack (Myocardial infarction)

If it's clear you're having a heart attack, you may be treated with clot-busting drugs or undergo a surgical procedure such as:
  • Angioplasty
    A catheter is inserted from the groin or wrist and a special balloon tipped catheter is placed at the blocked coronary artery. The balloon is inflated to open up the artery and usually stented to keep the artery open. This improves blood flow to your heart, the chest pain resolves and the ECG usually becomes normal again.

  • Coronary bypass surgery (CABG)
    This is an invasive surgical procedure where the blocked arteries are by passed using internal blood vessels or veins from the leg. It creates an alternative route for blood to go around a blocked coronary artery.
Usually angina is treated with medication, angioplasty or coronary bypass surgery. For people who don't respond to or who aren't candidates for these standard treatments, an alternative treatment called enhanced external counter pulsation (EECP) may be tried especially for the treatment of chronic angina.

Non-cardiac causes

Treatments for non-cardiac causes of chest pain depend on the type of problem. Usually you will be referred to the appropriate specialist.