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Dr Diana R Holdright

Consultant Cardiologist

Dr Diana Holdright

Common Problems - Chest Pain

Chest pain has a variety of causes, one of the most important of course being pain from the heart.  However, musculoskeletal problems and lung disease can also cause chest pain, and it is worth remembering that many pains have no obvious explanation, never cause any harm and frequently resolve spontaneously. 

Pain from the heart can occur following a viral infection that can inflame the outer lining of the heart (the pericardium), causing an intense pain that varies with respiration and posture. However, cardiac pain is usually due to narrowing and/or blockage of one or more of the coronary arteries (see figure). With physical activity the heart beats harder and faster and needs more oxygen, but if a coronary artery has become narrowed, the blood and oxygen supply to the heart muscle is inadequate, creating chest discomfort (patients rarely describe it as a pain) in the form of a tightness and pressure in the chest, and sometimes breathlessness, symptoms which disappear as the activity ceases and the heart’s requirements for blood and oxygen diminish; this is what the term angina means.  There is a very stable and predictable pattern to the symptoms in such cases, for example, chest discomfort with walking uphill or walking quickly.  It can also be more intense in the cold weather and with activity soon after eating a meal.  Sometimes it is the first effort of the day that causes angina and subsequent activities are relatively unrestricted.

Furring up of the arteries (atheroma) develops over many years and can occur both gradually and suddenly.  Gradual progression of the furring up process typically causes angina; however, another manifestation of the same disease process is a myocardial infarction, commonly known as a heart attack.  This typically occurs when an area of atheroma suddenly ruptures, exposing the undersurface of the artery lining and provoking an injury response, whereby a clot begins to form over the damaged area.  If the clot is large enough it can block the artery entirely and this is the substrate for a heart attack. In most cases this is unheralded and is often the first indication that a patient has a heart problem, hence the importance of screening in medium and high risk populations.  Sometimes a patient will have had angina symptoms which suddenly intensify such that chest discomfort develops with diminishing levels of exercise and is ultimately present at rest.  Most survivors describe a heart attack as an intense discomfort and heaviness in the chest, like an elephant is sitting on the chest, associated with sweating, nausea and breathlessness.  This is a medical emergency and needs immediate treatment to restore the blood supply to the heart and minimise damage to the heart muscle; during a heart attack, the heart muscle that received its blood supply from the affected artery will die, healing with time to leave a scar. The larger the scar, the greater the effect on the remaining healthy heart muscle, and the less effectively the heart will work in the future.

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