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Atypical Chest Pain

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Last updated October 15, 2020

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This article will review the symptoms, causes, and management of atypical chest pain. Atypical chest pain differs from chest pain indicative of a heart attack. Symptoms include sharp or tearing pain, shortness of breath, and back pain.

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What is atypical chest pain?

Summary

Atypical chest pain is defined as chest pain that does NOT have all three characteristics of chest pain that is typical of a heart attack. These typical indicators include: 1) chest pain or discomfort in the center of the chest behind the breastbone, 2) gets worse with exertion or stress, and 3) gets better with rest or a medication called nitroglycerin.

Instead, atypical chest pain will be sharp, stabbing, or tearing, in a specific area of the chest, and may last for hours or days. You may also experience a cough or shortness of breath as well as difficulty swallowing.

Atypical chest pain may be treated through monitoring, medications, or procedures. If the pain is severe or you experience shortness of breath, or you have a history of heart disease, you should seek immediate medical attention.

Recommended care

It looks like your chest pain is atypical, however further testing might be needed. Therefor, you should schedule an appointment within two days with your primary care physician who can coordinate these further tests. These will likely include a stress EKG (electrocardiogram), which is a readout of the hearts' electrical activity during exercise.

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Atypical chest pain symptoms

Main symptoms

As covered in the synopsis, atypical chest pain does not have all three characteristics of chest pain indicative of a heart attack. Therefore, atypical chest pain may instead have the following characteristics:

  • Quality: Unlike typical chest pain, which is usually a dull pain or pressure sensation, atypical chest pain may be sharp, stabbing, or tearing. Atypical chest pain may get worse when breathing in, may get better with leaning forward, and may be worse when you push on the chest. The pain may be worse with eating, which suggests a gastrointestinal cause.
  • Location: Atypical chest pain may be located in a specific area of the chest, unlike typical chest pain, which is usually felt throughout the chest. Atypical chest pain may also spread to the back. Pain that spreads to the arms or neck is more characteristic of typical chest pain.
  • Onset and timing: Atypical chest pain may come on suddenly, which is unusual for typical chest pain. Atypical chest pain may also last for hours or days, while typical chest pain usually does not last for more than 20 to 30 minutes.

Other symptoms

Other symptoms of atypical chest pain will likely include the following.

  • Cough or shortness of breath: Atypical chest pain may be associated with cough or shortness of breath, especially if it is due to a lung-related cause. Gastroesophageal reflux disease (GERD) can also cause a long-standing cough.
  • Painful or difficulty swallowing: Atypical chest pain may be associated with pain or difficulty swallowing if it is due to a gastrointestinal cause such as gastroesophageal reflux disease.

Atypical chest pain causes

Atypical chest pain refers to chest pain that is not “typical” of the kind caused by a heart attack. The definition of atypical chest pain is not clear, and different people may mean different things by atypical chest pain. Many things can cause atypical chest pain and a few are described below.

Heart-related causes other than heart attack

Other than a heart attack, other heart-related causes can cause atypical chest pain. A few of these include:

  • Inflammation of the heart: This may be of the lining of the heart (pericarditis) or of the heart muscle (myocarditis).
  • Diseases of the heart valves
  • Failure of the heart to pump normally
  • Aortic dissection: This is a tear in the large blood vessel that delivers blood from the heart.

Lung-related causes

Because the lungs are also located in the chest, lung disorders can also cause atypical chest pain. A few include the following:

  • Pulmonary embolism (PE): A blood clot in the lungs
  • Pneumothorax: A collapsed lung
  • Pneumonia: An infection of the lungs
  • Asthma
  • Chronic obstructive pulmonary disorder (COPD)
  • Lung cancer

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Gastrointestinal causes

The esophagus and stomach are both located in or near the chest, and disorders of these organs can cause atypical chest pain, such as the following.

  • Gastroesophageal reflux disease (GERD): A common cause of atypical chest pain, this occurs when acid from the stomach refluxes back into the esophagus, causing irritation.
  • Gastritis: This is inflammation of the stomach lining.
  • Inflammation of the esophagus
  • A tear in the lining of the esophagus

Musculoskeletal chest pain

Injury to the muscles or bones in the chest is another common cause of atypical chest pain. Musculoskeletal chest pain can be due to direct injury to the chest, which can lead to tissue damage and broken ribs, as well as injury to the chest from overuse.

Anxiety

Anxiety and panic attacks can cause symptoms that may feel like a heart attack. During a panic attack, you may experience sudden-onset chest pain or tightness, shortness of breath, dizziness, and intense fear. However, if you are younger than 40 years old, are otherwise healthy, and do not have a previous heart condition, it is more likely to be a panic attack.

Panic or anxiety attack(s)

Panic disorder means a generalized set of symptoms involving sudden, unexplained feelings of anxiety and overwhelming fear. The physical symptoms are very real and consist of sweating, pounding heart, and shortness of breath.

The cause is not known. It may involve changes in brain chemistry that cause a person to perceive danger where there actually is none. Severe and ongoing stress, as well as post-traumatic stress disorder (PTSD) may be factors.

Panic disorder is most common among women. It can affect anyone, however, especially with a family history.

This condition does not improve on its own. If left untreated, the patient may become isolated and even suicidal.

A doctor will do a complete workup, including blood tests, to rule out any physical causes for the symptoms. A psychological workup will also be done.

The first line of treatment is talking with a professional who can help with coping and stress management. Medication, including some antidepressants and calming drugs, may be used temporarily but can cause dependence and unpleasant side effects if used for too long.

Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) means "abnormal thickening of the heart muscle." This can interfere with the heart's ability to pump blood.

Most often, an inherited genetic mutation causes HCM. However, aging, high blood pressure, diabetes, or thyroid disease can sometimes bring it about.

Many people have no symptoms at all. Some have unexplained chest pain, shortness of breath, fainting, or the feeling of rapid, fluttering heartbeat, because the abnormally thick heart muscle interferes with normal heartbeat and causes an arrhythmia. Take the patient to the emergency room or call 9-1-1.

Untreated hypertrophic cardiomyopathy can lead to serious heart disease and even sudden cardiac arrest and death, especially in people under age 30.

Diagnosis is made through echocardiogram; electrocardiogram; treadmill stress test; and/or cardiac MRI.

Treatment involves medication to relax the enlarged heart muscle and slow the rapid pulse. Surgery to remove some of the thickened muscle may be done, or a defibrillator may be implanted.

Anyone with a family history of HCM should ask their medical provider about screening for the disease, which involves regular echocardiography.

Heart attack

Most heart attacks happen when a clot in the coronary artery blocks the supply of blood and oxygen to the heart. Often this leads to an irregular heartbeat - called an arrhythmia - that causes a severe decrease in the pumping function of the heart.

Call 911 and seek emergency care immediately

Atypical chest pain

Atypical chest pain describes the situation when someone's chest pain is unlikely to be related to heart or lung disease. There are many other possible causes that could explain chest pain, like sore chest wall muscles or psychological factors like stress and anxiety.

It looks like your chest pain is atypical, however further testing might be needed. Therefore, you should schedule an appointment within two days with your primary care physician who can coordinate these further tests. These will likely include a stress EKG (electrocardiogram), which is a readout of the heart's electrical activity during exercise.

Atrial fibrillation

Atrial fibrillation, or AFib or AF, is a rapid, quivering, abnormal heartbeat. It occurs when electrical signals in the two upper chambers of the heart do not coordinate with signals in the two lower chambers.

Heart damage from high blood pressure, congenital heart defects, viral infections, and sleep apnea can cause atrial fibrillation. Other risk factors include increasing age, obesity, family history, and drinking alcohol.

The patient may notice a jerky, fluttering heartbeat; shortness of breath; and weakness. Chest pain is a medical emergency. Take the patient to the emergency room or call 9-1-1.

Untreated atrial fibrillation may lead to heart failure. Blood clots can form in the stalled circulation within the quivering heart, travel to other parts of the body, and cut off the blood flow to other organs.

Diagnosis is made through electrocardiogram, echocardiogram, blood test, stress test, and chest x-ray.

Treatment involves cardioversion with mild electrical shock or medication to return the heart to normal rhythm. Surgery may be done. Blood thinners and medication to maintain heart rhythm will be prescribed.

Angina pectoris (chest pain from reduced cardiac blood flow)

Angina pectoris is chest pain that happens when heart muscle needs more blood than it is currently getting. This may result from coronary artery disease (CAD). CAD happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and other material, called plaque, on their inner walls.

You should visit your primary care physician within the next 24 hours. Your doctor will perform a thorough physical exam as well as an EKG (electrocardiogram) to see how your heart is beating. Prescription medication may be used to relax blood vessels, easing the heart's workload. A referral to a cardiologist might be needed.

Acute costochondritis (chest wall syndrome)

Acute costochondritis is also called anterior chest wall syndrome. It is an inflammation of the flexible cartilage that connects each rib to the breastbone.

Costochondritis is caused by excessive coughing or by straining the upper body, as with weightlifting. It is a common occurrence and is seen in children, teenagers, and adults.

Symptoms include a sudden, sharp, aching pain anywhere in the chest wall, especially near the breastbone where it connects to the ribs. The pain gets worse with deep breathing or with almost any movement.

Any sort of chest pain should be seen by a medical provider, especially if the person is over 35 and/or has had any cardiopulmonary symptoms. Heart attack symptoms can be mistaken for costochondritis in some cases.

Diagnosis is made through physical examination. X-rays or CT scans may be done to rule out any other causes for the pain.

Treatment involves rest along with over-the-counter, nonsteroidal anti-inflammatory drugs. Injection of corticosteroid medication to ease pain and inflammation is occasionally done.

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Treatment options and prevention for atypical chest pain

The treatment for atypical chest pain will vary depending on the cause of chest pain. Treatment may include clinical monitoring, medications, procedures, and/or surgery. Some examples of treatments for various causes of atypical chest pain are described below.

Monitoring

Some causes of atypical chest pain may not require treatment and may be clinically monitored by both you and your physician. For example, mild musculoskeletal pain that does not bother you can be monitored.

Medication

Some causes of atypical chest pain may be treated with medications.

  • For inflammation of the lining of the heart: This is usually treated with a combination of aspirin, ibuprofen (Advil, Motrin), or indomethacin (Indocin) with colchicine (Colcrys).
  • For a blood clot in the lungs (pulmonary embolism): People with a blood clot in the lungs may need to be treated with blood thinners such as heparin or warfarin (Coumadin).
  • For pneumonia: People with pneumonia may need to be treated with a course of antibiotics.
  • For gastroesophageal reflux disease (GERD): People with gastroesophageal reflux disease may benefit from a course of medications to decrease acid levels in the stomach such as omeprazole (Prilosec) or pantoprazole (Protonix).

Procedures or surgery

Some causes of atypical chest pain may require treatment with procedures and/or surgery.

  • For a heart attack: You will need to be treated with a procedure to open up the blocked blood vessel on the heart, or with open heart surgery to bypass the blocked blood vessel.
  • For a collapsed lung (pneumothorax): People with a collapsed lung may need to have a needle or tube inserted into their chest to help re-inflate the lung.
  • For an esophageal tear: People with a tear in their esophagus may need surgery to repair the tear.

When to seek further consultation for atypical chest pain

If you develop any symptoms of atypical chest pain such as the following, you should seek care right away:

  • A sharp chest pain that gets worse with breathing in or position changes
  • Back pain
  • Shortness of breath

If you have a history of heart disease, you should consider going straight to the emergency department or calling an ambulance. Even heart attacks can cause atypical chest pain, so it is important to be promptly evaluated by a doctor and treated.

Questions your doctor may ask to determine atypical chest pain

  • Have you been feeling more tired than usual, lethargic or fatigued despite sleeping a normal amount?
  • Do your symptoms occur after an emotional time or recent stress?
  • Any fever today or during the last week?
  • Do you have a cough?
  • Where is your chest pain exactly?

Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions.

Share your story
Dr. Rothschild has been a faculty member at Brigham and Women’s Hospital where he is an Associate Professor of Medicine at Harvard Medical School. He currently practices as a hospitalist at Newton Wellesley Hospital. In 1978, Dr. Rothschild received his MD at the Medical College of Wisconsin and trained in internal medicine followed by a fellowship in critical care medicine. He also received an MP...
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References

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