Feeling pain or discomfort in the chest is common, and although it can be associated with a less severe condition, it can be a sign of a serious life threatening condition such as heart attack and should never be ignored.

Chest pain generally originates from one of the organs in the chest (heart, lungs or esophagus) or from the components of the chest wall (skin, muscle or bone). Occasionally, organs close to the chest, such as the gall bladder or stomach, may cause chest pain. Pain in the chest may also be the result of neck pain that is referred to the chest.

In a heart disease known as coronary heart disease, the blood vessels which supply blood to the heart muscle, called coronary arteries, become clogged with fatty deposits. These deposits, called plaques, cause the coronary arteries to narrow and may prevent a normal amount of oxygen-rich blood from reaching the heart muscle leading to metabolic derangement with subsequent sensation of chest pain. Chest pain as a result of this inadequate supply of heart muscle with oxygen rich blood is called angina and is particularly common during physical activity when the heart rate and pressure are increased due to the heart’s demand for more oxygen.Other things that can increase oxygen demand in the heart include emotional stress, exposure to cold, and eating a meal.Angina develops if the demand for oxygen exceeds the amount of oxygen delivered, and if this isn’t treated urgently, can subsequently lead to a heart attack.It is commonly known that a heart attack is sudden, intense, and dramatic, but this is not always true. Many heart attacks start slowly as mild pain or discomfort, which builds in intensity with time

Heart attack occurs when part of a fatty plaque in these blood vessels supplying to the heart ruptures or a blood clot forms on the plaque, which can partially or completely block the artery. This blockage slows or blocks blood flow to the area of heart muscle fed by that artery. If this continues for more than 15 minutes, the muscle can become damaged or infarcted (that is, the tissue in that area dies)

Chest pain due to angina or heart attack

Patients with chest pain caused by angina or heart attack commonly feel chest discomfort rather than pain that is usually felt as pressure, tightness, or squeezing in the centre of the chest. It is usually not felt in any specific spot, but rather throughout the chest,spreading through the chest and others areas of the body, including the upper abdomen, shoulders, arms, neck and throat, or lower jaw and teeth and tends to come on gradually and get worse over time; it generally lasts from 2 to 5 minutes after resting if it is related to exertion, Lying down may make chest pain worse, while sitting up may reduce pain.

Other symptoms of angina or heart attack may include;Shortness of breath, Nausea, vomiting, or belching, sweating, palpitations (sensation of one’s own heartbeat), lightheadedness, feeling tired, fainting.

Risk factors for angina and heart attack

The likelihood that a person is having angina or heart attack is based upon their symptoms, physical examination, as well as the person’s underlying risk of coronary disease which include but not limited to; elderly age (male above 45 years and female above 55 years), cigarette smoking, a pasthistory of a heart attack, peripheral vascular disease, history of stroke, high blood pressure, diabetes, high cholesterol levels, obesity, sedentary lifestyle and a family history of heart disease or history sudden deaths in the family.

It is however important to know that even in the absence of the above risk factors, the remote possibility of coronary disease is not ignored, although other possible causes are also investigated.

Other heart diseases that present with chest pain include; inflammation of the membranes around the heart (pericarditis), inflammation of the heart muscle itself (myocarditis) often caused by a viral infection, and rarely but very serious condition called aortic dissection in which the layers of the aorta artery, which is the main artery in the body, separate and rupture causing the blood to flow into areas of the body outside of the circulatory system, and can be corrected by vascular surgery.

Chest wall pain;A number of conditions can cause the skin, muscles, bones, tendons, soft tissue and cartilage of the chest to become painful. These may include excessive physical exercise, inflammation of the cartilage that connects the ribs to the sternum, known as costochondritis, diseases such as arthritis, herpes zoster, and any form of trauma to the chest wall including recent surgery.

The esophagus, which is the tube that connects the mouth and throat to the stomach, and pain from this esophagus despite its cause, can mimic heart pain. Conditions related to the stomach and intestines can cause pain that spreads to or even begins in the chest, including ulcers, gallbladder disease, and pancreatitisA number of diseases affecting the lungs can cause chest pain. Many will cause pain that gets worse with breathing, and these might include; pneumonia, blood clot in the lungs (pulmonary embolism), inflammation of lung coverings (pleuritis) usually caused by viral infection and a collapsed lung.

Diagnosing the cause of ones chest pain is by history taking of the symptoms, physical examination, and investigations to confirm the diagnosis.

An electrocardiogram, or ECG, is a test which detects the flow of electrical waves through various parts of the heart and this often detects changes which occur in angina or heart attacks though a normal ECG means that a heart attack is less likely, but doesn’t exclude the diagnosis of angina or heart attack

Other tests such as blood tests, stress tests, cardiac catheterization can be done if an angina or heart attack is suspected

Treatment

Treatment depends on the cause of the chest pain.

If the chest pain is due to angina or heart attack, there are several types of drugs which can be administered to improve one’s health outcome, and this may include;medicines to reduce the symptoms of blocked arteries, medicines to prevent formation of blood clots, medicines preventing formation of fatty deposits in the blood vessels of the heart, medicines for lowering blood pressure, medicines to reduce the chest pain and medicines to prevent future heart attacks.

It is better that an angina, and the precipitating factors be detected and managed early before progression into a heart attack.

Surgery which involves either opening up the blocked blood vessels or bypassing the narrowed or blocked heart vessels to restore blood flow to the heart muscle can be performed for some forms of coronary heart disease.

It is important to know that the risk of suffering from coronary heart disease (most common cause of angina) and heart attack can be reduced by; stopping smoking, exercising regularly, avoiding sedentary life style, consuming low fat diet meals, good diabetic control if diabetic, taking drugs for High blood pressure as prescribed if found having elevated blood pressure.

Most of the risk factors for a heart attack don’t show any symptoms initially and are detected during routine medical checkups; hence a culture of routine medical checkups can be lifesaving.

Dr Ian Shyaka is a General Practitioner based in Kigali.