NON CARDIAC CHEST PAIN

                                            

          Non-cardiac chest pain (NCCP) is a term used to describe chest pain that resembles heart pain (also called angina) in patients who do not have heart disease. The pain typically is felt behind the breast bone (sternum) and is described as oppressive, squeezing or pressure-like or pricking type. It may radiate to the neck, left arm or the back (the spine). It may be precipitated by food intake. It lasts variable periods of time and it is not unusual for it to last hours. Because the pain is similar to heart pain (called angina), patients and physicians frequently attribute this pain to the heart. In fact, many patients present to emergency rooms concerned about a heart attack and commonly undergo cardiac studies (such as EKGs, laboratory tests, stress test and even coronary angiography – where dye is injected into the heart vessels). After these cardiac tests fail to show evidence of heart disease, the patients receive the diagnosis of NCCP, leading the physician to examine other causes for this chest pain.

The main causes of NCCP are:

Gastrooesophageal reflux
Tietze Syndrome  (Costochondritis)
Chest infection
Lung tumour
Referred pain from thoracic spine
Biliary Pain
Psychological causes

The most common causes of chest pain seen in the GP surgery are non-cardiac. This is especially so with the young women. They are usually differentiated by careful history taking. Gs Gastro-oesophageal reflux disease (GERD) is very common. It presents with epigastric or mid chest burning pain, acid reflux, and relief with antacids. Patients may also complain of associated reflux symptoms such as heartburn (a burning feeling behind the breast bone) or fluid regurgitation (a sensation of stomach juices coming back toward the chest and even to the mouth frequently with a bitter or sour taste).

Pleural pain may be caused by infection, pulmonary embolism or tumour. The character of the pain is important with elucidation of pulmonary symptoms. Musculoskeletal pain, such as with Tietz syndrome, is suggested by a pleuritic character and local tenderness. Referred pain from the thoracic spine can be suggested by previous history, trauma and local tenderness. Biliary pain with epigastric or right hypochondrial discomfort, is worse with fatty foods and associated with nausea.

Psychological causes include anxiety, panic attacks, and depression. Somatic symptoms of psychological disorders are very common; however, it is also important to remember that the onset of angina itself may induce significant anxiety.

Costochondritis (Tietze's syndrome) is an inflammation of the cartilage that connects the inner end of each rib with the breastbone (sternum), otherwise known as the costochondral joint. It can occur in any age group and is most common in young adults’ especially young women. In the US, costochondritis has been shown to account for 10 per cent of chest pain episodes in the community and 30 per cent of people with chest pain presenting as an emergency to hospital.

The risk of developing costochondritis increases with any physical activity that causes trauma or strain to the ribcage. It's a benign condition, usually of short duration that resolves completely. Sometimes though, it can recur or become persistent. The predominant symptom is a sharp pain in the affected area – most commonly involving the second or third ribs that are often very tender to touch. The pain is usually related to movement, coughing and sneezing and can occur in more than one place simultaneously. Pain can also radiate into the arm and can be associated with a feeling of tightness in the chest. On examination there will be swelling and tenderness in the affected areas. The person's medical history and results of examination are usually sufficient. But if the pattern of pain suggests that it could be heart pain, it needs to be thoroughly investigated.

Treatment of costochondritis is by rest, anti-inflammatory drugs, physical therapy, and in very resistant cases, corticosteroid injections have been used as therapy for the inflamed, painful cartilage of both costochondritis and Tietze's syndrome. Ice packs applied to local swelling can sometimes help to reduce pain and inflammation. Local applications like lignocaine or anti-inflammatory creams are very helpful in most cases. Costochondritis can be aggravated by any activity that involves stressing the structures in the front of the chest and so it is better to minimise these activities until the inflammation has subsided.