Chest Pain – Part 2 – more chest pains

By Julian Booker, MD

When we last spoke, we were discussing angina. We now know what it usually feels like and what it usually means. But there are many other reason to have chest pain, some dangerous and some not. We will spend the next bit of our time today discussing some causes of chest pain not related to the heart. Before we go further, remember any chest pain that is new or worsening, or any concerning symptoms whatsoever should be evaluated by a qualified health care professional.

We now know that angina most often feels like pressure, heaviness, tightness, fullness, etc. So what about sharp, piercing or stabbing pain? (Before we go too much further, I should probably disclose that a small percentage of people with angina will describe their pain as sharp piercing or stabbing.) Pain with this type of characteristic tends not to be heart related but there are some pretty dangerous conditions that present that way. This blog post is in no means mean to be exhaustive and will focus primarily on other causes of chest pain involving the heart and blood vessels.

Pulmonary embolism

Pulmonary embolism, or a blood clot in the lungs, is one of those dangerous causes that I was referring to. These blood clots usually originate in the legs and/or pelvis. Blood clots can occur if you have been very sedentary for long periods of time like during a plane trip or a long car ride. When the blood clots break free they travel through the heart and lodge themselves in the arteries that take blood through the lungs. The pain occurs on the same side where the lung’s artery is blocked. The pain is pleuritic meaning that it is worse with taking a deep breath or coughing. As you might imaging, the decreased blood flow through the lung can lead to shortness of breath and low oxygen levels. If the blood clot is large enough, it can put a tremendous strain on your heart and even cause it to fail. Treatment for pulmonary emboli is primarily accomplished with blood thinners but more severe cases may require “clot busting” medications or surgery.

Aortic dissection

Aortic dissection is a tear in the wall of the aorta. The aorta is the largest, most important artery in the body. It is attached directly to the heart and supplies blood to the entire body. The wall of the aorta is made of several layers, like an onion, and the tear allows blood flow to travel between the layers instead of down the barrel of the blood vessel. People describe the pain associated with dissection as a ripping or tearing within the chest. The pain is severe and starts suddenly. The pain often moves to the back between the shoulder blades if the involved section is within the chest or includes the abdomen in the extent involves the abdominal aorta. Other symptoms include fainting spells, heart failure, stroke and sudden cardiac death.

A tear can start small but can extend the entire extent of the aorta. If the dissection becomes too large, it can compromise blood flow to the body’s organs or even cause the aorta to burst. If this stuff sounds scary, it is because it is scary. Aortic dissection is considered a medical emergency for a reason.  Emergency surgery may be required. About 40% of patients never make it to the hospital for evaluation. Your physician can evaluate for aortic dissection by special imaging tests. If their concern for dissection is low then a simple blood test may be all that is required.

An aortic aneurysm is when the aorta becomes abnormally large. Aortic aneurysms typically are not painful although if your aneurysm is growing quickly, there can be associated discomfort. It is important to take note of your aneurysm because they predispose to aortic dissection and rupture. Aneurysms are not medical emergencies per se but can evolve into one if you are not careful. Certain situations predispose to aneurysm and dissection such as Marfan syndrome, Ehlers-Danlos syndrome, bicuspid aortic valve, strong family history of problems with the aorta, etc.


Pericarditis is inflammation involving the protective sac surrounding the heart called the pericardium. Some of the more frequent causes of pericarditis include recent myocardial infarction, viral infection, and in the setting of end-stage renal disease or auto-immune diseases such as lupus. Pericarditis has presents as sharp chest pain that sometimes radiates to the mid back. The characteristic that makes chest pain from pericarditis stand out from all other chest pain is that is has a very specific positional pattern. Your chest pain will be worse when lying down but improved with sitting up or leaning forward. The diagnosis of pericarditis is primarily made from the history of physical examination but documentation of fluid in the pericardial space on echocardiography or CT can provide a helpful clue.

Pericarditis is not going to kill you (although it may feel like it) but can be associated with some other conditions that cause some problems. If too much fluid collects around the heart then it can compromise blood though through the heart chambers and can lead to collapse of your circulatory system. Your doctor can figure this out by the physical examination and echocardiography. Sometimes if the inflammation becomes chronic, it can lead to hardening of the pericardial sac leading to a condition called constrictive pericarditis (This will have to be a whole different post unto itself).

Aortic stenosis

The aortic valve allows blood to flow from the heart into the aorta but prevents blood from leaking back into the heart.  In aortic stenosis, sometimes called aortic valve stenosis, the aortic valve does not open normally. This forces the heart to work harder and can even result in diminished blood flow to the body. The heart’s struggle leads to chest pain that is very similar to angina. From this point, you should refer to my post on aortic stenosis.

We have spent our time today reviewing non-coronary causes of cardiovascular chest pain. If you have further questions you can always contact us at MyHeart but don’t forget to communicate with your physician. Most of the time chest pain is benign but when it is not benign, it can be a killer. Respect chest pain syndromes and keep yourself safe.

The next entry will deal with some of the non-cardiovascular causes of chest pain.

About Julian Booker, MD

I am a noninvasive cardiologist at the University of Alabama at Birmingham specializing in multi-modality cardiovascular imaging and preventative medicine. My training was primarily at Baylor College of Medicine in Houston TX and the National Institutes of Health in Bethesda MD.
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7 Responses to Chest Pain – Part 2 – more chest pains

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