Chest Pain
Chest pain at rest is a medical emergency and should not be ignored. If you experience chest pain at rest, seek medical attention immediately by calling 999 — it may be a heart attack. Please do not try to self-diagnose chest pain.
Chest pain means different things to different people. When you see a cardiologist with chest pain, the main concern is usually angina — the medical term for chest pain caused by coronary artery disease. Classic angina is a heaviness in the central chest that may spread up to the neck and jaw or down the left arm, often with sweating or nausea, typically worse on exertion and relieved by rest. There are big variations on this theme: some patients describe it as indigestion, an ache in the jaw or teeth, or aching in the right arm.
What causes chest pain?
Cardiac chest pain (angina) is usually caused by a narrowing in one of the coronary arteries. Other cardiac causes include pericarditis (inflammation of the lining around the heart), aortic stenosis, and cardiomyopathy. Non-cardiac causes range from musculoskeletal pain to pulmonary embolism, oesophageal disease, and anxiety.
How is chest pain assessed?
The workup depends on the suspected cause. The first step is always a careful clinical assessment, including the character and triggers of the pain and your cardiovascular risk factors. Investigations may include:
- Electrocardiogram (ECG) — looks for evidence of ischaemia, arrhythmia, or previous heart attack. Often performed both at rest and during exercise.
- Blood tests — including troponin if there is any suggestion of an acute coronary syndrome, plus a lipid profile, glucose, kidney and liver function.
- CT coronary angiography — a non-invasive scan that directly visualises the coronary arteries; usually the first-line test in stable chest pain with a suggestion of coronary artery disease.
- Stress echocardiography — exercise (or pharmacological stress) combined with echocardiography to look for areas of the heart that don’t function normally under stress.
- Cardiac MRI — useful for non-coronary causes such as myocarditis, pericarditis, microvascular disease, or cardiomyopathy. Can also be used as a stress test (perfusion MRI).
- Ambulatory ECG monitoring — if the chest pain is suspected to relate to an intermittent arrhythmia.
- Invasive coronary angiography — a thin tube passed up to the heart from the wrist or groin, with X-ray dye injected into the coronary arteries. Used in higher-risk patients, those with strongly positive non-invasive tests, or where treatment may be needed at the same time.
What experience does Dr Dawkins have in the management of chest pain?
Dr Dawkins is an interventional cardiologist at the John Radcliffe Hospital in Oxford, where he is one of the consultants responsible for the Heart Attack Service and provides emergency angioplasty for patients having heart attacks.