Pain in middle of chest

Introduction

Pain in the middle of the chest is a common symptom that can signal a wide range of medical conditions. It may originate from the heart, lungs, gastrointestinal tract, musculoskeletal structures, or psychological factors. Prompt evaluation is essential to identify potentially life-threatening causes and guide appropriate management.

Anatomy of the Chest

Bony Structures

The central chest contains several bony landmarks that provide structural support and attachment points for muscles and ligaments:

• Sternum: Composed of the manubrium, body, and xiphoid process, the sternum protects underlying mediastinal structures.
• Ribs and Costal Cartilages: Twelve pairs of ribs articulate with the thoracic vertebrae and sternum, forming the rib cage.
• Thoracic Vertebrae: The twelve thoracic vertebrae provide posterior support and articulation for the ribs.

Muscles and Soft Tissue

Several muscles contribute to chest wall movement and stability:

• Pectoralis Major and Minor: These muscles facilitate shoulder movement and support the anterior chest wall.
• Intercostal Muscles: Located between the ribs, they assist in respiration by expanding and contracting the thoracic cavity.
• Diaphragm: The primary muscle of respiration, forming the floor of the thoracic cavity and separating it from the abdominal cavity.

Heart and Great Vessels

The heart and major vessels are located centrally and are key structures in mid-chest pain evaluation:

• Heart Chambers and Valves: The atria, ventricles, and associated valves maintain unidirectional blood flow.
• Aorta and Pulmonary Arteries/Veins: Major vessels that transport blood to and from the heart and lungs.
• Coronary Arteries: Supply oxygenated blood to the myocardium and are critical in ischemic chest pain.

Lungs and Pleura

The lungs and their surrounding pleura contribute to respiration and may be sources of chest pain:

• Right and left lungs, each divided into lobes for gas exchange
• Visceral pleura covering the lungs and parietal pleura lining the thoracic cavity, which can become inflamed in pleuritis

Esophagus and Gastrointestinal Structures

The esophagus passes through the thorax posterior to the heart and can be involved in chest pain:

• Esophagus course through the thorax, susceptible to reflux or spasm
• Proximity of the stomach and diaphragm may allow gastrointestinal conditions to mimic cardiac pain

Nerves and Other Structures

Several nerves and mediastinal structures are present in the central chest:

• Intercostal nerves providing sensation to the chest wall
• Vagus and phrenic nerves contributing to autonomic and motor functions
• Other mediastinal structures including lymph nodes and thymus gland in certain age groups

Etiology of Mid-Chest Pain

Cardiac Causes

• Acute Coronary Syndrome: Includes unstable angina and myocardial infarction, typically presenting with pressure or squeezing chest pain.
• Pericarditis: Inflammation of the pericardial sac causing sharp, pleuritic chest pain that may improve when sitting forward.
• Myocarditis: Inflammation of the heart muscle leading to chest discomfort, fatigue, and possible arrhythmias.
• Cardiomyopathy or Heart Failure: Can present with exertional chest discomfort, shortness of breath, and exercise intolerance.

Vascular Causes

• Aortic Dissection: Severe, sudden tearing chest pain radiating to the back or abdomen, often associated with hypertension.
• Pulmonary Embolism: Acute onset chest pain with dyspnea, sometimes accompanied by hemoptysis or syncope.
• Thoracic Aortic Aneurysm: Often asymptomatic but may cause central chest pain if expanding or ruptured.

Respiratory Causes

• Pneumothorax: Sudden unilateral chest pain with dyspnea due to collapsed lung.
• Pneumonia or Pleuritis: Infection or inflammation causing localized, sharp chest pain worsened by breathing.
• Pulmonary Hypertension: Chronic vascular disease causing retrosternal discomfort and exertional dyspnea.

Gastrointestinal Causes

• Gastroesophageal Reflux Disease (GERD): Burning chest pain often worse after meals or lying down.
• Esophageal Spasm or Motility Disorders: Intermittent chest pain mimicking angina, sometimes triggered by swallowing.
• Peptic Ulcer Disease: Epigastric discomfort that can radiate to the mid-chest.
• Hiatal Hernia: Can cause retrosternal burning or pressure sensation.

Musculoskeletal Causes

• Costochondritis or Tietze Syndrome: Localized tenderness of the costal cartilage producing reproducible chest pain.
• Muscle Strain or Trauma: Pain from pectoral or intercostal muscle injury.
• Rib Fractures: Acute, localized pain exacerbated by movement or palpation.

Psychogenic Causes

• Anxiety or Panic Attacks: Sudden, intense chest tightness often accompanied by palpitations, sweating, and shortness of breath.
• Somatic Symptom Disorder: Chronic chest discomfort without identifiable organic cause.

Other Causes

• Herpes Zoster: Pre-eruptive phase may cause localized burning or tingling chest pain.
• Mediastinal Masses or Tumors: Rare, but can compress mediastinal structures causing central chest discomfort.
• Referred Pain: From cervical spine or shoulder pathologies presenting as mid-chest pain.

Clinical Presentation

History

A detailed patient history is essential to differentiate causes of mid-chest pain. Important aspects include:

• Onset, duration, intensity, and character of pain (pressure, burning, sharp, or squeezing)
• Aggravating factors such as exertion, deep inspiration, swallowing, or body position
• Relieving factors including rest, medications, or antacids
• Associated symptoms like dyspnea, palpitations, nausea, sweating, or syncope
• Past medical history including cardiac, pulmonary, gastrointestinal, or psychiatric conditions
• Family history of cardiac disease or sudden death

Physical Examination

Physical examination aims to identify signs pointing to specific etiologies:

• Inspection: Observe respiratory effort, chest wall deformities, or visible swelling.
• Palpation: Evaluate for localized tenderness, masses, or costal cartilage inflammation.
• Auscultation: Listen to heart sounds for murmurs, rubs, or gallops; lungs for crackles, wheezing, or diminished breath sounds.
• Vital Signs and Perfusion: Assess blood pressure, heart rate, respiratory rate, oxygen saturation, and peripheral perfusion.
• Special Tests: May include orthostatic measurements, jugular venous pressure, or chest wall reproducibility tests.

Diagnostic Workup

Laboratory Tests

• Cardiac Biomarkers: Troponin and CK-MB to detect myocardial injury.
• Complete Blood Count and Inflammatory Markers: White blood cell count, ESR, and CRP to identify infection or inflammatory processes.
• Arterial Blood Gas: Assessed if respiratory compromise is suspected, such as in pulmonary embolism or pneumonia.

Imaging

• Chest X-ray: Evaluates lung fields, heart size, and mediastinal abnormalities.
• Electrocardiography (ECG): Detects ischemic changes, arrhythmias, or pericarditis.
• Echocardiography: Assesses cardiac structure, function, and pericardial effusion.
• CT or MRI: Used for aortic dissection, pulmonary embolism, or mediastinal masses.
• Upper Gastrointestinal Endoscopy: Evaluates esophageal pathology if gastrointestinal cause suspected.

Other Diagnostic Procedures

• Stress Testing or Coronary Angiography: Determines coronary artery disease and myocardial perfusion.
• Holter Monitoring: Continuous ECG monitoring for arrhythmias contributing to chest pain.
• Esophageal pH Monitoring or Manometry: Detects acid reflux or esophageal motility disorders.

Management

Cardiac Management

• Acute Coronary Syndrome: Administer medications, perform percutaneous coronary intervention, or surgery as indicated.
• Pericarditis and Myocarditis: Anti-inflammatory therapy including NSAIDs or colchicine; severe cases may require corticosteroids.

Vascular Management

• Aortic Dissection: Emergency surgical or endovascular repair.
• Pulmonary Embolism: Anticoagulation therapy or thrombolysis depending on severity and risk.

Respiratory Management

• Pneumothorax: Observation for small cases; chest tube or surgical intervention for larger or tension pneumothorax.
• Pneumonia: Appropriate antibiotics and supportive care including oxygen therapy if needed.

Gastrointestinal Management

• GERD: Lifestyle modifications, proton pump inhibitors, and H2 blockers.
• Esophageal Spasm: Smooth muscle relaxants or calcium channel blockers to relieve pain.
• Peptic Ulcer Disease: Proton pump inhibitors, H. pylori eradication therapy, and dietary adjustments.

Musculoskeletal and Psychogenic Management

• Costochondritis: Analgesics, local heat, and gentle stretching exercises.
• Muscle Strain or Rib Injury: Rest, analgesics, and physical therapy as appropriate.
• Anxiety or Panic Disorders: Cognitive-behavioral therapy, stress management techniques, and pharmacologic treatment if needed.

Complications

• Myocardial Infarction: Can lead to heart failure, arrhythmias, or sudden cardiac death if not promptly treated.
• Aortic Dissection or Rupture: Life-threatening complication causing massive internal bleeding and shock.
• Pulmonary Embolism: May result in respiratory failure or chronic thromboembolic pulmonary hypertension.
• Chronic Pain Syndromes: Persistent musculoskeletal or gastrointestinal chest pain can reduce quality of life.
• Arrhythmias: Untreated cardiac conditions may predispose to atrial or ventricular arrhythmias.

Prevention and Rehabilitation

• Cardiovascular Risk Factor Management: Control of hypertension, diabetes, dyslipidemia, and smoking cessation to prevent ischemic heart disease.
• Regular Exercise and Healthy Diet: Promotes cardiovascular fitness and reduces obesity-related risks.
• Post-Event Rehabilitation: Cardiac rehabilitation for myocardial infarction or surgery; pulmonary rehabilitation for respiratory conditions; physiotherapy for musculoskeletal injuries.
• Stress Reduction and Mental Health Support: Counseling, relaxation techniques, and treatment of anxiety disorders to reduce psychogenic chest pain.
• Routine Monitoring: Follow-up visits, imaging, and lab tests as appropriate to detect recurrence or progression of underlying conditions.

References

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