Not a Heart Attack? Other Common Causes of Chest Pain
Chest pain can be frightening to experience. How do you know when it’s something benign, or when you should call 911? Let’s learn about chest pain while we dissect a surprising case.
Sanaz Majd, MD
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Not a Heart Attack? Other Common Causes of Chest Pain
Chest pain is not so uncommon. In fact, many of us have experienced it at some point or another. But it can be a frightening experience. How do you know when it’s something concerning or not? As I have previously discussed in prior episodes, much of the time, chest pain is benign and not anything life-threatening—especially in young people without risk factors for heart disease. However, it is also one of those symptoms you should never ignore as a patient (no matter what age), one that doctors take very seriously because the small percentage of those whose symptoms truly are due to something concerning is enough to keep us on our toes.
Let’s discuss a mysterious case of chest pain with a surprising ending.
The Patient History
Chad came to follow up with me, his primary care doctor, in clinic after a recent one night hospital stay for chest pain. He’s a 56-year-old pleasant gentleman whose health is not in the best condition. His body mass index falls in the obesity category, and he suffers from type II diabetes, hypertension, fatty liver, and high cholesterol.
He tells me that the chest pain episode began after eating dinner, while he and his wife had just sat down to watch the next Lord of the Rings movie on DVD. The pain began rather suddenly, was located in the center of his chest, and was severe enough to break out in a sweat. In fact, he called it “excruciating.” So his concerned wife, with good reason, called an ambulance which transported him to the nearest emergency room (ER). Howeber, he’s never had heart problems in the past.
The Hospital Course
After the ER doctor examined him and ran some normal preliminary tests, she still decided to keep him overnight for observation and further testing. After all, Chad has numerous risk factors for heart disease—his sex and age, in addition to his diagnoses of diabetes, hypertension, high cholesterol, and obesity. He’s high risk. And heart disease is the number one killer of men and women in the United States, so she did not want to potentially miss something so vital.
Chad was then hooked up to a heart monitor to make certain that he’s stable throughout his stay. The pain medications they gave him while in the hospital seemed to keep his pain at bay, until the morning when he was scheduled for a cardiac stress test. A stress test places your heart under stress, to determine if there is sufficient blood flow to the heart. If there isn’t enough blood flow under stress, let’s say from a clogged artery feeding the heart, patients often experience what we call “angina,” which is similar to what Chad was experiencing.
Thankfully, Chad’s cardiac stress test was normal. So he was sent home afterwards, and quite relieved, nevertheless. But only to find himself confused as to what could have possibly caused this type of pain if it is not heart-related.
And he was here to follow up with me to help determine the cause.
The Most Common Causes of Chest Pain
As a physician, I need to think about all of those potential causes (termed a “differential diagnosis”) of chest pain that I’ve discussed in prior episodes. After reviewing his normal blood work, heart monitor, and stress test results from the ER, in addition to a normal physical exam in the office, here are some of the top culprits that immediately run through my mind that I need to work through:
1. Anxiety: Panic attacks and anxiety are common causes of chest pain. This type of chest pain can present similarly—sudden onset, severe, and associated with other symptoms such as shortness of breath, rapid heart rate, the sweats, and a feeling of “impending doom.” I do see this a great deal in younger patients, but it can happen at any age. But most people Chad’s age have already experienced it at some point previously, and Chad denies any history of prior panic attacks. In fact, he was having a happy moment at that time, anticipating another Hobbit adventure, his favorite sci-fi saga. Although, no one would argue that Smigel’s character is rather stress-inducing in and of itself, right? The poor guy is simply brimming with anxiety.
2. Chest Wall Strain: Our heart and lungs are encased by a wall made of muscle, ribs, and cartilage. And just like other musculoskeletal regions of the body, it too can get strained and inflamed. Chad has been working in construction for decades, and his job is a very physical one. He reports no recent injuries, but does lift heavy equipment routinely. On exam, however, Chad’s pain was not reproducible to the touch—this is a key finding in those with chest wall strain. In general, if I can touch the chest wall and reproduce the same pain, then it is musculoskeletal, and not involving the heart.
3. Lung Causes: The lungs are close in proximity to the heart, and can also cause chest pain. These conditions include pneumonia, pneumothorax (a collapse of the lung), pulmonary emboli (a clot that travels from the leg to the lung), and pericarditis (inflammation of the lining of the lungs). However, most of these conditions also accompany some type of respiratory symptom, such as shortness of breath, cough, or pain with respiration. None of these conditions fit Chad’s picture.
4. Acid reflux: As the acidic contents of the stomach rise into the esophagus, it can burn the lining and cause pain. Chad does tell me that he was battling acid reflux chronically since gaining significant weight 15 years ago, and seemed to resolve after a gastric bypass. He reports that his reflux was in remission seemingly until now. He shares that his symptoms do seem to mimic the symptoms he experienced prior to having his gastric bypass long ago.
Bingo. This sounds like the most likely cause of Chad’s symptoms so far.
Further Tests
Chad had gained much of the weight back after his gastric bypass, and this excess weight could be a cause for the return of his acid reflux symptoms. Or perhaps this is an ulcer or esophageal erosion. It did occur after a meal after all. So I send a referral for him to be evaluated with an upper endoscopy, a camera introduced into the mouth and down the esophagus and into the stomach to visualize the lining. In the meantime, I also prescribe an acid reducer for Chad to help keep his symptoms at bay.
Progression of Symptoms
But the following week, I see Chad back in the office once again—he had another episode of severe chest pain that took him back to the ER. This time it woke him up from sleep. And knowing that it is not his heart, after controlling his pain, the ER sent him back home. But he tells me that the pain was so severe that he couldn’t handle it. So what was he to do?
After prescribing something for pain in case it returns, I changed the status of his referral to Gastroenterology from “routine” to “stat.” I really need this endoscopy ASAP, as I don’t want Chad to continue to re-experience these episodes.
So he sees GI the next day, they schedule his endoscopy for the following week. But Chad once again ends up in the ER for severe pain before his scope. And again, they release him after his symptoms abate.
Endoscopy Results
What is even more baffling is that his endoscopy the following week is normal. No inflammation from acid reflux. No ulcers or erosions.
After his gasteroenterologist disclosed the endoscopy results, Chad followed up with me in clinic. As a next step, I decided to order a chest CT to further evaluate the blood vessels and organs in the chest.
Much to my surprise, it showed a distended and inflamed gallbladder that is somewhat displaced in the right upper abdomen. And an abdominal ultrasound further confirmed it, which is the best test to visualize the gallbladder (and not the CT).
Patients with “cholecystitis,” or inflamed gallbladder that is often due to stones, typically experience the pain in the right upper abdomen or less frequently in the upper middle abdomen and not in the chest. However, given Chad’s prior gastric bypass surgery, some shifting had occurred yielding a pain that is slightly higher than typical. Central obesity can also aid in shifting our organs.
Chad had his gallbladder removed the following week. And his chest pain was completely resolved.
Another mystery diagnosis solved.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.
