Acute Chest Pain - Causes, Symptoms, Rapid Assessments, and Latest Advances

Introduction:

Chest pain is an emergency situation that requires rapid management. The accurate evaluation of chest pain can prevent patients from undergoing morbidity or mortality. Severe chest pain is commonly related to myocardial ischemia, in which the heart muscles are devoid of blood flow, and coronary artery disease, which causes the build-up of plaque in the blood walls and slows down the rate of blood flow. Chest pain can be sharp or dull, and sometimes the pain can reach up to the jaw or both arms. Evaluating tools include electrocardiograms, blood tests, echocardiograms, CT (computed tomography) scans, and cardiac biomarkers.

What Are the Causes of Acute Chest Pain?

The causes of acute chest pain due to heart-related problems are:

• Angina (reduced flow of blood to the heart).

• Aortic dissection (a slit in the artery that supplies blood to the body called the aorta and forms a false lumen).

• Pericarditis (inflammation of the membrane of the heart).

• Heart attack or myocardial infarction (complete stoppage of blood flow to the heart).

Digestive-Related Causes Are:

• Swallowing disorders.

• Gallbladder or pancreas problems such as inflammation or stones in the gallbladder.

• Heartburn.

Muscle and Bone-Related Causes Are:

• Injured ribs.

• Costochondritis (inflamed rib cartilage).

• Sore muscles.

Lung-Related Causes are:

• Pulmonary embolism (blockage in the pulmonary artery of the lung by a clot).

• Pleurisy (inflammation of the lung membrane).

• Collapsed lung (escape of air from the lungs).

• Pulmonary hypertension (increased pressure of blood in the lung arteries).

Other Causes Are:

• Panic Attack: This occurs due to intense fear that causes physical reactions such as increased heartbeat, sweating, dizziness, and shortness of breath.

• Shingles: A viral infection that causes rashes on the body, including the chest area, which are very painful.

What Are the Symptoms of Acute Chest Pain?

The symptoms of acute chest pain due to heart problems are:

• Pressure or tightness in the chest.

• Crushing pain that spreads to the jaw, neck, back, shoulders, and arms.

• Pain that is present for a few minutes reduces but comes back.

• Shortness of breath.

• Increased heartbeats.

• Dizziness.

• Weakness.

• Cold sweats.

• Nausea or vomiting.

Which Rapid Assessments Are Performed for Acute Chest Pain?

The important goal in assessing patients should include the evaluation of risk and identifying or excluding acute coronary syndromes, which are due to reduced blood supply to the heart. The evaluation of risk in chest pain includes the patient's history, initial clinical presentation, along with electrocardiographic findings. If none of these are present, the patient is considered low risk. Even in case of low risk, further evaluation is considered before discharging the patient. If there is no evidence of myocardial infarction, further confirmatory tests are done to evaluate ischemia (decreased blood flow to a part of the body). Rapid assessments include:

• Electrocardiogram (EKG OR ECG): It is a painless and noninvasive diagnostic method that measures the heart’s electrical activity and other conditions such as irregular heart rates, blocked arteries, history of previous attacks, and efficacy of treatment such as a pacemaker.

• Blood Tests: This is done to detect proteins that are involved in heart damage.

• Chest X-ray: This can help in detecting the lung problems such as collapsed lung or pneumonia (inflammation of the lung sacs). This can also show the heart's shape and its blood vessels.

• Computerized Tomography (CT) Scan: This can help detect blood clots in the lung or arteries of the heart. This can also help in detecting aortic dissection.

Other tests may include:

• Echocardiogram: A type of ultrasound scan that uses high-frequency sound waves to detect the heart and its vessels.

• Coronary Catheterization: This includes the insertion of a thin long flexible tube called a catheter into the arm or leg to evaluate the functions of the heart.

• Stress Tests: This test shows the condition of the heart during physical activity. Stress tests involve riding a stationary bike or walking on a treadmill. This can help in assessing blood pressure, heart rate, and breathing.

• Coronary Artery Calcium Scores: This help detect the amount of calcified plaque in the arteries. Because the build-up of plaque is the main cause of atherosclerotic cardiovascular disease (ASCVD) which causes acute chest pain and heart attacks. The scores include:

  1. Score 0: Indicates no calcified plaque.

  2. Score 1 to 10: Indicates a small amount of calcified plaque, but the risk is too low.

  3. Score 11 to 100: Indicates a moderate chance of heart attack.

  4. Score 101 to 400: Indicates a high to moderate chance of heart attack.

  5. Above 400: Indicates a large amount of build-up of plaque and are high-risk patients.

What Are the Latest Advances in Assessing Acute Chest Pain?

The latest advances in assessing acute chest pain are:

1. Cardiac Biomarkers: These are powerful diagnostic tools that can help in diagnosing, managing, and evaluating the prognosis of heart disease.

Biomarkers used in case of myocardial necrosis are:

• CK-MB Fraction (Creatine Kinase-Myocardial Band): CK-MB is a type of muscle enzyme that is released in case of myocardial necrosis. This enzyme occurs within 4 to 6 hours after the chest pain. Even a rise of 5 % can indicate damage to the heart muscle.

• Myoglobin: It is a protein that helps in transferring oxygen. These levels increase rapidly within 1 hour, peak in 8 to 10 hours, and become normal within 24 hours.

• Cardiac Troponins: These are a type of muscle protein that occur in blood when there is muscle damage. This enzyme enters the blood after 3 to 9 hours of heart damage.

Biomarkers used in case of myocardial ischemia are:

• Ischemia-Modified Albumin (IMA): It is a serum albumin that rises within 6 hours and stays high for 12 hours after an infarct.

• Heart-Type Fatty Acid-Binding Protein (H-FABP): A type of low molecular weight protein. These appear in the bloodstream within 1 to 3 hours of an infarct.

Biomarkers used in the case of prognosis are:

• C-Reactive Protein: A type of protein that is produced by the liver. If CRP levels are more than 10 mg/L (milligrams per liter), it indicates an illness that requires immediate treatment. Less than 1 mg/L indicates low risk.

• Homocysteine: A type of amino acid that helps assess the risk for atherosclerosis.

1. Noninvasive Imaging: It includes:

• Cardiac CT Angiography: This is used in detecting high-grade stenoses with no calcium deposits in the arteries. Therefore helps in detecting noncalcified coronary stenoses.

• Myocardial Perfusion Imaging (Nuclear Stress Test): A type of test in which a radioactive tracer, a radioactive substance, is injected into the blood. A scan is taken after, which shows areas of good blood flow where the tracer is absorbed, or areas of damaged blood flow where the tracer is not absorbed, and the areas are called cold spots. This test is done during rest and during exercise, which causes stress in the heart. There are two types which are:

  • Single photon emission computed tomography (SPECT).

  • Positron emission tomography (PET).

Conclusion:

Acute chest pain is a serious emergency situation that requires rapid evaluation and treatment. Rapid assessment with the help of noninvasive tools such as electrocardiogram, cardiac CT angiography, myocardial perfusion imaging, and cardiac biomarkers can decrease the mortality and morbidity of the patient.