Mild pain in the middle of the sternum. Causes of chest pain

A very common symptom that every person can encounter; it occurs, as a rule, with a disease of organs located directly in the chest. It is also an echo of a disease of the abdominal organs. Such an ailment can become a symptom of diseases of the heart, lungs, esophagus or diaphragm. Let's take a closer look at each case.

With heart diseases such as coronary heart disease, angina pectoris or myocardial infarction, a person always feels pain in the chest on the left, which can radiate to the left arm, left shoulder or both arms, it is also possible to feel pain between the shoulder blades, in the neck and lower jaw. In this case, as a rule, the sensations of pain are strong, squeezing and pressing, there is a feeling of heaviness and lack of air, the pain is stabbing in nature, as if “thousands of needles are stuck inside.”

Intense physical activity can trigger this pain.(for example, climbing the stairs to the 5th floor). This pain lasts no more than 10 minutes; this is a very dangerous symptom, because attacks of pain in the heart often lead to death. With sharp pain in the middle of the chest, a person may go into a state of painful shock. There may even be dizziness, clouding of consciousness and fainting. The pulse becomes rapid or there is a feeling of interruptions in the functioning of the heart, the lips and face turn pale, cold sticky sweat appears, the eyes express fear.

If such pain occurs in the chest area, you should consult a cardiologist., or call an ambulance if an attack has already occurred. The first emergency aid in such cases is to take nitroglycerin, which dilates blood vessels and leads to normalization of the patient’s condition; the pain completely disappears within 5 minutes.

So, the cause of chest pain may be:

• heart disease;
• lung diseases;
• chest injuries;
• diseases of the esophagus.

Chest pain due to lung disease

Pain in the middle of the chest may result from lung disease - pulmonary pleurisy, bronchitis, tracheitis, pneumonia. In this case, pain occurs as a result of a prolonged, dry, strong cough with sputum production. As a rule, they intensify with coughing attacks and sharp breaths. Temperature rises, headache, muscle and joint pain, general weakness and shortness of breath appear. When a large amount of fluid accumulates in the pleural area, there is a possibility of blue skin. Lung diseases, especially complicated ones, lead to damage to the intercostal muscles and diaphragm, which in turn causes pain.

Some diseases of the digestive tract also lead to sensations of pain in the chest in the middle. Such diseases include: gastric or duodenal ulcer, diaphragmatic abscess, reflux esophagitis. With such diseases, an upset stomach radiates into the chest. As a rule, this symptom is accompanied by the appearance of heartburn (burning sensation, terrible sensations in the chest), belching sour or bitter, nausea, possibly vomiting, irritability, poor sleep, pain in the left hypochondrium or in the stomach.

Chest pain due to injury

Rib cage may hurt as a result of injury during a fight, fall or accident. Punches to the chest can cause blood vessels or muscles to rupture, resulting in chest pain. The pain usually intensifies with a sharp and deep breath, bending, turning and twisting the torso. After particularly severe injuries, you may feel unwell even when feeling with your hands. In this case, most often there is a crack or fracture of the sternum. It is necessary to consult a doctor as soon as possible, who, in turn, will determine the exact cause of the unpleasant painful sensations and provide you with appropriate assistance.

The pain described above can also be a sign of thyroid disease. Characteristic symptoms in this case may be a tumor in the neck or chest (a symptom of a thyroid goiter), a sudden change in behavior, weakness, slowness, fatigue, and a rapid increase or decrease in the patient’s weight. Blood pressure and body temperature, physical and mental activity may decrease.

Chest pain is directly affected by instability of the thoracic spine. The most basic disease is osteochondrosis. Osteochondrosis is an inflammatory process of the cartilage tissue of the joints. This disease can be caused by incorrect posture, the position of the spine in an uncomfortable position associated with immobile work or a sedentary lifestyle.

In this case, pain in the chest is either constant or paroxysmal. Almost always, the characteristic changes in pain depend on a change in the position of the patient’s body - the pain intensifies when the back is bent and subsides when the person lies on a flat surface or sits with his back straight.

The disease usually does not appear immediately, begins, like any damage to cartilage tissue, with pain at the beginning of movement, which disappears after movement for a certain period of time. Many people do not attach importance to these symptoms, which is wrong, the disease progresses, and more unpleasant symptoms appear. Since the thoracic spine is inactive, the load on it is not large, so even the appearance of an intervertebral hernia in this area will most likely go unnoticed, unless, of course, one of the many nerve roots is pinched.

A symptom of many pathologies is pain in the middle of the chest. The condition causes discomfort and fear in a person about the cause of the pain syndrome. It can be of varying intensity, but regardless of its characteristics, a visit to a therapist is required. This will prevent possible consequences and may save the patient’s life.

Organs located in the middle of the chest

The central part of the chest is called the mediastinum. It is located between the lungs and consists of:

• bronchi;
• lymph nodes;
• hearts;
• large vessels (vena cava, aorta);
• trachea;
• esophagus;
• muscles, ligaments, nerves.

Pain in the chest in the middle can be caused by pathologies of organs located near the mediastinum (diaphragm, abdominal cavity, chest wall, liver). Doctors call this condition referred pain syndrome.

How does chest pain manifest?

Classification of chest pain syndrome in the middle is carried out according to the main characteristics:

• localization - behind the sternum, in the central part, under the ribs, with irradiation from organs located outside the mediastinum;
• intensity – weak, moderate, strong, unbearable;
• duration – constant, periodic, paroxysmal;
• the nature of the sensations is dull, pressing, cutting, sharp, stabbing, aching.

Causes of pain in the middle of the chest

The etiology of pain syndrome in the thoracic region is due to disruption of the normal functioning of the systems, compression of nerve endings. Based on the signs, you can guess the cause of the malaise:

• when coughing – laryngotracheitis, pneumonia;
• on a sigh - bronchitis, pericarditis, rib injury, stomach ulcer;
• after eating – reflux, esophagitis, peptic ulcer;
• when moving – myocardial infarction, intercostal neuralgia;
• severe pain – cardiac neurosis, aortic dissection;
• when pressed, pressing – muscle overstrain;
• aching pain – oncology of the respiratory system, atrial fibrillation.

Digestive system diseases

Gastrointestinal disorders are characterized by symptomatic pain in the middle of the chest. Discomfort occurs due to spasms of the stomach, esophagus, and gall bladder. An aching, dull pain intensifies with pressure on the epigastric region, complemented by radiating pain in the back. Acute pancreatitis causes burning pain in the sternum.

Unpleasant sensations appear both before and after eating. The pain subsides after using antispasmodics. Possible diseases and additional signs:

• inflammation of the mucous membrane of the esophagus (esophagitis) - lump in the throat, heartburn, increased discomfort after eating, difficulty swallowing, belching;
• peptic ulcer - pain similar to heart disease, appears 1-2 hours after eating and disappears if you eat something;
• subphrenic abscess – increased discomfort when coughing, moving, high temperature;
• gastroesophageal reflux - burning pain in the central region of the sternum, nausea.

Cardiovascular pathologies

This group of diseases is the most common cause of pain in the sternum in the middle. Characteristics:

• myocardial infarction - stabbing in the middle of the chest, panic occurs, pain is observed on the left and spreads throughout the chest;
• angina pectoris – there is a feeling of chest fullness, reflected pain in the left arm or under the shoulder blade, the pain does not go away at rest, lasts 3–15 minutes;
• thromboembolism - discomfort during inspiration due to a blood clot in the pulmonary artery.

Relationship between chest pain and spine

If there is pressure in the middle of the sternum, this is a symptom of problems with the spine:

• Osteochondrosis – pain depends on the position of the body (paroxysmal or constant). It decreases when lying down and increases when walking. The clinical course is characteristic of thoracic radiculopathy (a complication of osteochondrosis).
• Intercostal neuralgia - in the spine can compress the nerve endings, which causes painful, cutting colic. Neuralgia is characterized by pulsating, intense pain in the middle of the sternum, and lack of effect after taking heart medications.

Heaviness behind the sternum as a sign of respiratory disease

Pain behind the sternum in the middle, accompanied by a continuous cough, is caused by impaired functionality of the respiratory system (pleurisy, tracheitis, lung abscess, pneumonia). The pain syndrome increases with sneezing and coughing. The condition is characterized by additional symptoms:

• bluish skin;
• labored breathing;
• fever;
• arrhythmia.

Why does the middle of the chest hurt in men?

One of the causes of pain in the middle of the sternum in men is increased physical activity. Pain is caused by the following conditions:

• ischemia, heart failure - stabbing nature of increasing pain;
• scoliosis - pathology of bones and muscles is manifested by constant, aching pain in the central part of the chest;
• diaphragmatic hernia - severe pain when lying down and sitting, which goes away when standing up;
• arterial hypertension - acute pain in the middle of the chest, accompanied by shortness of breath, dizziness, fainting;
• joint diseases - increased pain at night, after intense physical activity;
• injuries - cutting pain (rib fracture), dull pain (bruise from a fall), increasing pain (impact);
• Smoking – aggravates existing health problems and causes pain when coughing.

Causes of pain in the center of the sternum in women

Median chest pain syndrome is caused by emotional experiences and frequent stress in women. Common reasons:

• mastopathy - soreness of the mammary gland with irradiation into the sternum due to compression of the nerve receptors;
• diseases of the thyroid gland (nodular goiter, hyperthyroidism) - intermittent aching pain, accompanied by pressure changes, a lump in the throat;
• excess weight – excessive load on the spine causes pain when walking and physical activity;
• wearing uncomfortable underwear - a tight bra puts pressure on the nerve endings, causing pain in the middle of the chest area;
• bad habits (smoking) – cause the development of chronic bronchitis;
• mastalgia - pain, swelling of the glands appear 3-5 days before the start of the menstrual cycle;
• breast cancer - manifests itself in the later stages with a burning sensation around the mammary gland, reflected pain in the middle of the sternum.

The main causes of pain between the breasts:

• 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 specific or atypical pain between the breasts.

Pain between the breasts is not limited to a certain age group, but is more common in adults than 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 pain between the breasts 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 interbreast pain, the clinician must weigh all relevant options for potential causes of pain, determine when intervention is necessary, and choose from among a virtually limitless number 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 pain between the breasts often represents a complex interaction of psychological, pathological and psychosocial factors. This makes it the most common problem in primary care.

When considering pain between the breasts, the following five elements need to 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, we can distinguish the following 6 groups of causes of pain between the breasts:

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 shoulder girdle muscles.
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 the range of possible diseases (acute myocardial infarction, pulmonary embolism, dissecting aortic aneurysm, spontaneous pneumothorax).

The main causes of acute pain between the breasts, which 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 pain between the breasts 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 pain between the breasts

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.

Pain between the breasts 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 the young or middle age of patients, mostly 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 is detected. 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, pain between the breasts may occur, as well as paresthesia and muscle twitching in the limbs due to the resulting 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 (pain between the chests, 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.

The origin of pain in the heart in neurotic conditions is also explained from the standpoint of the cortico-visceral 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 treating cardialgia with 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 the zones of hyperalgesia in the muscles of the anterior chest wall to the corresponding segments of the 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 of pain sensitivity in vegetative-vascular dystonia is also important.

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 of 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 of the nerve endings located in the epicardium, as well as with inflammatory swelling 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 carbon monoxide poisoning), 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 pain between the breasts, 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.

Pain between the breasts 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 go as part of the vagus nerve. The mucous membrane of small bronchi and pulmonary parenchyma probably does not contain pain receptors, so pain during primary damage to these formations appears only when the pathological process (pneumonia or tumor) reaches the parietal pleura or spreads to large bronchi. The most severe pain is observed during the destruction of 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. Severe constant pain, aggravated by breathing, moving 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 blood 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 concomitant severe diseases (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 a positive response to 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 between the breasts is observed, associated with damage to the bronchopulmonary apparatus.

Pain between the breasts, difficult to interpret due to its vagueness 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, and 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 the clinical picture of this acute situation is blurred.

Pain between the breasts 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 in the chest, 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 the left half of the chest, shoulders, and 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 coincidence in time of the onset of pain and a decrease in pH is a good diagnostic sign of esophagitis, i.e. really a criterion for the esophageal origin of pain.

Pain between the breasts, 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 substernal pain of varying duration comes to the fore. 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 esophageal disorders in the patient and compare 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 pain between the breasts. 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 between the breasts 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 spine, which causes 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 in the 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 when coughing, deep breathing, and can decrease in some comfortable position for the 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 pain between the breasts, not consistent with 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 the integumentary tissues innervated to the altered 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 the receptors of the affected motor segment are irritated (receptors of the fibrous ring of the intervertebral disc, posterior longitudinal ligament, joint capsules, autochthonous muscles of the spine), not only local pain and muscle-tonic disorders occur, but also a variety of reflex responses at a distance - in the area of ​​​​the integumentary tissues that are innervated with affected vertebral 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 the influence of several etiological factors, muscle-tonic reactions develop in the form of hypertonicity of the affected muscle or group of muscles, 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 encountered in the following variants of syndromes: glenohumeral periarthritis, scapular-costal syndrome, anterior chest wall syndrome, interscapular pain syndrome, pectoralis minor syndrome, anterior scalene muscle 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 between the breasts, aggravated by pressure on the xiphoid process, 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 the upper part of the 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.

Pain between the breasts 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 from gastric and duodenal ulcers and chronic cholecystitis can sometimes 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 the 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 are varied: usually dysphagia and pain in the lower 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 pain between the breasts and make a correct diagnosis, the general practitioner should conduct a thorough examination and questioning of the patient and take into account the possibility of the existence of all the above conditions.

There can be many reasons for women to feel pain in the middle of their chest. This area contains the respiratory organs, esophagus and heart. The spine and ribs can also cause chest pain. And, of course, we should not forget about the specifics of the mammary glands, which most often cause an unpleasant symptom.

If a woman has pain in the middle of her chest, then the reasons can be characterized as physiological or pathological. The first category includes those symptoms that are a consequence of natural processes in the body. They may be unpleasant, but they do not pose a danger to life or health.

Pathological pain is a signal from the body about the presence of a disease. In this case, only a doctor can determine the degree of health hazard. Therefore, it is important to learn to distinguish between types of pain in order to independently determine their cause and, if possible, eliminate it without leaving home.

But if you have any doubts, it is better not to delay visiting a doctor. Pain is a common symptom of cardiovascular diseases and cancer. Early diagnosis of these pathologies helps to cure the patient with minimal damage to health and wallet.

The most common reason that a woman has chest pain in the middle is a mistake in choosing underwear. Bras of the wrong size, putting pressure on the mammary glands, disrupt the normal blood supply to the tissues. This is how pain arises. Unfortunately for women who have been blessed by nature with large breasts, such symptoms can also occur when wearing underwear of an adequate size.

Another common cause of chest pain is mastalgia. This is a common symptom of premenstrual syndrome. In this case, the woman’s body, “hoping” for pregnancy, begins preliminary preparations.

For the mammary glands this results in:

• swelling;
• the appearance of nodules;
• the pain is accompanied by a burning sensation.

Such symptoms develop during the week before each period and completely disappear after the end of menstruation. Another important difference from pathological processes is that both mammary glands are necessarily affected.

A similar manifestation of symptoms is possible during a more rare event – ​​pregnancy. But in this case, the process becomes longer and is accompanied by a delay in menstruation. This is one of the signs of the birth of a new life in a woman’s body. In this case, it is better to play it safe and purchase a test at any pharmacy in order to register with the antenatal clinic on time and prevent many of the dangers of pregnancy.

Lungs

Another common reason that a woman has pain in the middle of her chest is pathologies of the respiratory system.

They are quite diverse:

It can also be caused by the strain of many days of severe coughing or hemoptysis. Therefore, determining the need to visit a doctor is quite simple.

Gastrointestinal tract

Despite the significant differences, women often confuse the stomach with the heart when they try to independently diagnose the cause of chest pain. As a result, the frightened patient learns already in the hospital that he has serious digestive problems, which also require appropriate treatment.

Diseases of the gastrointestinal tract as the cause of chest pain can be distinguished by the following accompanying symptoms:

• heartburn and burning in the throat;
• difficulty swallowing;
• nausea or vomiting;
• pain in the upper abdomen.

A more accurate self-diagnosis can be carried out if you track the time of pain onset. With an ulcer, the stomach cannot tolerate hunger. With gastritis, symptoms develop immediately after eating. The duodenum, as the most “patient”, responds with pain an hour after a heavy lunch.

A similar set of symptoms can occur without pathologies. This is how a pregnant woman’s body reacts to food intake. Symptoms in this case appear due to fetal pressure on the internal organs.

Heart and blood vessels

One of the most dangerous categories of reasons why a woman has pain in the middle of her chest is pathology of the cardiovascular system. Most often, pain is a companion to hypertension or heart failure.

But before you get scared, it's important to remember that pain is not the only symptom. Unpleasant sensations should also manifest themselves through:

1. Deterioration of the body's functioning. Problems with the heart and blood vessels provoke deterioration in performance, weakness and pale skin. At the same time, physical activity and stress often provoke exacerbation.
2. Increased heart rate. Trying to cope with the load, the heart works too quickly, which is easy to feel. This causes burning and pain in the lungs, which can no longer cope with increased gas exchange.
3. Neurological reactions. Exacerbation of problems with the cardiovascular system manifests itself through anxiety and confusion. The person sweats profusely and feels a severe headache.

If even some of these symptoms appear, it is better to consult a doctor.

UDF

The spine can also “give” a woman chest pain. In this case, it occurs as a result of curvature or osteochondrosis. The ribs often react to scoliosis, which is why it begins to sting in the side.

Osteochondrosis is dangerous because it can lead to pinched nerves. In this case, a woman can easily confuse severe chest pain with a heart attack. The difference will manifest itself through a burning sensation in the back. There will also be specific pain when trying to press on the shoulders.

Problems with the spine are rarely life-threatening, but they can significantly limit a person for many years. Therefore, you should not be negligent about the health of your skeleton, so as not to end up bedridden later.

Sudden acute chest pain is the most important symptom of acute diseases of the chest organs and one of the most common reasons for patients to visit a doctor. Often in these cases emergency assistance is required.

It should be emphasized that acute chest pain, which appears in the form of an attack, may be the earliest and, up to a certain point, the only manifestation of a disease requiring emergency care; such a complaint should always alert the doctor. Such patients must be examined especially carefully. And in most cases, based on medical history, examination data and ECG, the correct diagnosis can be made already at the pre-hospital stage.

Why does your chest hurt?

The main causes of pain are as follows.

Heart diseases - acute myocardial infarction, angina pectoris, pericarditis, myocardial dystrophy.

Vascular diseases - dissecting aortic aneurysm, pulmonary embolism (PE) as causes of chest pain.

Respiratory diseases - pneumonia, pleurisy, spontaneous pneumothorax.

Diseases of the digestive system - esophagitis, hiatal hernia, gastric ulcer.

Diseases of the musculoskeletal system – thoracic radiculitis, chest injuries.

Shingles.

Neuroses as causes of chest pain.

Why does my chest hurt when I have problems with my lungs?

Thromboembolism of the pulmonary arteries often develops in patients who have undergone surgery, suffer from phlebothrombosis of the deep veins of the legs or atrial fibrillation. In this case, acute, intense pain occurs in the center of the sternum, the right or left half of the chest (depending on the location of the pathological process), which lasts from 15 minutes to several hours. The pain may be accompanied by severe shortness of breath, a drop in blood pressure, and in every tenth patient, fainting (syncope). The ECG may show signs of overload in the right side of the heart - a tall pointed P wave in leads II, III, and VF, deviation of the electrical axis of the heart to the right, the McGean-White sign (deep S wave in standard lead I, deep Q wave in lead III ), incomplete blockade of the right bundle branch. The pain is relieved with narcotic analgesics.

In lung diseases, chest pain is usually characterized by a clear connection with breathing. The localization of pain in pleuropneumonia and pulmonary infarction usually depends on the location of the inflammatory focus in the lungs. Breathing movements, especially deep breaths and coughing, lead to increased pain, which in these diseases is caused by irritation of the pleura. In this regard, when breathing, patients usually spare the affected side; breathing becomes shallow, the affected side lags behind. It should be emphasized that with pleuropneumonia and pleurisy in the first hours and days of illness, pain is often the main subjective symptom, against the background of which other manifestations of the disease are less significant for the patient. Percussion and auscultation of the lungs play a vital role in making a correct diagnosis, allowing one to identify objective signs of pulmonary pathology. Pain associated with pleural irritation is well relieved with non-narcotic analgesics.

Pneumothorax as a cause of pain in the chest

With spontaneous pneumothorax, the pain is usually prolonged, most pronounced at the time of pneumothorax development, intensifies with breathing, and then shortness of breath comes to the fore. The pain is accompanied

• pallor of the skin,
• weakness,
• cold sweat
• cyanosis,
• tachycardia,
• decrease in blood pressure.

The lag of half of the chest during breathing and tympanitis on the affected side revealed by percussion are characteristic; breathing over these sections is sharply weakened or cannot be heard.

On the ECG, you can see a slight increase in the amplitude of the R wave in the chest leads or a sharp change in the electrical axis of the heart. The appearance of severe chest pain in a patient with pneumonia, combined with severe shortness of breath, intoxication, and sometimes collapse, is characteristic of a lung abscess breaking into the pleural cavity and the development of pyopneumothorax. In such patients, pneumonia may be abscess-forming from the very beginning, or the abscess may develop later.

Heart disease as a source of chest pain

The main task when carrying out a differential diagnosis in a patient with acute chest pain is to identify prognostically unfavorable forms of pathology, primarily heart disease.

Why does the chest hurt during a heart attack?

Acute strong squeezing, squeezing, tearing, burning pain behind the sternum or to the left of it is the most important symptom of a heart attack. Pain may appear during exercise or at rest in the form of an attack or frequently recurring attacks. The pain is localized behind the sternum, often involving the entire chest; it typically radiates to the left shoulder blade or both shoulder blades, back, left arm or both arms, and neck. Its duration ranges from several tens of minutes to several days.

It is very important that pain during a heart attack is the earliest and up to a certain point the only symptom of the disease, and only later do characteristic ECG changes appear (ST segment elevation or depression, T wave inversion and the appearance of a pathological Q wave). Often the pain is accompanied

• shortness of breath,
• nausea,
• vomiting,
• weakness,
• increased sweating,
• heartbeat,
• fear of death.

There is no effect when taking nitroglycerin repeatedly. To relieve pain or reduce its intensity, narcotic analgesics must be reintroduced.

Why does the chest hurt with angina?

Short-term acute compressive pain behind the sternum or to the left of it, appearing in the form of attacks, is the main symptom of angina pectoris. Pain during angina pectoris can radiate to the left arm, left shoulder blade, neck, epigastrium; Unlike other diseases, irradiation into the teeth and lower jaw is possible. Pain occurs at a height of physical exertion - when walking, especially when trying to walk faster, climbing stairs or uphill, with heavy bags (angina pectoris), sometimes as a reaction to a cold wind. The progression of the disease and further deterioration of coronary circulation lead to the appearance of angina attacks with less and less physical activity, and then at rest.

With angina, the pain is less intense than with myocardial infarction, much less durable, most often lasts no more than 10–15 minutes (cannot last for hours) and is usually relieved with rest when taking nitroglycerin. Chest pain, which appears in the form of attacks, may be the only symptom of the disease for a long time. The ECG may show signs of a previous myocardial infarction, and at the time of a painful attack – signs of myocardial ischemia (depression or ST segment elevation or T wave inversion). It should be noted that ECG changes without a corresponding history cannot be a criterion for angina pectoris (this diagnosis is made only after careful questioning of the patient).

On the other hand, a careful examination of the patient, including electrocardiography, even during a painful attack may not reveal significant deviations from the norm, although the patient may need emergency care.

In cases where acute, sharp, compressive pain behind the sternum or in the region of the heart with irradiation to the left shoulder, the lower jaw develops at rest (usually during sleep or in the morning), lasts 10 - 15 minutes, is accompanied by a rise in the ST segment at the time of the attack and quickly relieved by Nitroglycerin or Nifedipine (Corinfar), one can think about variant angina (Prinzmetal's angina).

Chest pain, indistinguishable in nature from angina pectoris, occurs with stenosis of the aortic mouth. The diagnosis can be made on the basis of a characteristic auscultation pattern and signs of severe left ventricular hypertrophy.

Pain during pericarditis is characterized by a gradual increase, but at the height of the process (when exudate appears), the pain may decrease or disappear; it is associated with breathing and depends on the position of the body (usually decreases when sitting and bending forward).

• The pain is often cutting or stabbing in nature,
• localized behind the sternum,
• can radiate to the neck, back, shoulders, epigastric region, and usually lasts for several days.

A pericardial friction rub detected during auscultation allows an accurate diagnosis to be made. The ECG may reveal synchronous (concordant) ST segment elevation in all leads, which often leads to an erroneous diagnosis of myocardial infarction. Typically, there is no effect from taking nitroglycerin; pain is best relieved with non-narcotic analgesics.

Aortic aneurysm as a cause of chest pain

Chest pain, which is not inferior in intensity to pain during myocardial infarction, and sometimes exceeds it, can be a symptom of a relatively rare disease - dissecting aortic aneurysm. The pain occurs acutely, more often against the background of a hypertensive crisis or during stress (physical or emotional), is localized behind the sternum with irradiation along the spine, sometimes spreading along the aorta to the lower abdomen and legs. It has a tearing, bursting, often wave-like character, lasting from several minutes to several days. Pain may be accompanied by asymmetry of the pulse in the carotid and radial arteries, rapid fluctuations in blood pressure (BP) from a sharp rise to a sudden drop until the development of collapse. Often there is a significant difference in blood pressure levels in the left and right arms, corresponding to pulse asymmetry.

Due to the deposition of blood under the intima of the aorta, signs of anemia increase. Differential diagnosis with acute myocardial infarction is especially difficult in cases where changes appear on the ECG - nonspecific or in the form of depression, sometimes ST segment elevation (although without the cyclical nature of ECG changes characteristic of myocardial infarction during dynamic observation). Repeated administration of narcotic analgesics, including intravenous, often does not relieve pain.

Differential diagnosis of diseases causing chest pain: table 1

Differential diagnosis of non-coronarogenic cardialgia and angina pectoris

Gastroenterological causes of chest pain

Acute chest pain caused by diseases of the esophagus (ulcerative esophagitis, damage to the mucous membrane by a foreign body, cancer of the esophagus) is characterized by localization along the esophagus, connection with the act of swallowing, the appearance or sharp increase in pain when food passes through the esophagus, a good effect of antispasmodics and local anesthetics funds. The antispasmodic effect of nitroglycerin determines its effectiveness in pain syndrome due to spasm of the esophagus, which can complicate the differential diagnosis with an attack of angina.

Prolonged pain in the area of ​​the lower third of the sternum at the xiphoid process, often combined with pain in the epigastric region and usually occurring immediately after eating, can be caused by a hiatal hernia with the protrusion of the cardiac part of the stomach into the chest cavity. In addition, these cases are characterized by the appearance of pain when the patient is sitting or lying down and its decrease or complete disappearance in an upright position. Usually, upon questioning, signs of reflux esophagitis (heartburn, increased salivation) and good exercise tolerance are revealed.

Antispasmodics and antacids are effective for chest pain (for example, Maalox, Rennie, etc.); Nitroglycerin in this situation can also relieve pain. Often, pain caused by diseases of the esophagus or hiatal hernia is similar in location and sometimes in nature to the pain of angina pectoris. The difficulty of differential diagnosis is aggravated by the effectiveness of nitrates and possible electrocardiographic changes (negative T waves in the precordial leads, which, however, often disappear when recording an ECG in a standing position). It should also be taken into account that in these diseases true attacks of reflex angina are often observed.

Bone, viral and post-traumatic causes of chest pain

Acute, prolonged pain in the chest associated with body movement (bending and turning) is the main symptom of thoracic radiculitis. Pain with radiculitis, in addition, is characterized by the absence of paroxysmal attacks, intensification with arm movements, tilting the head to the side, deep inspiration, and localization along the nerve plexuses and intercostal nerves; there, as well as upon palpation of the cervicothoracic spine, severe pain is usually determined. When determining local pain, you should clarify with the patient whether this is the same pain that forced him to seek medical help, or whether it is another, independent pain. Taking nitroglycerin and validol almost never reduces the intensity of pain, which often subsides after using analgin and mustard plasters.

With chest trauma, diagnostic difficulties may arise in cases where pain does not appear immediately, but after several days. However, indications in the anamnesis of injury, clear localization of pain under the ribs, its intensification during palpation of the ribs, movement, coughing, deep inspiration, i.e. in situations where some displacement of the ribs occurs, facilitate recognition of the origin of the pain. Sometimes there is a discrepancy between the intensity of pain and the nature (strength) of the injury. In such cases, it should be borne in mind that with the slightest injury, a hidden pathology of the bone tissue of the ribs can be revealed, for example, with their metastatic lesion, myeloma. X-rays of the ribs, spine, flat bones of the skull, and pelvis help to recognize the nature of bone pathology.

Acute pain along the intercostal nerves in the chest is characteristic of herpes zoster. Often the pain is so strong that it deprives the patient of sleep, is not relieved by repeated administration of analgin and is somewhat reduced only after the injection of narcotic analgesics. The pain occurs before the typical shingles skin rash appears, making diagnosis difficult.

Hormonal, neurological and other causes of chest pain

Pain in the heart area of ​​an aching, stabbing nature is a common complaint of patients with neurosis. Pain in neuroses almost never has a clear attack-like pattern, is not associated with physical activity, and is located in the area of ​​the apex of the heart. The pain appears gradually, lasts for hours, sometimes for days, maintaining a monotonous character and not significantly affecting the general condition of the patient. Often attention is drawn to the unusual variety of patient complaints and the excessively colorful description of pain.

Careful questioning reveals that there is no connection between the occurrence or intensification of pain and physical activity (however, sometimes pain occurs after physical activity or against the background of emotional stress). Moreover, physical work and sports often lead to the cessation of pain. Pain in the heart area does not prevent patients with neurosis from falling asleep - a situation that is impossible in the event of an angina attack.

The effect of nitrates in these patients is in most cases unclear; sometimes patients note a decrease in pain 20–30 minutes after taking nitroglycerin. The attack can be stopped by taking validol and sedatives. A course of treatment with beta blockers and psychotropic drugs usually leads to an improvement in the well-being of patients and the cessation of painful attacks.

With dyshormonal myocardial dystrophy (menopausal cardiopathy), patients describe cardialgia as a feeling of heaviness, tightness, cutting, burning, piercing, piercing pain to the left of the sternum, in the area of ​​the apex of the heart or the left nipple, with possible irradiation to the left arm, scapula. The pain can be short-term, but more often it lasts for hours, days, months, periodically intensifying (especially at night, as well as in spring and autumn), is not associated with physical activity, does not decrease with rest, and is not clearly relieved by nitrates.

Dyshormonal myocardial dystrophy can be suspected in a patient of the appropriate age (45 - 55 years old) when cardialgia is combined with hot flashes (suddenly occurring feeling of heat in the upper half of the body, skin of the face and neck, followed by hyperemia and sweating), vegetative crises, often mental disorders (usually depression ). Characteristic ECG changes, often mistakenly taken as a sign of myocardial ischemia, are a negative T wave in leads V 1 – V 4. Drug therapy includes beta-blockers, and, if necessary, psychotropic drugs (neuroleptics, antidepressants).

Chest pain due to alcohol abuse

For toxic myocardial dystrophy (alcoholic cardiomyopathy)

• nagging, aching, stabbing pain localized in the area of ​​the nipple, apex of the heart,
• sometimes it involves the entire precordial region;
• not related to physical activity,
• appears gradually, gradually;
• lasts for hours and days, not relieved by nitroglycerin.
• Painful sensations are often combined with a feeling of lack of air (dissatisfaction with inhalation), palpitations, and coldness of the extremities.

At the initial stages of the disease, the correct diagnosis is helped by the connection between the occurrence of cardialgia and alcoholic excess, which is revealed through careful questioning - pain occurs the next day or a few days after alcohol abuse, when the patient comes out of binge drinking.

Characteristic appearance of a patient with chest pain due to alcoholism

• facial hyperemia,
• severe hand tremors.
• In later stages of the disease, an objective examination reveals signs of enlargement of the left and right parts of the heart,
• rhythm disturbances and symptoms of heart failure.

The ECG shows overload of the right and left parts of the heart, characteristic changes in the final part of the ventricular complex in the form of depression of the ST segment, the appearance of a pathological high, biphasic, isoelectric, negative T wave. Rapid - within 5 - 7 days - restoration of the normal ECG pattern in the absence of a characteristic An angina pectoris clinic can, as a rule, exclude coronary heart disease, so making an accurate diagnosis often requires hospitalization and observation in a cardiology department. Additional research methods - daily ECG-T monitoring, bicycle ergometry, echocardiography - may also be required to make a differential diagnosis.