Constant pain behind the sternum. Pathological conditions of the heart and blood vessels. Chest pain with Prinzmetal angina

Pain in the middle of the chest, just behind the sternum, is a common complaint in medical practice. She has scientific name"retrosternal".

To understand why pain occurs behind the sternum, you need to know which organs are in this area. The anatomical region located between the lungs is called the mediastinum. The mediastinum contains the heart, esophagus, large vessels, trachea, bronchi, and lymph nodes.

Diseases of the listed organs can provoke pain in the chest in the middle of this anatomical region. Much less often, referred pain may occur here, for example, associated with pancreatitis. Diseases of the chest wall can also cause severe pain. Some cases are explained by psychiatric reasons.

Heart pathologies causing chest pain

Sharp pain in the heart is what a person usually fears when experiencing oppressive feeling behind the sternum. The patient is driven to see a doctor by fear of myocardial infarction.

It is also important for a physician to determine in time whether the patient’s complaints are of cardiac origin or not. Fortunately, heart pathology is not that common. Among all people who visit a clinic doctor for the first time withretrosternal sharpness and aching pain, only 15-18% have cardiac problems.

Angina and myocardial infarction

Angina is pain that occurs when the coronary vessels spasm. Coronary vessels are blood branches that supply the heart with oxygen. If the spasm of the coronary vessels lasts long enough, irreversible damage to the heart muscle develops due to oxygen starvation. Angina pectoris is complicated by myocardial infarction.

How to recognize the warning signs of angina and heart attack? Pain in the middle of the chest due to angina pectoris can be perceived as a feeling of heaviness, pressure behind the sternum. Pain may radiate to the arm, neck, jaw or shoulder blade. An attack of pain is caused by physical activity, cold, excitement, and food.

With angina, the pain lasts 1-15 minutes. It stops on its own in the absence of movement or after taking a nitroglycerin tablet. The intensity of pain is not affected by breathing, coughing or body position.

Angina pectoris and heart attack are stages of the development of one process. When a heart attack develops, pain is not relieved by nitroglycerin. Severe myocardial infarction is accompanied by shortness of breath, decreased blood pressure and cold sweat.

Acute pericarditis

Pericarditis is inflammation of the pericardium, the outermost lining of the heart. The pericardium is also called the “heart sac”. Severe pain during pericarditis, as with a heart attack, can radiate to the arm, neck, or shoulder blade. Pain associated with inflammation of the pericardium intensifies with inspiration and in the supine position. Pericarditis is often accompanied by shortness of breath and increased body temperature.

Atrial fibrillation

Sometimes the pressure in the middle is accompanied by atrial fibrillation - a common type of heart rhythm disorder. With it, the atria contract very often (several hundred times per minute), which reduces the efficiency of the pumping function of the heart.

Mitral valve prolapse syndrome

Prolapse, i.e. sagging of the mitral valve leaflets occurs in a large number of people. In some patients it is accompanied by symptoms of dysfunction of the autonomic nervous system. These include chest pain. The pain is usually weak and intermittent.

Pathologies of large vessels

Pain in the center of the chest can be caused by pathology of large vessels: the aorta and pulmonary artery.

Aortic dissection

Against the background of severe atherosclerotic changes, syphilis and some other reasons, delamination of the membranes of the wall of the largest vessel may occur. This is an extremely life-threatening situation that can result in rupture of the aorta. The penetration of blood between the layers of the vessel wall is accompanied by very severe “tearing” pain in the chest.

Pulmonary embolism

Pulmonary embolism (PE) is the blockage of a blood vessel by a blood clot. This is a dangerous condition with an unclear clinical picture. When diagnosing, in addition to other symptoms, one must also rely on the presence of a possible source of a blood clot in the veins lower limbs. The pain of PE occurs in the middle of the sternum and can be similar to a myocardial infarction. Pulmonary artery thrombosis is often accompanied by blood in expectorated sputum and shortness of breath.

Respiratory diseases

Laryngotracheitis, bronchitis

Inflammation of the trachea and bronchi against the background of ARVI is often the cause of pain behind the sternum. In addition to pain, there may be an increase in body temperature, cough, and hoarseness.

Pleurisy

The mediastinum is located between the lungs. Therefore, when the layers of the pleura (the lining of the lungs) facing the mediastinum become inflamed, severe pain occurs in the middle of the chest. Most often, pleurisy develops against the background of pneumonia. The pain syndrome is accompanied by cough and increased body temperature.

Cancer (lung, bronchi, pleura, metastatic lesions of lymph nodes)

Persistent, prolonged pain can be caused by tumors growing in the mediastinum. These include organ neoplasms respiratory system. Lymph nodes can be affected by metastases of distant tumors, and also enlarge due to oncological blood diseases.

Diseases of the esophagus are one of the most common causes pain syndrome in the middle of the chest. The stomach located below can also be a source of attacks.

Gastroesophageal reflux disease (GERD)

The word “reflux” in the name of the disease reveals the mechanism of the pathological process. Reflux is a reverse reflux gastric juice into the esophagus. The mucous membrane of the esophagus is not adapted to the ingress of aggressive acidic liquid. Due to its effects, aching pain behind the sternum or heartburn appears. In addition to pain, a large number of other pathological effects are associated with GERD: chronic cough, hoarseness, feeling of a lump in the throat, etc.

Esophagitis

The esophagus, like all other organs, can become inflamed. Its inflammation is called esophagitis. Esophagitis is usually accompanied by difficulty swallowing. Pain with esophagitis varies in nature and intensity. Sometimes it mimics a heart attack, occurring in the middle of the sternum.

Foreign bodies of the esophagus

Acute foreign body may injure the wall of the esophagus. A voluminous foreign object can put pressure on the walls of the esophagus, getting stuck in the lumen of the organ and causing pain in the sternum.

Stomach ulcer

A stomach ulcer is often accompanied by reflux of gastric contents into the esophagus. Therefore, if there is persistent heartburn, pain in the lower middle of the sternum and in the upper abdomen associated with eating, it is necessary to exclude a peptic ulcer.

Pathologies of the chest wall causing pain in the middle

One of the most common causes of pain is. Usually, questioning and palpating the sternum and intercostal spaces are sufficient to diagnose the problem. Inflammation of the joints connecting the ribs and sternum can also cause pain in this area.

When something hurts, we try by any means to alleviate the condition and get rid of the pain. But it is not always possible to achieve the desired effect, and the reason for this is the lack of necessary knowledge. So as not to get lost in similar situations, you need not only to be able to determine possible reason illness, but also to know what measures should be taken.

Most often, people are bothered by pain behind the sternum in the middle, which can be either a consequence of ordinary indigestion or a sign of the development of a dangerous disease. Having studied the symptoms of the most common diseases, you will know exactly what to do: get examined in a clinic, solve the problem yourself, or call an ambulance at home.

Most often, chest pain is associated with problems of cardio-vascular system. And in most cases, such assumptions are fully confirmed during the survey. Among the most serious pathologies there are some forms coronary disease and aortic aneurysm.

Cardiac ischemia

IHD (coronary heart disease) is one of the most common causes of disability and mortality. Its development is provoked by a lack of oxygen in the heart muscle due to contraction coronary arteries. Despite all the advances in medicine, no means have yet been found to completely cure ischemic heart disease. All known treatment methods can only control the disease and slow down the development process. Depending on the degree of oxygen deficiency and its duration, several forms of cardiac ischemia are distinguished.

Forms of IHD have different durations, intensity of development, and are often combined with each other. Depending on the individual characteristics of the body, the course of the disease is acute or chronic.

Symptoms of the disease:

• dull, pressing or sharp burning pain behind the sternum, radiating to the arm, under the shoulder blade, in the neck;
• shortness of breath while walking, climbing stairs, or other physical activity;
• frequent heartbeat, irregular heart rhythm;
• increased blood pressure;
• headache;
• the appearance of edema;
• pale skin.

If pain occurs for the first time, you must immediately stop moving, sit down, or even better, lie down and try to calm down and even out your breathing. If the room is cold, you need to cover yourself with a blanket, since hypothermia can also cause heart attacks. Usually the pain goes away on its own within a minute.

For repeated attacks, it is advisable to have nitroglycerin on hand. As soon as pain appears, you need to take a lying position, straighten up, put a tablet under your tongue and hold it until it is completely absorbed. If 5 minutes have passed and the pain has not disappeared, take another tablet. You can take no more than 5 nitroglycerin tablets at a time at five-minute intervals. If after this it does not get better, you must urgently call an ambulance.

Typically, pain symptoms chronic form IBS can be quickly treated with tablets or drops. Aerosols act a little slower, but give a longer lasting effect.

Here it is very important to notice in time the moment when the disease begins to progress: attacks become more frequent, shortness of breath appears faster when walking, to eliminate the pain you no longer need 1, but 2-3 tablets. Having discovered such signs, you need to be examined by a cardiologist at the first opportunity.

Aortic aneurysm is a dangerous disease. It represents an expansion of individual sections of the aorta due to thinning of the vascular walls. As a result, pressure on the walls of the aorta increases, fibrous tissue stretch, rupture and hemorrhage occur. As a rule, without qualified assistance, a person dies.

An aneurysm almost always develops asymptomatically, and this process can last for years. Only at a later stage, when blood vessel increases significantly and puts pressure on adjacent organs, the patient begins to experience attacks of pain in different parts bodies. An aneurysm can be detected using x-rays and ultrasound, while examining the patient for other diseases. Timely identified pathology must be treated urgently, since a rupture can occur at any time.

Symptoms:

• very sharp, deep pain behind the sternum of a pulsating nature;
• back pain along the spine;
• shortness of breath and cough;
• pale skin;
• a sharp decrease in pressure;
• pulse asymmetry;
• darkening of the eyes;
• dizziness and weakness.

Sharp pain, pallor and other symptoms of an aneurysm

What to do in such a situation? First of all, you need to call emergency help. Before the doctor arrives, the patient should lie down so that the upper body is elevated. You should not move or take any medications - this may increase the bleeding. All further actions are taken by the doctor, the patient is hospitalized and the operation is performed.

For heart pain, exercise should be reduced and avoided if possible. stressful situations, give up coffee and bad habits. It is advisable to always have medications with you, because it is unknown when an attack will occur. If you suddenly don’t have nitroglycerin at hand, you can chew 1 aspirin tablet. You cannot stand up, strain, or walk until the pain disappears completely. And even after that, it’s better to lie a little quietly for a while longer.

If there is no one nearby, and there is no medicine either, and the symptoms of an attack are already appearing, use a very effective and simple method. You need to take a deep breath and cough hard, as if getting rid of phlegm. Again a strong breath and cough, and so on every 2 seconds for several minutes in a row.

What this does: when you inhale, the blood is saturated with oxygen, and coughing accelerates its circulation, causing heart contractions. Very often this technique allows you to normalize heartbeat even before the ambulance arrives.

Autonomic disorders are most often observed in children and adolescents, and the causes of their occurrence include psycho-emotional factors, perinatal lesions nervous system, hereditary predisposition. Usually the disease occurs in mild form and is treated on an outpatient basis. In rare cases, VSD acquires a severe degree, in which the patient’s ability to work sharply decreases or is completely lost. Such patients are treated only inpatiently.

Symptoms:

• sudden attacks of chest pain of a squeezing or pressing nature;
• cardiopalmus;
• suffocation;
• feeling of panic;
• pressure surges;
• low temperature;
• nausea and vomiting;
• bowel irregularities for no obvious reason;
• severe dizziness;
• sleep disorders;
• increasing lethargy;
• frequent depression.

Choking, panic, depression and other symptoms

In addition, many patients complain of constant coldness in their feet and toes, increased sweating, and abdominal pain. During the examination, the majority physical indicators are within normal limits. Attacks can last from several minutes to several days, and the pain either increases or decreases. Typically, an attack is preceded by severe anxiety or sudden physical exertion.

If you feel an attack approaching, you need to take any sedative - validol, motherwort tincture, valerian, and find a quiet, calm place where you can lie down or at least sit comfortably.

Validol - tablets

Try to breathe evenly and deeply, disconnect from all problems and external irritating factors. Self-massage of the head for a few minutes helps relieve tension. When the intensity of the attack begins to subside, you need to go out into the fresh air and walk a little - this will improve your well-being, reduce pain and tension. At the first opportunity, you should be examined by a neurologist.

Pain due to gastrointestinal pathologies

Pain in diseases of the stomach, intestines, and certain types of hernias differ in nature from heart pain, although they are localized in the chest area. Taking heart medications in this case has no effect and may even worsen the situation. To relieve a pain attack, you need to know what exactly causes it.

Diaphragmatic hernia

This type of hernia is characterized by displacement of the peritoneal organs through the openings of the diaphragm into chest cavity. Most often this is part of the esophagus and the cardiac part of the stomach, but sometimes intestinal loops are displaced. The cause of the pathology is congenital or acquired defects of the diaphragm, tissue weakness, regular overeating, and hard work.

Symptoms:

• heartburn and frequent belching;
• moderate chest pain;
• fast saturation;
• vomit;
• rumbling and gurgling in the chest.

Heartburn, vomiting, chest pain - symptoms of diaphragmatic hernia

If the hernia is complicated by strangulation, the person feels sudden pain in the left side of the sternum and abdomen, severe vomiting appears, and stool disturbances may occur. This condition requires hospitalization and surgical intervention. At sliding hernia no surgery is needed, the patient is simply prescribed a special diet with fractional meals, means to reduce acidity and reduce the production of gastric juice. In addition, you need to avoid physical activity, wearing tight bandages or belts that compress the stomach and increase the pressure inside the abdominal cavity.

To alleviate the condition, you should eat in small portions, sleep in a half-sitting position with 2 or 3 pillows under your head, and avoid sudden bending of the body.

Take medications only those prescribed by the doctor.

Gastritis and peptic ulcers are diagnosed in people of almost all age groups. If detected early, these diseases can be successfully treated. One of common symptoms Both pathologies include pain in the chest, attacks of which are sometimes very painful. The pain is accompanied by other symptoms:

• dyspepsia;
• belching;
• severe heartburn;
• feeling of fullness and burning in the stomach;
• irritability;
• tachycardia.

In case of an acute attack, it is best to call a doctor; in other cases, you can relieve your health on your own. The most effective pain relievers are antacids, which are acid neutralizers. These include Gastal, Rennie, Maalox, Almagel, Megalac and others.

No-shpa

Antispasmodics, for example, No-shpa and Papaverine (no more than 2 tablets), also help reduce pain. If there are no medications at hand and the pain is severe enough, you can use folk remedies. For ulcers, a glass of warm milk or a small amount of semolina porridge, a decoction of elecampane, an infusion of chamomile, celandine and yarrow quickly helps.

For gastritis, raw potato juice is very effective: 2 tubers are thoroughly washed, chopped in a meat grinder and the juice is squeezed out. Drink it on an empty stomach, an hour before meals, the course of treatment is 1 month.

After the first treatments, the intensity of pain decreases. If the attack is severe, you need to clear your stomach: to do this, drink 2-3 glasses warm water and cause vomiting. Next, rest is recommended, therapeutic fasting for 2 days, drink plenty of fluids.

Osteochondrosis

Chest pain is also among the symptoms. Damage to the discs between the vertebrae and pinched nerve roots in the thoracic area of ​​the spine cause pain similar to heart pain. This often leads to misdiagnosis and complicates treatment.

Osteochondrosis can be distinguished from other diseases by certain specific signs , among which:

• numbness and strain in the back muscles;
• increased pain when bending and turning the body, raising arms, hypothermia, as well as at night;
• pain appears when taking a deep breath;
• a feeling of tingling and “goosebumps” in certain parts of the body;
• tightness in the chest;
• pain between the ribs when walking;
• feeling of cold or burning in the legs.

Taking nitroglycerin or other heart medications has no effect, which is also evidence of the neuralgic origin of the pain. Changing the position of the body helps to alleviate the condition - the pain does not disappear completely, but its intensity decreases. Used for treatment medicines, acupuncture, traction, massotherapy and special gymnastics.

To cure osteochondrosis, you need to be patient. Proper nutrition means a lot, with an emphasis on foods containing magnesium, calcium and vitamins.

These are seafood, nuts, legumes, spinach and cabbage, fresh milk, bran bread. This diet will also help you lose excess weight, which puts additional stress on the vertebrae. Regular moderate exercise is no less important: daily exercise strengthens the back and reduces the risk of complications for the spine.

Video - Pain behind the sternum in the middle: what to do

The human body is very complex. The same symptoms described by two different people may indicate the development of the most various diseases. Feelings that interfere with breathing may indicate diseases of various organs and systems.

Heaviness in the chest always needs to be differentiated. This symptom has many shades that help determine the cause of the pain.

Causes

Chest heaviness is a difficult syndrome to diagnose and can cause difficulties even for an experienced doctor. If the patient has pressure in the chest, it is necessary to clarify several points:

• The place of pain is in the middle of the chest, in the left or.
• The nature of the sensations is squeezing, burning, sharp, stabbing, cutting pain.
• Shortness of breath or other forms of difficulty breathing.
• A lump in the throat that makes it difficult to breathe or swallow.
• Association of symptoms with physical or emotional stress.
• Irradiation of pain – where does it go?
• Which helps relieve discomfort.
• Duration of symptoms.

All these points will help determine the cause of pressing pain in the chest.

Heaviness in the chest can be caused by the following diseases:

1. Pathology of the osteoarticular system: spine, osteochondrosis, congenital anomalies.
2. Cardiovascular diseases: angina pectoris, myocardial infarction, aortic aneurysm.
3. Diseases digestive system: GERD, esophagitis.
4. Respiratory diseases: pleurisy, pneumonia, lung abscess.

Laboratory and instrumental methods help to understand the causes of pain, but preliminary diagnosis help to establish the features of the clinical picture of the disease.

Osteoarticular pathology

Heaviness in the chest may be associated with. The most common cause of this symptom from the musculoskeletal system is kyphoscoliotic deformity of the chest.

With this disease, severe curvature of the spine leads to the development of deformation of the chest with compression of the lungs and mediastinal organs. The characteristic features of the pathology are following symptoms:

• Compression of the chest increases gradually with the development of spinal deformity.
• Acute pain is not typical.
• The sensation occurs when you inhale forcefully or bend your torso.
• Emotional stress does not affect pain.
• There is usually no lump in the throat.
• Patients find it difficult to breathe only when there is severe compression of the lungs.
• Depending on the type of curvature, pain can be localized in different parts of the chest.

Such sensations may be associated with structural features of bone tissue, abnormalities of the sternum and ribs. In this case, although the changes are congenital, they may begin to bother the patient in adulthood.

X-rays of the spine and chest can confirm or refute the diagnosis of bone disease.

Osteochondrosis

The feeling of something squeezing or squeezing can accompany an extremely common pathology - spinal osteochondrosis. This disease is associated with degeneration of intervertebral cartilage, which leads to the appearance neurological symptoms due to compression of the spinal roots.

When the process is localized in the thoracic part of the spine, osteochondrosis leads to the so-called. This symptom complex has a number of characteristic features:

• The pain is most often located in the left or right half of the chest, less often in the middle.
• The patient has difficulty breathing due to pain at the height of inspiration.
• Possible lump in the chest.
• Symptoms are triggered by physical activity.
• Most often the pain is stabbing or aching, but can be squeezing.
• It resolves on its own with rest; nitroglycerin does not have a positive effect.

After taking anti-inflammatory drugs, the symptoms usually go away, as their causes are eliminated - swelling and compression of the nerve roots of the intercostal nerves.

Angina and heart attack

Any person needs to be alert when a lump or pain appears in the chest precisely because of the possible cardiac causes of this symptom. Coronary heart disease, which combines angina pectoris and myocardial infarction, can cause the patient's death.

The pain with this disease is quite typical and has the following characteristics:

• Initially occurs in the middle of the sternum.
• It has a squeezing, squeezing, burning character.
• Spreads over the left side of the body.
• The causes of pain are physical and emotional stress.
• Analogues of typical angina are a lump in the throat or difficulty breathing.
• Symptoms go away after 10–15 minutes and are relieved with nitroglycerin.
• Longer pain with the described characteristics corresponds to myocardial infarction and requires emergency care.

Such symptoms should bring the patient to the doctor as soon as possible, since treatment of coronary heart disease helps prevent the development of cardiovascular accidents and sudden death.

Pain in the chest in the middle, spreading to the left side of the body, a lump in the throat, the connection of symptoms with stress - reasons to take your health seriously.

Aortic aneurysm

Another cardiac cause of chest pain is dissecting aortic aneurysm. This condition is a severe pathology that leads to the appearance of a defect in the inner layer of the aorta, the largest human vessel.

Blood penetrates into the defect in the inner lining and splits the vessel wall into two halves. False and true lumens of the vessel appear, this disrupts blood circulation and leads to compression of the branches of the aorta.

The condition is accompanied by pain with the following characteristics:

• Intense, burning in nature, in the middle of the sternum.
• It spreads along the course of the vessel dissection.
• If localized in the descending aorta, the pain may be in the left side of the chest.
• A lump in the chest is not typical for the disease, the sensations are sharp and vivid.
• Physical activity, intoxication, and hypertensive crisis may precede the onset of symptoms.
• Possible neurological disorders and loss of consciousness.

Dissecting aortic aneurysm can cause cardiac tamponade, collapse, shock, and sudden death. To prevent this from happening, it is necessary to begin therapeutic measures as early as possible.

MRI allows you to confirm the diagnosis, which in some cases requires surgical intervention on the vessel.

Esophagitis

Another cause of chest pain in some cases is diseases of the digestive system.

Gastroesophageal reflux disease (GERD) is a condition in which acidic stomach contents back up into the esophagus. There is a burning sensation in the chest and others characteristic symptoms:

• Belching sour.
• Bad breath.
• Nausea and vomiting.
• Attacks are triggered by eating.
• They are observed in smokers, as well as people who frequently drink coffee and alcohol. These factors reduce the tone of the lower esophageal sphincter.
• A feeling of difficulty breathing is not typical for the disease.

Acidic stomach contents reflux into the esophagus can lead to esophagitis - inflammation of the organ mucosa. However, GERD is not the only cause of esophagitis; the disease can be caused by chemical and thermal burns of the organ, and alcoholism.

Damage to the esophageal mucosa can lead to complications and therefore requires timely treatment. FGDS, intragastric pH-metry and other instrumental research methods help confirm the diagnosis.

Lung diseases

The cause of chest pain can be a variety of pathological conditions of the respiratory system. Diseases of the trachea and bronchi are usually accompanied by severe cough and other symptoms of acute respiratory disease, their diagnosis is not difficult.

If the main clinical manifestation is chest pain, then the following diseases can be suspected:

1. Pneumonia - in some cases, pneumonia is not accompanied by a severe cough and sputum discharge. With pneumonia, fever is typical. Chest pain can be in different parts, but localization in the middle is not typical.
2. Lung abscess is a limited purulent inflammatory process in the lung, most often accompanied exclusively by pain. Painful sensations arise in the part of the chest in the projection of which the abscess is located. An abscess is characterized by high body temperature.
3. Pleurisy is an inflammatory process in the area of ​​the pleura - the lining of the lungs. Symptoms are related to breathing and worsen at the height of inspiration. There is often difficulty and heaviness in breathing. The pain may shift to the middle of the chest with significant accumulation of exudate and compression of the mediastinum.

From the above we can conclude that chest pain is an extremely nonspecific symptom. To make a correct diagnosis and avoid complications, you need to consult a doctor in time, who will prescribe the correct diagnostic tests.

Substernal pain it is a common complaint in the emergency department; its diagnosis presents certain difficulties for a number of reasons:

when complaining of chest pain or pain in the upper abdominal cavity, there is always the possibility of heart disease;

pain associated with visceral organs can always radiate to various places in the chest or abdominal wall;

accurate diagnosis requires interpretation of the patient's subjective perception of pain;

the diagnosis is based primarily on anamnestic data, the collection of which depends, of course, on the experience and erudition of the doctor;

assessment of physical signs and data from additional tests are not often helpful in the emergency department.

For rate acute chest pain special schemes and algorithms were developed. However, their widespread distribution in clinical practice limited nearby factors:

studies are aimed at identifying patients with acute myocardial infarction and, as a rule, ignore other diagnoses, many of which are potentially fatal and require urgent hospitalization of the patient;

Based on statistical data, these algorithms are based on the probability of diagnosis, but the probability of a particular diagnosis is difficult to apply to a specific patient;

even if the likelihood of a serious complication (such as acute heart attack myocardium) is low, local diagnostic standards and potential liability often force hospitalization of the patient;

Absolute sensitivity of the system is impossible with any diagnostic scheme. Modern research helps to clarify the role of physical diagnostic methods in the assessment of chest pain.

At acute chest pain The emergency department physician must first think about its potentially life-threatening reasons:

unstable angina,

acute myocardial infarction,

aortic dissection,

pulmonary embolism,

spontaneous pneumothorax

esophageal rupture.

If serious or potentially life-threatening causes of chest pain are excluded, the patient can be released for follow-up outpatient observation (if necessary).

Onset and duration of pain

Typical angina pectoris (angina) is episodic, lasts 5-15 minutes, occurs during physical activity and goes away after 3-5 minutes at rest or with sublingual nitroglycerin. Unstable angina It can also occur at rest, lasts longer and does not disappear so easily. Variant angina(Prinzmetal's angina) occurs without provocation, often at rest or at night, but usually resolves with nitroglycerin. Patients with variant angina usually tolerate moderate physical activity without any particular difficulty.

Pain during acute myocardial infarction, as a rule, lasts more than 15-30 minutes. Pain when myocardial ischemia in typical cases, it has an increasing character until maximum intensity is reached, while pain from aortic dissection or pulmonary embolism is usually severe at the very beginning.

Pain of esophageal origin is described by the patient as either heartburn, or as pain when swallowing (odynophagia) and/or pain resembling spasm. Heartburn is a burning sensation in the sternum, often with an epigastric component. It usually occurs 15-60 minutes after eating, more often after a heavy meal. It can be triggered by certain body positions, such as bending or lying on your back or left side. Odynophagy This is a sensation of pain in the esophagus during the passage of a bolus.

The pain may be described by the patient as burning. It occurs when a bolus of food comes into contact with an inflamed mucous membrane, or is noted as very strong, but short-term pain when the bolus passes through a narrowing of the esophagus. Esophageal spasm is perceived by the patient as a dull pain in the center of the chest, which lasts from several seconds to several minutes. However, it is often almost impossible to distinguish between esophageal and cardiac pain.

Almost one third of patients with acute myocardial infarction or unstable angina has heartburn as the main complaint. Chest wall pain may last only a few seconds or continue for hours. The key points in differentiating such pain are their connection with a certain body position and local pain on palpation chest wall.

Characteristics of chest pain

Sharp, piercing and cutting pain in the chest usually has musculoskeletal origin. In one large study, 74% of patients with documented PE had pleuritic nature of chest pain, and in another 14% of patients it is non-pleuritic. IN differential diagnosis etiology of visceral retrosternal pain, the quality of pain turns out to be insufficiently informative: in patients with acute myocardial infarction the pain can be burning, and in patients with esophageal reflux it is usually pressing.

At angina pain There is almost always a retrosternal component, as with many other causative factors of deep visceral pain. With angina, pain often radiates to the neck, shoulders and down the inside left hand or both hands. In patients with aortic dissection, pain usually radiates to the back and top part abdomen as the dissection progresses. In patients with esophageal reflux the pain always has both retrosternal and epigastric components and radiates infrequently; in approximately 20% of cases in the back, much less often in the upper extremities (with severe exacerbations).

The main causes of chest pain

There are several groups of patients admitted to intensive care with chest pain, so knowledge of the most common diagnoses in similar cases can be quite useful. Substernal pain in childhood and adolescence, they rarely have a cardiac origin and are most often associated with pathology of the chest wall, respiratory tract, with feelings of fear and anxiety, or with any idiopathic reasons. Patients with numerous unexplained symptoms often complain of pain in the region of the heart, but they can usually be recognized by the unusual abundance of these “symptoms” without any convincing data, negative examination results, or medical history with numerous visits to doctors.

Elderly patients who develop acute myocardial infarction, more often come either with non-retrosternal chest pain, or without pain (compared to persons more young). In addition, older adults with confirmed acute myocardial infarction are more likely to have nonspecific symptoms, such as:

• weakness;

  confusion;

In typical cases angina pectoris is paroxysmal in nature, lasts 5-15 minutes (rarely more than 20 minutes), is caused by reproduced by physical activity and resolves with rest or with sublingual nitroglycerin, usually within 3 minutes. In more than 90% of patients, pain is localized retrosternally. In almost 70%, the pain usually radiates to the neck, shoulders or upper limbs. For each patient, the nature of repeated attacks changes very slightly. In a lying position, patients usually do not feel better, although they lie down to rest at the beginning of an attack: most often it is better for them to sit quietly. Only 50% of patients with spontaneous angina ECG changes are noted during an acute and painful attack.

Variant angina occurs without provocation, often during rest or during normal daily activities. During an acute attack, the ECG increases the ST segment, which indicates transmural myocardial ischemia. Variant angina is believed to be caused by spasm of the epicardial coronary arteries either in normal vessels (about 1/3 of such patients), or in vessels affected by atherosclerosis (about 2/3 of patients). Seizures may become more complicated tachyarrhythmias, bundle branch block or block in the AV node. Variant angina usually resolves with sublingual administration nitroglycerin.

Unstable angina

Unstable angina is a syndrome that occupies an intermediate position between ordinary angina And acute myocardial infarction. If left untreated, it often leads to early heart attack and death. Modern methods treatments significantly reduce this risk, so timely recognition of the disease and hospitalization of the patient are very important. Depending on the course of the disease, there are three subgroups:

angina pectoris with recent onset - 4-8 weeks;

angina with a variable pattern, becoming more frequent, severe, or resistant to nitroglycerin;

resting angina.

The last two subgroups are associated with more high risk early myocardial infarction and death. In unstable angina, the ECG may show nonspecific changes in the ST segment; increases in serum levels of CK and CK-MB are also minimal and have no diagnostic significance.

Acute myocardial infarction

Anginal pain, lasting more than 15 minutes, not relieved by nitroglycerin or accompanied by profuse sweat, shortness of breath, nausea or vomiting, suggests acute myocardial infarction. Long-term population-based studies indicate that approximately 20% of acute myocardial infarctions are clinically unrecognized. It is assumed (although there is no consensus on this issue) that patients diabetes mellitus more prone to silent myocardial infarction.

Due to the possible missed diagnosis of myocardial infarction, most doctors are quite conservative and hospitalize patients who have any episode suggesting myocardial ischemia; This is why the sensitivity of clinical tests for acute myocardial infarction reaches 87-98%, but at the same time this means that their specificity is low, and therefore the diagnosis of acute myocardial infarction is confirmed in less than 1/3 of such patients. However, the significance of hospitalization of such patients cannot be assessed only by these data, since they do not include patients with unstable angina, in whom the development of acute myocardial infarction is prevented by hospitalization and aggressive treatment.

Aortic dissection

The incidence of aortic dissection is approximately 1000 times lower than the incidence of myocardial infarction, so, unfortunately, the initial diagnosis of this disease in patients with chest pain rarely considered. Approximately 80% of patients are hypertensive between the ages of 50 and 70 years. The most common symptom of aortic dissection is the sudden onset of tearing pain in the chest or interscapular area. About 30% of patients have focal or generalized neurological signs.

The incidence of other symptoms and signs varies depending on the location of the dissection: in the ascending and/or descending aorta. Treatment in acute period requires careful blood pressure control to prevent further delamination and rupture. After relative normalization of pressure, angiography is recommended to clarify the diagnosis and plan possible surgical intervention.

Pericarditis

Pain when pericarditis are often sharp, persistent and severe, localized behind the sternum and radiating to the back, neck or lower jaw. The pain may increase with each contraction of the heart, movement of the chest or breathing and is relieved by sitting and bending forward. If there is a connection with damage to the pleura (pleuropericarditis), then the pain may be predominantly pleuritic.

The diagnosis of pericarditis is confirmed by the presence of a pericardial friction rub, which can have from one to three components:

presystolic;

systolic;

early diastolic.

However, a pericardial friction rub is heard only periodically. The ECG shows an increase in the ST segment or T wave inversion, depending on the stage of the disease; these changes are best determined on serial ECGs. In the cavity pericardium there is often a small amount of free fluid present, but this may only be apparent when echocardiography.

Other causes of chest pain

Anginal pain may be caused by hypertrophic cardiomyopathy(idiopathic hypertrophic subaortic stenosis) and stenosis aortic valve, which is presumably due to insufficient blood supply hypertrophied myocardium. Substernal pain can sometimes occur with mitral valve prolapse or mitral stenosis. Nitroglycerin, as a rule, does not help.

At pulmonary embolism the most common symptoms are pleuritic pain in the chest, as well as:

• tachypnea;

  tachycardia.

In some patients, the pain is not pleuritic in nature; a musculoskeletal component is often present. Most patients with documented PE experience the following:

factors (in history) predisposing to venous thrombosis (immobilization, cancer, obesity, pregnancy, taking contraceptives);

history of congestive heart failure, venous thrombosis, or pulmonary embolism;

physical signs of deep vein thrombosis.

Between acute viral-idiopathic pleurisy and acute pulmonary embolism there is significant difference; the former disease is usually self-limiting and benign, whereas the latter can be recurrent and fatal. While most patients with PE experience some X-ray abnormalities, patients with pleurisy have normal chest radiographs, and only 10-15% of them have pleural effusion.

Mediastinitis usually occurs after spontaneous or traumatic rupture (perforation) of the esophagus and is characterized by retrosternal pain, fever and leukocytosis peripheral blood. At x-ray examination The chest may exhibit widening of the mediastinum or emphysema due to infection with gas-forming microorganisms. Mediastinal emphysema can also result from rupture of the pulmonary alveoli or bronchioles, which is most often seen in acute attacks bronchial asthma . Severe chest pain and mediastinal crackling on auscultation suggest diagnosis of mediastinitis.

Substernal pain can be caused by the most various diseases lungs or pleura. At spontaneous pneumothorax There is usually a sudden onset of acute pleuritic chest pain and shortness of breath, but a small pneumothorax may be accompanied by very few symptoms and signs. Spontaneous pneumomediastinum usually causes severe precordial pain, dyspnea, dysphagia, neck pain, and subcutaneous crepitus.

Mediastinal crackling during auscultation (Hammen's sign) is detected in approximately 50% of cases. Although both spontaneous pneumothorax and pneumomediastinum are often benign and self-limiting. A more liberal approach to obtaining is needed chest x-ray to detect these diseases in small air accumulations. Pneumonia or respiratory infection usually presents with a productive cough, fever, shortness of breath, and pleuritic or persistent chest pain. With a sharp exacerbation of obstructive pulmonary disease, the appearance of chest pain is also possible, usually covered by a symptom shortness of breath. If such pain is present, especially in the elderly, an ECG and radiography are performed to exclude myocardial ischemia or pneumothorax.

Pathology of the esophagus

Acute chest pain may be caused by various esophageal disorders (observed in combination or in isolation):

gastroesophageal reflux;

hiatal hernia;

achalasia;

diffuse spasm of the esophagus;

hypertension in the lower esophageal sphincter;

nonspecific movement disorders of the esophagus.

At pain identification of esophageal origin, the following should be noted:

frequent heartburn;

symptoms of acid regurgitation (regurgitation);

odynophagia;

sensation of a food bolus;

quick satiety after starting a meal;

pain that occurs a few minutes after stopping physical activity;

pain that persists for hours as a background;

absence of lateral irradiation of pain.

If you have chest pain, you should seek help from a cardiologist, therapist, or neurologist. A study of the body will determine the exact cause of pain. Recovery may take from six months to a year.

The main causes of chest pain:

• diseases of the musculoskeletal system: costochondritis, rib fracture;
• cardiovascular diseases: cardiac ischemia caused by atherosclerosis of the heart vessels; unstable/stable angina; cardiac ischemia caused by coronary vasospasm (angina pectoris); mitral valve prolapse syndrome; cardiac arrhythmia; pericarditis.
• gastrointestinal diseases: gastroesophageal reflux, esophageal spasm, stomach and duodenal ulcers, gallbladder diseases;
• anxiety states: vague anxiety or “stress”, panic disorders;
• pulmonary diseases: pleurodynia (pleuralgia), acute bronchitis, pneumonia;
• neurological diseases;
• uncharacteristic definite or atypical chest pain.

Chest pain is not limited to a certain age group, but is more common in adults than in children. The highest percentage is observed among adults over 65 years of age, followed by male patients aged 45 to 65 years.

Frequency of diagnoses, by age and gender

No less difficult is the position of the doctor during the initial interpretation of pain, when he tries to connect it with the pathology of a particular organ. The observation of clinicians of the last century helped them formulate assumptions about the pathogenesis of pain - if an attack of pain occurs without a reason and stops on its own, then the pain is probably functional in nature. Works devoted to a detailed analysis of chest pain are few; the pain groups proposed in them are far from perfect. These shortcomings are due to the objective difficulties of analyzing the patient’s feelings.

The difficulty of interpreting pain in the chest is also due to the fact that the detected pathology of a particular organ of the chest or musculoskeletal formation does not mean that it is the source of pain; in other words, identifying a disease does not mean that the cause of pain is precisely determined.

When assessing patients with chest pain, the clinician must weigh all relevant options. potential causes pain, determine when intervention is needed, and choose from a virtually limitless range of diagnostic and therapeutic strategies. All of this must be done while simultaneously responding to the distress experienced by patients concerned about having a life-threatening illness. The difficulty in diagnosis is further complicated by the fact that chest pain often represents a complex interaction of psychological, pathological and psychosocial factors. This makes it the most common problem in primary care.

When considering substernal pain, the following five elements must be considered (at a minimum): predisposing factors; characteristics of the attack of pain; duration of pain episodes; characteristics of the pain itself; factors that relieve pain.

With all the variety of causes that cause pain in the chest, pain syndromes can be grouped.

Approaches to groupings may be different, but basically they are built on a nosological or organ principle.

Conventionally, the following 6 groups of causes of chest pain can be distinguished:

1. Pain caused by heart disease (so-called heart pain). These pain sensations can be the result of damage or dysfunction of the coronary arteries - coronary pain. The “coronary component” does not take part in the origin of non-coronary pain. In the future, we will use the terms “cardiac pain syndrome”, “heart pain”, understanding their connection with one or another heart pathology.
2. Pain caused by pathology of large vessels (aorta, pulmonary artery and its branches).
3. Pain caused by pathology of the bronchopulmonary apparatus and pleura.
4. Pain associated with pathology of the spine, anterior chest wall and muscles shoulder girdle.
5. Pain caused by pathology of the mediastinal organs.
6. Pain associated with diseases of the abdominal organs and pathology of the diaphragm.

Pain in the chest area is also divided into acute and long-term, with an obvious cause and without an obvious cause, “non-dangerous” and pain that is a manifestation of life-threatening conditions. Naturally, first of all it is necessary to establish whether the pain is dangerous or not. “Dangerous” pain includes all types of anginal (coronary) pain, pain due to pulmonary embolism (PE), dissecting aortic aneurysm, and spontaneous pneumothorax. Classified as “non-dangerous” - pain due to pathology of the intercostal muscles, nerves, and osteochondral formations of the chest. “Dangerous” pain is accompanied by a suddenly developed serious condition or severe disorders of cardiac or respiratory function, which immediately allows you to narrow down the circle possible diseases(acute myocardial infarction, pulmonary embolism, dissecting aortic aneurysm, spontaneous pneumothorax).

The main causes of acute chest pain that are life-threatening:

• cardiological: acute or unstable angina, myocardial infarction, dissecting aortic aneurysm;
• pulmonary: pulmonary embolism; tension pneumothorax.

It should be noted that the correct interpretation of chest pain is quite possible with a routine physical examination of the patient using a minimum number of instrumental methods (conventional electrocardiographic and x-ray examination). An erroneous initial understanding of the source of pain, in addition to increasing the period of examination of the patient, often leads to serious consequences.

History and physical examination to determine the cause of chest pain

Cardialgia (non-anginal pain). Cardialgia caused by certain heart diseases are very common. In terms of its origin, significance and place in the structure of population morbidity, this group of pains is extremely heterogeneous. The causes of such pain and their pathogenesis are very diverse. Diseases or conditions in which cardialgia is observed are the following:

1. Primary or secondary cardiovascular functional disorders - the so-called neurotic-type cardiovascular syndrome or neurocirculatory dystonia.
2. Pericardial diseases.
3. Inflammatory diseases of the myocardium.
4. Dystrophy of the heart muscle (anemia, progressive muscular dystrophy, alcoholism, vitamin deficiency or starvation, hyperthyroidism, hypothyroidism, catecholamine effects).

As a rule, nonanginal pain is benign, since it is not accompanied by coronary insufficiency and does not lead to the development of myocardial ischemia or necrosis. However, in patients with functional disorders, leading to an increase (usually short-term) in the level of biologically active substances (catecholamines), the likelihood of developing ischemia still exists.

Chest pain of neurotic origin. We are talking about pain in the heart area, as one of the manifestations of neurosis or neurocirculatory dystonia (vegetative-vascular dystonia). Usually these are pains of an aching or stabbing nature, of varying intensity, sometimes long-lasting (hours, days) or, conversely, very short-term, instantaneous, piercing. The localization of these pains is very different, not always constant, and almost never substernal. The pain can intensify with physical activity, but usually with psycho-emotional stress, fatigue, without a clear effect of using nitroglycerin, it does not decrease at rest, and, sometimes, on the contrary, patients feel better when moving. The diagnosis takes into account the presence of signs of a neurotic state, autonomic dysfunction (sweating, dermographism, low-grade fever, fluctuations in pulse and blood pressure), as well as young or average age patients, predominantly female. These patients experience increased fatigue, decreased tolerance to physical activity, anxiety, depression, phobias, fluctuations in pulse and blood pressure. In contrast to the severity of subjective disorders, objective research, including using various additional methods, does not reveal a specific pathology.

Sometimes among these symptoms of neurotic origin the so-called hyperventilation syndrome. This syndrome is manifested by voluntary or involuntary increase and deepening of respiratory movements, tachycardia, arising in connection with adverse psycho-emotional influences. In this case, chest pain may occur, as well as paresthesia and muscle twitching in the limbs due to respiratory alkalosis. There are observations (not fully confirmed) indicating that hyperventilation can lead to a decrease in myocardial oxygen consumption and provoke coronary spasm with pain and ECG changes. It is possible that hyperventilation may be the cause of pain in the heart area during exercise testing in persons with vegetative-vascular dystonia.

To diagnose this syndrome, a provocative test with induced hyperventilation is performed. The patient is asked to breathe more deeply - 30-40 times per minute for 3-5 minutes or until the patient's usual symptoms appear (chest pain, headaches, dizziness, shortness of breath, sometimes fainting). The appearance of these symptoms during the test or 3-8 minutes after its completion, with the exclusion of other causes of pain, has a definite diagnostic value.

Hyperventilation in some patients may be accompanied by aerophagia with the appearance of pain or a feeling of heaviness in the upper part of the epigastric region due to stretching of the stomach. These pains can spread upward, behind the sternum, into the neck and area of ​​the left shoulder blade, simulating angina pectoris. Such pain intensifies with pressure on the epigastric region, while lying on the stomach, with deep breathing, and decreases with belching of air. With percussion, an expansion of the zone of Traube's space is found, including tympanitis over the area of ​​absolute dullness of the heart; with fluoroscopy, an enlarged gastric bladder is found. Similar pain can occur when the left corner of the colon is distended by gases. In this case, the pain is often associated with constipation and is relieved after defecation. A careful history usually allows one to determine the true nature of the pain.

The pathogenesis of cardiac pain in neurocirculatory dystonia is unclear, which is due to the impossibility of their experimental reproduction and confirmation in the clinic and experiment, in contrast to anginal pain. Perhaps due to this circumstance, a number of researchers generally question the presence of pain in the heart in neurocirculatory dystonia. Similar trends are most common among representatives of the psychosomatic direction in medicine. According to their views, we are talking about the transformation of psycho-emotional disorders into pain.

Origin of heart pain neurotic states finds an explanation from the standpoint of the corticovisceral theory, according to which, when the autonomic devices of the heart are irritated, a pathological dominant arises in the central nervous system with the formation of a vicious circle. There is reason to believe that pain in the heart with neurocirculatory dystonia occurs due to impaired myocardial metabolism against the background of excessive adrenal stimulation. In this case, a decrease in the content of intracellular potassium, activation of dehydrogenation processes, an increase in the level of lactic acid and an increase in myocardial oxygen demand are observed. Hyperlactatemia is a well-proven fact in neurocirculatory dystonia.

Clinical observations indicating a close connection between pain in the heart and emotional influences confirm the role of catecholamines as a trigger for pain. This position is supported by the fact that when isadrin is administered intravenously to patients with neurocirculatory dystonia, they experience pain in the heart area such as cardialgia. Obviously, catecholamine stimulation can also explain the provocation of cardialgia by a test with hyperventilation, as well as its occurrence at the height of respiratory disorders in neurocirculatory dystonia. This mechanism can also be confirmed by the positive results of treatment of cardialgia. breathing exercises aimed at eliminating hyperventilation. A certain role in the formation and maintenance of painful cardiac syndrome in neurocirculatory dystonia is played by the flow of pathological impulses coming from zones of hyperalgesia in the muscles of the anterior chest wall to the corresponding segments spinal cord, where, according to the “gate” theory, the phenomenon of summation occurs. In this case, a reverse flow of impulses is noted, causing irritation of the thoracic sympathetic ganglia. Of course, a low threshold also matters pain sensitivity with vegetative-vascular dystonia.

Factors that have not yet been sufficiently studied, such as impaired microcirculation, changes in the rheological properties of blood, and increased activity of the kininkallikrein system, may play a role in the occurrence of pain. It is possible that with the long-term existence of severe vegetative-vascular dystonia, its transition to ischemic heart disease with unchanged coronary arteries is possible, in which pain is caused by spasm of the coronary arteries. In a targeted study of a group of patients with proven coronary artery disease with unchanged coronary arteries, it was found that all of them had suffered from severe neurocirculatory dystonia in the past.

In addition to vegetative-vascular dystonia, cardialgia is also observed in other diseases, but the pain is less pronounced and usually never comes to the fore in the clinical picture of the disease.

The origin of pain when the pericardium is damaged is quite clear, since the pericardium contains sensitive nerve endings. Moreover, it has been shown that irritation of certain areas of the pericardium gives different localization pain. For example, irritation of the pericardium on the right causes pain along the right midclavicular line, and irritation of the pericardium in the left ventricle is accompanied by pain spreading along the inner surface of the left shoulder.

Pain in myocarditis of various origins is a very common symptom. Their intensity is usually low, but in 20% of cases they have to be differentiated from pain caused by ischemic heart disease. Pain in myocarditis is probably associated with irritation nerve endings located in the epicardium, as well as with inflammatory edema of the myocardium (in the acute phase of the disease).

The origin of pain in myocardial dystrophies of various origins is even more uncertain. Probably, the pain syndrome is caused by a violation of myocardial metabolism, the concept of local tissue hormones, convincingly presented by N.R. Paleev et al. (1982), may shed light on the causes of pain. In some myocardial dystrophies (due to anemia or chronic poisoning carbon monoxide), pain can be of mixed origin, in particular the ischemic (coronary) component is significant.

It is necessary to focus on the analysis of the causes of pain in patients with myocardial hypertrophy (due to pulmonary or systemic hypertension, valvular heart disease), as well as in primary cardiomyopathies (hypertrophic and dilated). Formally, these diseases are mentioned in the second heading of anginal pain, caused by an increase in myocardial oxygen demand with unchanged coronary arteries (the so-called non-coronarogenic forms). However, in these pathological conditions, in some cases, unfavorable hemodynamic factors arise, causing relative myocardial ischemia. It is believed that angina-type pain observed with aortic insufficiency depends primarily on low diastolic pressure, and therefore low coronary perfusion (coronary blood flow occurs during diastole).

In aortic stenosis or idiopathic myocardial hypertrophy, the appearance of pain is associated with impaired coronary circulation in the subendocardial sections due to a significant increase in intramyocardial pressure. All pain in these diseases can be designated as metabolically or hemodynamically caused anginal pain. Despite the fact that they do not formally relate to ischemic heart disease, one should keep in mind the possibility of the development of small focal necrosis. At the same time, the characteristics of these pains often do not correspond to classical angina, although typical attacks are also possible. In the latter case, the differential diagnosis with ischemic heart disease is especially difficult.

In all cases of detection of non-coronary causes of chest pain, it is taken into account that their presence does not at all contradict the simultaneous existence of coronary artery disease and, accordingly, requires an examination of the patient in order to exclude or confirm it.

Chest pain caused by pathology of the bronchopulmonary apparatus and pleura. Pain quite often accompanies a variety of pulmonary pathologies, occurring in both acute and chronic diseases. However, it is usually not a leading clinical syndrome and is quite easily differentiated.

The source of pain is the parietal pleura. From pain receptors located in the parietal pleura, afferent fibers go as part of the intercostal nerves, so pain is clearly localized on the affected half of the chest. Another source of pain is the mucous membrane of the large bronchi (which is well proven by bronchoscopy) - afferent fibers from the large bronchi and trachea are part of vagus nerve. The mucous membrane of the small bronchi and pulmonary parenchyma probably does not contain pain receptors, so pain in the case of primary damage to these formations appears only when the pathological process (pneumonia or tumor) reaches parietal pleura or spreads to large bronchi. Most severe pain noted during destruction lung tissue, sometimes acquiring high intensity.

The nature of the pain depends to some extent on its origin. Pain in the parietal pleura is usually stabbing and clearly associated with coughing and deep breathing. Dull pain is associated with stretching of the mediastinal pleura. Strong constant pain, which intensifies with breathing, movement of the arms and shoulder girdle, may indicate tumor growth into the chest.

The most common causes of pulmonary-pleural pain are pneumonia, lung abscess, tumors of the bronchi and pleura, and pleurisy. For pain associated with pneumonia, dry or exudative pleurisy, auscultation may reveal wheezing in the lungs and pleural friction noise.

Severe pneumonia in adults has the following clinical signs:

• moderate or severe respiratory depression;
• temperature 39.5 °C or higher;
• confusion;
• respiratory rate - 30 per minute or more often;
• pulse 120 beats per minute or faster;
• systolic arterial pressure below 90 mm Hg. Art.;
• diastolic blood pressure below 60 mm Hg. Art.;
• cyanosis;
• over 60 years old - features: confluent pneumonia, more severe with accompanying serious illnesses(diabetes, heart failure, epilepsy).

NB! All patients with signs of severe pneumonia should be immediately referred to hospital treatment! Referral to hospital:

• severe form of pneumonia;
• patients with pneumonia from socioeconomically disadvantaged backgrounds or who are unlikely to follow doctor's orders at home; who live very far from a medical facility;
• pneumonia in combination with other diseases;
• suspicion of atypical pneumonia;
• patients who do not have positive reaction for treatment.

Pneumonia in children is described as follows:

• retraction of the intercostal spaces of the chest, cyanosis and inability to drink in young children (from 2 months to 5 years) is also a sign of a severe form of pneumonia, which requires urgent referral to a hospital;
• Pneumonia should be distinguished from bronchitis: the most valuable sign in the case of pneumonia is tachypnea.

Pain sensations with damage to the pleura are almost no different from those with acute intercostal myositis or injury to the intercostal muscles. With spontaneous pneumothorax, acute unbearable pain behind the sternum is observed, associated with damage to the bronchopulmonary apparatus.

Pain behind the sternum, difficult to interpret due to its uncertainty and isolation, is observed in the initial stages of bronchogenic lung cancer. The most excruciating pain is characteristic of the apical localization of lung cancer, when damage to the common trunk of the CVII and ThI nerves and the brachial plexus almost inevitably and quickly develops. The pain is localized mainly in the brachial plexus and radiates along the outer surface of the arm. Horner's syndrome (constriction of the pupil, ptosis, enophthalmos) often develops on the affected side.

Pain syndromes also occur with mediastinal localization of cancer, when compression of nerve trunks and plexuses causes acute neuralgic pain in the shoulder girdle, upper limb, chest. This pain gives rise to the erroneous diagnosis of angina pectoris, myocardial infarction, neuralgia, and plexitis.

The need for differential diagnosis of pain caused by damage to the pleura and bronchopulmonary apparatus with ischemic heart disease arises in cases where the picture of the underlying disease is unclear and pain comes to the fore. In addition, such differentiation (especially in acute unbearable pain) should also be carried out with diseases caused by pathological processes in large vessels - pulmonary embolism, dissecting aneurysm of various parts of the aorta. The difficulties in identifying pneumothorax as the cause of acute pain are due to the fact that in many cases clinical picture this acute situation is erased.

Chest pain associated with pathology of the mediastinal organs is caused by diseases of the esophagus (spasm, reflux esophagitis, diverticula), mediastinal tumors and mediastinitis.

Pain in diseases of the esophagus is usually of a burning nature, localized behind the fudina, occurs after eating, and intensifies in a horizontal position. Common symptoms such as heartburn, belching, and difficulty swallowing may be absent or mildly expressed, and substernal pain, often occurring during physical activity and inferior to the action of nitroglycerin, comes to the fore. The similarity of these pains with angina pectoris is complemented by the fact that they can radiate to left half chest, shoulders, arms. Upon more detailed questioning, it turns out, however, that the pain is most often associated with food, especially a lot of food, and not with physical activity; it usually occurs in a lying position and goes away or is relieved when moving to a sitting or standing position, when walking, after taking antacids, for example, soda, which is not typical for IHD. Often palpation of the epigastric region intensifies these pains.

Retrosternal pain is also suspicious for gastroesophageal reflux and esophagitis. to confirm the presence of which 3 types of tests are important: endoscopy and biopsy; intraesophageal infusion of 0.1% hydrochloric acid solution; intraesophageal pH monitoring. Endoscopy is important to detect reflux, esophagitis and to exclude other pathologies. X-ray examination of the esophagus with barium reveals anatomical changes, but its diagnostic value is considered relatively low due to the high frequency of false-positive signs of reflux. When perfused with hydrochloric acid (120 drops per minute through a probe), the appearance of pain that is normal for the patient is important. The test is considered highly sensitive (80%), but not specific enough, which requires repeated studies if the results are unclear.

If the results of endoscopy and hydrochloric acid perfusion are unclear, intraesophageal pH can be monitored using a radiotelemetry capsule placed in the lower part of the esophagus for 24-72 hours. The timing of the onset of pain and the decrease in pH is good. diagnostic sign esophagitis, i.e. really a criterion for the esophageal origin of pain.

Chest pain, similar to angina pectoris, can also be a consequence of increased motor function of the esophagus with achalasia (spasm) of the cardiac region or diffuse spasm. Clinically, in such cases there are usually signs of dysphagia (especially when ingesting solid food, cold liquids), which, unlike organic stenosis, is unstable. Sometimes chest pain comes to the fore of different durations. The difficulties of differential diagnosis are also due to the fact that this category of patients is sometimes helped by nitroglycerin, which relieves spasm and pain.

Radiologically, with achalasia of the esophagus, expansion of its lower part and retention of barium mass in it are detected. However, X-ray examination of the esophagus in the presence of pain is of little information, or rather of little evidence: false positive results were noted in 75% of cases. It is more effective to conduct esophageal manometry using a triple-lumen probe. The coincidence in time of the onset of pain and increased intraesophageal pressure has a high diagnostic value. In such cases, the positive effect of nitroglycerin and calcium antagonists may occur, which reduce smooth muscle tone and intraesophageal pressure. Therefore, these drugs can be used in the treatment of such patients, especially in combination with anticholinergics.

Clinical experience suggests that in cases of esophageal pathology, ischemic heart disease is often misdiagnosed. In order to make a correct diagnosis, the doctor must look for other symptoms of a disorder of the esophagus in the patient and make a comparison clinical manifestations and the results of various diagnostic tests.

Attempts to develop a set of instrumental studies that would help distinguish between anginal and esophageal pain were unsuccessful, since a combination of this pathology with angina pectoris is often found, which is confirmed by bicycle ergometry. Thus, despite the use of various instrumental methods, the differentiation of pain sensations still presents great difficulties.

Mediastinitis and mediastinal tumors are infrequent causes of chest pain. Typically, the need for differential diagnosis with ischemic heart disease occurs at advanced stages of tumor development, when, however, there are still no pronounced symptoms of compression. The appearance of other signs of the disease greatly facilitates diagnosis.

Pain behind the sternum due to diseases of the spine. Pain in the chest can also be associated with degenerative changes in the spine. The most common disease of the spine is osteochondrosis (spondylosis) of the cervical and thoracic, in which there is pain, sometimes similar to angina pectoris. This pathology is widespread, since after 40 years, changes in the spine are often observed. When the cervical and (or) upper thoracic spine is affected, the development of secondary radicular syndrome is often observed with the spread of pain in the chest area. These pains are associated with irritation of the sensory nerves by osteophytes and thickened intervertebral discs. Usually, in this case, bilateral pain appears in the corresponding intercostal spaces, but patients quite often concentrate their attention on their retrosternal or pericardial localization, referring them to the heart. Such pains can be similar to angina pectoris in the following ways: they are perceived as a feeling of pressure, heaviness, sometimes radiate to the left shoulder and arm, neck, can be provoked by physical activity, and are accompanied by a feeling of shortness of breath due to the inability to breathe deeply. Taking into account the elderly age of patients in such cases, a diagnosis of ischemic heart disease is often made with all the ensuing consequences.

At the same time degenerative changes spine and the pain caused by them can also be observed in patients with undoubted ischemic heart disease, which also requires a clear delineation of the pain syndrome. It is possible that in some cases, angina attacks against the background of atherosclerosis of the coronary arteries in patients with spinal lesions also occur reflexively. Unconditional recognition of this possibility, in turn, shifts the “center of gravity” to the pathology of the spine, reducing the importance of independent damage to the coronary arteries.

How to avoid diagnostic errors and make the correct diagnosis? Of course, it is important to conduct an X-ray of the spine, but the changes detected during this process are completely insufficient for diagnosis, since these changes can only accompany coronary artery disease and (or) not appear clinically. Therefore, it is very important to find out all the characteristics of pain. As a rule, pain depends not so much on physical activity as on changes in body position. The pain often intensifies with coughing, deep breathing, and may decrease to some extent. comfortable position patient after taking analgesics. These pains differ from angina pectoris in a more gradual onset, longer duration, they do not go away with rest and after the use of nitroglycerin. Irradiation of pain in the left hand occurs along the dorsal surface, in the 1st and 2nd fingers, whereas with angina - in the 4th and 5th fingers of the left hand. Of particular importance is the detection of local pain in the spinous processes of the corresponding vertebrae (trigger zone) when pressing or tapping paravertebrally and along the intercostal spaces. Pain can also be caused by certain techniques: strong pressure on the head towards the back of the head or stretching one arm while turning the head in the other direction. During bicycle ergometry, pain in the heart area may appear, but without characteristic ECG changes.

Thus, the diagnosis of radicular pain requires a combination of radiological signs of osteochondrosis and characteristic features of chest pain that do not correspond to coronary artery disease.

The frequency of muscular-fascial (muscular-dystonic, muscular-dystrophic) syndromes in adults is 7-35%, and in certain professional groups it reaches 40-90%. In some of them, heart disease is often misdiagnosed, since the pain syndrome in this pathology has some similarities with pain in cardiac pathology.

There are two stages of the disease of musculofascial syndromes (Zaslavsky E.S., 1976): functional (reversible) and organic (muscular-dystrophic). There are several etiopathogenetic factors in the development of musculofascial syndromes:

1. Soft tissue injuries with the formation of hemorrhages and sulfur-fibrinous extravasates. As a result, compaction and shortening of muscles or individual muscle bundles, ligaments, and a decrease in the elasticity of the fascia develops. As a manifestation of the aseptic inflammatory process, connective tissue is often formed in excess.
2. Microtraumatization of soft tissues during certain types of professional activities. Microtraumas disrupt tissue circulation, cause muscle-tonic dysfunction with subsequent morphological and functional changes. This etiological factor is usually combined with others.
3. Pathological impulses in visceral lesions. This impulse, which occurs when internal organs are damaged, is the cause of the formation of various sensory, motor and trophic phenomena in integumentary tissues, innervationally connected with the changed internal organ. Pathological interoceptive impulses, switching through the spinal segments, go to the corresponding connective tissue and muscle segments affected by the internal organ. The development of musculofascial syndromes accompanying cardiovascular pathology can change the pain syndrome so much that diagnostic difficulties arise.
4. Vertebrogenic factors. When irritating the receptors of the affected motor segment (receptors of the fibrous ring intervertebral disc, posterior longitudinal ligament, joint capsules, autochthonous muscles of the spine) not only local pain and muscle-tonic disorders occur, but also various reflex responses at a distance - in the area of ​​integumentary tissues innervated to the affected spinal segments. But not in all cases there is a parallelism between the severity of radiological changes in the spine and clinical symptoms. Therefore, radiographic signs of osteochondrosis cannot yet serve as an explanation for the cause of the development of musculofascial syndromes solely by vertebrogenic factors.

As a result of exposure to several etiological factors muscular-tonic reactions develop in the form of hypertonicity of the affected muscle or muscle group, which is confirmed by electromyographic study. Muscle spasm is one of the sources of pain. In addition, disruption of microcirculation in the muscle leads to local tissue ischemia, tissue edema, accumulation of kinins, histamine, and heparin. All these factors also cause pain. If musculofascial syndromes are observed for a long time, fibrous degeneration of muscle tissue occurs.

The greatest difficulties in the differential diagnosis of musculofascial syndromes and pain of cardiac origin are found in the following variants of syndromes: glenohumeral periarthritis, scapulocibular syndrome, anterior chest wall syndrome, interscapular pain syndrome, small pectoral muscle, anterior scalene syndrome. Anterior chest wall syndrome is observed in patients after myocardial infarction, as well as in non-coronary heart lesions. It is assumed that after a myocardial infarction, the flow of pathological impulses from the heart spreads through the segments of the autonomic chain and leads to dystrophic changes in the corresponding formations. This syndrome in persons with a known healthy heart may be caused by traumatic myositis.

More rare syndromes, accompanied by pain in the anterior chest wall, are: Tietze syndrome, xyphoidia, manubriosternal syndrome, scalenus syndrome.

Tietze syndrome is characterized by severe pain at the junction of the sternum with the cartilages of the II-IV ribs, swelling of the costochondral joints. It is observed mainly in middle-aged people. The etiology and pathogenesis are unclear. There is an assumption about aseptic inflammation of the costal cartilages.

Xyphoidia is manifested by sharp pain behind the sternum, which intensifies with pressure on the xiphoid process, and is sometimes accompanied by nausea. The cause of the pain is unclear, perhaps there is a connection with the pathology of the gallbladder, duodenum, and stomach.

With manubriosternal syndrome, acute pain is noted over top part sternum or slightly laterally. The syndrome is observed in rheumatoid arthritis, but occurs in isolation and then there is a need to differentiate it from angina pectoris.

Scalenus syndrome is compression of the neurovascular bundle of the upper limb between the anterior and middle scalene muscles, as well as the normal first or accessory rib. Pain in the anterior chest wall is combined with pain in the neck, shoulder girdle, shoulder joints, and sometimes there is a wide area of ​​irradiation. At the same time, autonomic disorders are observed in the form of chills and pale skin. Difficulty breathing and Raynaud's syndrome are noted.

Summarizing the above, it should be noted that the true frequency of pain of this origin is unknown, therefore it is not possible to determine their proportion in the differential diagnosis of angina pectoris.

Differentiation is necessary in the initial period of the disease (when one first thinks about angina) or if the pain caused by the listed syndromes is not combined with other signs that allow them to correctly recognize their origin. At the same time, pain of this origin can be combined with true ischemic heart disease, and then the doctor must also understand the structure of this complex pain syndrome. The need for this is obvious, since the correct interpretation will influence both treatment and prognosis.

Chest pain caused by diseases of the abdominal organs and pathology of the diaphragm. Diseases of the abdominal organs are quite often accompanied by pain in the heart region in the form of typical angina or cardialgia syndrome. Pain due to peptic ulcer of the stomach and duodenum, chronic cholecystitis sometimes they can radiate to the left half of the chest, which creates diagnostic difficulties, especially if the diagnosis of the underlying disease has not yet been established. Such irradiation of pain is quite rare, but its possibility should be taken into account when interpreting pain in the heart and behind the sternum. The occurrence of these pains is explained by reflex effects on the heart during damage to internal organs, which occur as follows. In internal organs interorgan connections were discovered, through which axon reflexes are carried out, and, finally, polyvalent receptors were identified in blood vessels and smooth muscles. In addition, it is known that, along with the main border sympathetic trunks, there are also paravertebral plexuses that connect both border trunks, as well as sympathetic collaterals located parallel and on the sides of the main sympathetic trunk. Under such conditions, afferent excitation, directed from any organ along a reflex arc, can switch from centripetal to centrifugal pathways and thus be transmitted to various organs and systems. At the same time, viscero-visceral reflexes are carried out not only by reflex arcs that close at various levels of the central nervous system, but also through autonomic nerve nodes in the periphery.

As for the causes of reflex pain in the heart area, it is assumed that a long-existing painful focus disrupts the primary afferent impulse from the organs due to a change in the reactivity of the receptors located in them and in this way becomes a source of pathological afferentation. Pathologically altered impulses lead to the formation of dominant foci of irritation in the cortex and subcortical region, in particular in the hypothalamic region and in the reticular formation. Thus, the irradiation of these stimuli occurs with the help of central mechanisms. From here, pathological impulses are transmitted by efferent pathways through the underlying parts of the central nervous system and then reach the vasomotor receptors of the heart along sympathetic fibers.

Diaphragmatic hernia can also be causes of chest pain. The diaphragm is a richly innervated organ, mainly due to the phrenic nerve. It runs along the front inner edge of m. scalenus anticus. In the mediastinum it goes along with the superior vena cava, then, bypassing the mediastinal pleura, reaches the diaphragm, where it branches. Hiatal hernias are more common. Symptoms of diaphragmatic hernias vary: usually dysphagia and pain in the lower parts chest, belching and a feeling of fullness in the epigastrium. When a hernia is temporarily inserted into the chest cavity, severe pain is observed, which can be projected onto the lower left half of the chest and spreads to the interscapular region. Concomitant spasm of the diaphragm can cause pain reflected due to irritation of the phrenic nerve in the left scapular region and in the left shoulder, which suggests “heart” pain. Considering the paroxysmal nature of the pain, its occurrence in middle-aged and elderly people (mainly in men), a differential diagnosis should be made with an attack of angina pectoris.

Painful sensations can also be caused by diaphragmatic pleurisy and, much less frequently, by subdiaphragmatic abscess.

In addition, upon examination of the chest, herpes zoster may be detected; palpation may reveal a rib fracture (local tenderness, crepitus).

Thus, to find out the cause of chest pain and make a correct diagnosis to the doctor general practice Careful examination and questioning of the patient should be carried out and the possibility of the existence of all of the above conditions should be taken into account.