Chest pain can arise from a number of disorders. A cardiac source is the most concerning cause, as it is the most life-threatening; thus, it must be excluded as soon as possible.
Once a cardiac source of pain has been excluded, a variety of other sources should be considered, such as muscular skeletal or pulmonary causes. For example, an individual who is exercising after a period of physical inactivity may experience discomfort, heaviness, chest pain, and possibly even damage or trauma. Muscular skeletal causes are common sources of chest pain. Chest pain can also be triggered by pulmonary conditions such as an infection in the lungs.
Once cardiac, muscular, and pulmonary conditions have been excluded, the vast majority of patients are found to have an esophageal source for their chest pain. The 3 main causes of esophageal chest pain result from an underlying disturbed nerve sensation and muscle and mucosal dysfunction. The most common esophageal cause of pain is gastroesophageal reflux disease. Reflux of acid can present with chest pain, heartburn, or swallowing difficulties; chest pain is only 1 manifestation of this condition. Esophageal chest pain can also occur when the esophagus undergoes a strong spasm caused by a motility disorder of the esophagus. The third cause of esophageal chest pain, which has been a focus of my research for the last one-and-a-half decades, is an abnormal sensory function of the esophagus called esophageal hypersensitivity. In this sensory disorder, the muscle, nerve, and receptors of the esophageal wall are overly sensitive.
Finally, anxiety or an underlying psychiatric disorder can manifest as chest pain in some individuals.
How are cardiac and esophageal causes of chest pain differentiated?
It is often difficult to distinguish between cardiac and esophageal causes of chest pain based upon symptom presentation alone because the nerves that supply the heart also supply the esophagus. Therefore, patients may think they are experiencing pain of a cardiac origin when the pain is, in fact, coming from the esophagus. Likewise, individuals who think that they are experiencing heartburn may actually be having a heart attack. Another example is an individual who is exercising and experiencing chest discomfort and pain radiating to the arm; this scenario may appear to suggest a cardiac etiology, but exercise is also known to trigger reflux, which could result in reflux pain. Thus, physicians are increasingly relying less upon symptoms and more upon objective data.
Nevertheless, symptoms may offer some hints. For example, it is not very likely that a 20-year-old nonsmoker complaining of chest pain who is otherwise ft and active has coronary artery disease. On the other hand, it is not possible to judge whether chest pain in a 50-year-old smoker with a family history of hypertension is due to a cardiac or a noncardiac source.
For cardiac evaluation, patients should undergo a stress test and angiogram performed via magnetic resonance studies or other techniques. These tests are the most effective methods for excluding vascular disease in the heart. To find out more about the life expectancy of congestive heart failure