Chest pain is a common symptom that may affect anyone. Its causes may vary from simple muscle pain or air in the oesophagus to myocardial infarction. Such a pain can make people panic. It is therefore important to understand the nature of the chest pain and to know what to do if someone suddenly starts complaining of such a pain. Angina pectoris There are five important causes of chest pain that should be eliminated before thinking of a benign cause: angina pectoris, myocardial infarction, acute aortic dissection, pulmonary embolism and spontaneous pneumothorax. Angina pectoris is essentially due to a narrowing of the coronary arteries and the part of the heart muscle called the myocardium will suffer. The patient may feel chest pain or oppression. This pain occurs when movement or effort is made. In such a case, it is called stable angina pectoris. If the same pain occurs during rest it is called unstable angina. The pain is usually felt behind the sternum and irradiates to the shoulder and the little finger. It does not last long. It disappears when the patient stops making the effort or takes a sublingual tablet that dilates the coronary arteries. The tracing of the electrocardiogram may sometimes be normal or may show signs of diminished blood supply to the myocardium, a situation called myocardial ischaemia in medical terms. The electrocardiogram done during exercise will show signs of ischaemia. The patient may then need cardiac catheterisation to do a coronary artery angiography, in order to visualise the coronary arteries on a video that is actually seen on the computer. The patient may be treated either with balloon dilatation, the insertion of a stent, coronary artery bypass grafting or medications. Myocardial infarction Myocardial infarction is due to sudden or rapid obstruction of a coronary artery by a thrombus or a plaque of calcium of the atherosclerosis. The area of myocardium supplied by this artery may necrose or die. The chest pain in case of myocardial infarction is severe and lasts for at least 30 minutes. During the four hours that follow the occurrence of the infarction, it is still possible to salvage the myocardium by injecting a substance that dissolves the thrombus and that opens the coronary artery. Such a substance is called a fibrinolytic drug. Fibrinolytic drugs include streptokinase, that should only be given in a hospital for fear of its adverse reaction, and tPA, which may be given at home. There are new versions of such drugs, but they are all expensive. Acute aortic dissection Acute aortic dissection is a rupture of the aortic wall. Blood creates a channel inside the wall of the aorta, giving two lumens: the original one and the false one. Acute aortic dissection gives severe agonising chest pain that irradiates to the back. It is an emergency. The patient should be operated on in emergency, having his aorta replaced by a prosthetic tube. Aortic dissection is classified according to the place of the root of entry or the site, where the aorta has ruptured. When the rupture is in the ascending aorta or the arch, surgery is a must, but when the rupture is in the thoracic aorta some medical teams may adopt a conservative attitude by administering drugs that lower blood pressure to avoid total rupture of the aorta. Pulmonary embolism Pulmonary embolism is the migration of a thrombus from the lower limb veins to the right atrium and to the pulmonary artery to obstruct the pulmonary vascular bed. It occurs in patients, who have undergone abdominal, gynaecological or bone surgery and have stayed in bed without moving. It can occur after a long period of immobility, either in an aircraft or car, or in patients with chronic deep vein thrombosis. It gives severe chest pain in the side. If the embolism is minor or moderate, the chest pain may disappear. If it is massive, the patient may feel severe breathing discomfort and may undergo cardiac arrest. The electrocardiogram tracing is nearly normal, but blood gas analysis will show low oxygen and carbon dioxide pressure in the blood. The main treatment for pulmonary embolism is prophylactic. Cardiac surgery to remove the obstruction in the pulmonary artery is rarely indicated. Fibrinolytic drugs may be also used in such cases. Spontaneous pneumothorax Spontaneous pneumothorax is the presence of air in the thoracic cavity from the rupture of a lung bulla. It may occur in emphysematous patients or in a young man after exertion. The diagnosis is easy by chest X-ray, where the lung appears collapsed. Insertion of a chest tube connected to an underwater seal is lifesaving, allowing drainage of air and extension of the lung. When someone experiences sudden chest pain, the people with him shouldn't panic. They should calm the patient down and ring 123 for an ambulance. If a physician is in the vicinity and a heart attack is diagnosed, he may call 3302-5044, which is the emergency number of the National Heart Institute. An ambulatory ICU may go to the patient's home and do the necessary before having him transferred to hospital. The main thing is not to panic, to reassure the patient and to call for help, either ringing 123 or the NHI emergency number or the emergency number of any other cardiac centre.
