Causes of Chest Pain or Discomfort

We can divide the causes of chest pain into two major categories: those caused by cardiac issues, and those caused by other, non-cardiac issues.

Causes of cardiac chest discomfort (pain)

Myocardial Ischemia and Injury (oxygen supply to heart not sufficient to meet metabolic demands of myocardium) – coronary artery disease (CAD) – manifested as angina or myocardial infarction

Risk factors for CAD:

  • Advancing age (males over 45 or females over 55 or premature menopause without estrogen replacement),
  • Cigarette smoking,
  • Diabetes Mellitus,
  • Hypertension,
  • Elevated low-density lipoprotein cholesterol (LDL-C),
  • Low high-density lipoprotein cholesterol (HDL-C),
  • Premature family history of CAD (for males who are over 55 or females who are over 65 and who are first degree relatives of CAD patients), and
  • On initial examination:
    • Angina description,
    • Prior myocardial infarction,
    • Sex (male)
    • Above major risk factors

  1. Angina Pectoris:
    Canadian Cardiovascular Society Classification of Angina
    • Class I – Angina occurs only with strenuous exercise.
    • Class II – Angina occurs with moderate activity such as:
      • Walking quickly,
      • Climbing stairs,
      • Walking uphill, or
      • Walking at a normal pace more then 2 blocks or more than 1 flight of stairs
    • Class III – Angina occurs with mild activity such as climbing 1 fight of stairs or walking level for 1 to 2 blocks.
    • Class IV – Angina occurs with any physical activity and may be present at rest.

    See also: Types of Angina

  2. Other Cardiac Causes of Chest Pain or Discomfort

    1. Acute Pericarditis

    2. Valvular Heart Disease

    3. Aortic Disease

Non-cardiac causes of chest pain

Definition – chest pain that is due to causes other than heart disease and often referred to as atypical chest pain.

Significant because the cardiac chest pain in women and diabetics may not be classic angina pectoris and may mimic non-cardiac chest pain


  1. Chest wall disorders:
    1. Musculoskeletal
      • Costochondral – Costosternal
        • Exercise or movement induced chest pain.
        • Injury
        • Inflammation
        • Tietze’s syndrome
          1. Pain over musculoskeletal area of anterior chest, especially over the costochondral junctions that are red, swollen, warm and tender
          2. Pain is fleeting and sharp
      • Rib Fracture:
        • Direct trauma
        • Cough.
        • Malignancy
      • Intercostal or pectoral muscle strain – exercise

    2. Nerve Pain
      • Herpes Zoster in the pre-eruptive stage
      • Post-viral or viral neuritis
      • Referred nerve root pain from compression or irritation of cervical or thoracic nerve roots

  2. Pleuritic Pain (sharp or cutting secondary to coughing) is due to inflammation of the pleura
    • Viral pleuritis due to Coxsackie B or pleurodynia
    • Pneumonia with pleural inflammation (knifelike pain exacerbated by inspiration or coughing)
    • Pulmonary infarction in a minority of pulmonary embolism cases
    • Connective tissue disease – Rheumatoid Arthritis (RA), Systemic Lupus Erythematosus (SLE) - especially in lupus
    • Cancer involving the pleura – heavy or dragging sensation
    • Pneumonthorax

  3. Esophageal Pain
    • Gastroesophageal Reflux Disease (GERD)
      • Variable symptoms
      • Most frequent symptoms:
        1. Heartburn
        2. Acid regurgitation
        3. Dysphagia
        4. Pain worsened by alcohol, aspirin or some foods and by lying down.
        5. Pain relieved by antacids.

    • Esophageal spasm
      • Squeezing pain
      • Hard to diagnose

    • Esophageal injury
      • Mallory-Weiss tear – due to severe retching and vomiting

  4. Peptic Ulcer Disease
    • Abdominal pain
    • Often 60 to 90 minutes after meals.
    • Increased appetite or anorexia
    • Weight loss
    • Nausea and vomiting
    • Heartburn
    • Food intolerance
    • Bloating and belching.
    • Upper GI bleeding

  5. Cholecystitis with gallstones
    • Occasional chest pain.
    • Symptoms:
      • None, or
      • Biliary colic (prolonged periods of right upper quadrant (RUQ) pain or epigastric pain that frequently radiates to right shoulder and may be associated with nausea and vomiting

  6. Pancreatitis
    • Abdominal pain
    • Occasional chest pain
    • Patient is often an alcoholic

  7. Emotional and Psychiatric Conditions – pain is often variable (visceral tightness that lasts more than 30 minutes or is fleeting, sharp or localized),and clues as to origin are depression, prior panic attacks, somatization, agoraphobia.

See also: Palpitations

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