Have you ever rushed a family member to the emergency room fearing the worst because they complained of tightness in the chest or a dull, aching feeling near the breastbone, only to be told after a thorough examination that there was nothing wrong with their heart?
The doctor most likely would have made a diagnosis of gastric trouble or a condition affecting the oesophagus (the tube that connects the mouth to the stomach, commonly known as the food pipe).
What is non-cardiac chest pain?
Non-cardiac chest pain (NCCP) is described as pain in the chest area that could present as a sharp stab or a recurring pain and feels like it is emanating from the heart. In some people, it could also radiate to the arms and back.
NCCP is not related to the heart, and the most common cause for this type of pain is acid reflux or an abnormality in the oesophagus. Other causes for NCCP include musculoskeletal conditions, stomach ulcers, stress/anxiety disorders or more serious conditions such as lung collapse and chest injury. Doctors advise that any type of chest pain should be taken seriously and considered an emergency.
In a 2018 study, ‘Non-cardiac chest pain: prognosis and secondary healthcare utilisation’, published in the journal Open Heart, researchers found that around 60 per cent of people, who went to hospital emergency departments with chest pain were discharged with NCCP. The study revealed that mortality rate of people with cardiac-related chest pain was higher than those with NCCP and that 13.7 per cent of people diagnosed with NCCP came back to the emergency room with similar symptoms within a year.
“Any kind of chest pain should be considered as a medical emergency. The typical symptoms of heart attack are acute pain in the chest and shoulders, radiating to the arm. But nowadays, people may not present typical symptoms, so the treating doctor should take the medical history of the person and conduct a thorough examination. An electrocardiogram (ECG) must be done to rule out coronary heart disease. Apart from chest pain, if the person has recurring symptoms such as heartburn and regurgitation, it may most likely be a gastrointestinal (GI) problem. Many people who report chest pain may have earlier been diagnosed with irritable bowel syndrome (IBS),” says Dr Ashok Kumar, senior surgical gastroenterologist and Professor Emeritus at the Institute of Gastroenterology Sciences and Organ Transplant, Bengaluru.
Conditions that cause non-heart related chest pain
- Gastroesophageal reflux disease (GERD) — A disorder that affects the digestive system, GERD occurs when acids, food and other contents of the stomach flow back into the oesophagus and up into the throat and mouth. This happens when the valve at the junction of the lower oesophagus and the stomach does not close properly because of weakness. Acid reflux may affect most people once in a while, but if it occurs continuously for more than once a week, then it is termed as GERD. Heartburn, regurgitation (food coming back into the mouth) and chest pain are the most common symptoms of this disorder. GERD causes irritation of the inner lining of the oesophagus and if untreated for long, it can cause serious GI problems.
- Hiatal hernia — It is a condition where the stomach pushes through an opening in the diaphragm and protrudes into the chest, sometimes resulting in the stomach becoming twisted. The pressure on the stomach pushes the acids up into the oesophagus, resulting in nausea, chest pain, heart burn and difficulty in swallowing.
- Acid peptic disease (APD) — APD is a group of GI disorders caused by excessive production of acid in the stomach and upper part of the GI tract (duodenum) that causes irritation and inflammation of the inner mucosal lining of the stomach and duodenum. Gastritis is induced by the Helicobacter pylori bacterium, certain anti-inflammatory drugs or alcohol consumption; stomach and duodenal ulcers are all examples of APD.
- Problems with the oesophagus — A few conditions that affect the food pipe may result in chest pain. These include muscle spasms (abnormal twisting and squeezing of the oesophagus); hypersensitive oesophagus (muscles and nerves in the food pipe are overly sensitive and small changes in the pressure and nature of the acid can bring on chest pain) and inflammation of the oesophagus due to infections or allergic reactions to foods.
- Musculoskeletal conditions — Ailments that affect the muscles and bones near the heart, lungs and oesophagus can produce pain in the chest wall. Costochondritis is one such condition, which occurs when the cartilage that connects part of the rib cage to the breastbone gets inflamed. Chest trauma caused by injury to the chest wall and nearby bones and muscles may also cause chest pain.
- Pneumothorax or lung collapse — Lung collapse occurs when air leaks into the gap between the lungs and chest wall. It often happens as a result of injury to the chest area and can cause severe chest pain.
- Pulmonary embolism — In this ailment that affects the lungs, blood flow to the organ is blocked because of blood clots in the pulmonary artery. Symptoms of pulmonary embolism include acute chest pain and difficulty in breathing.
- Psychological issues — Recurrent chest pain may also be an indication of stress, depression, anxiety disorders and panic attacks.
“Obesity, pregnancy, poor food habits and stress are the main risk factors for NCCP. Lifestyle changes are necessary to prevent recurrent chest pain of this kind, otherwise the affected person may have a poor quality of life,” adds Dr Kumar.
Tips to prevent NCCP
- Avoid overeating or keeping your stomach empty for long periods.
- Adopt a fitness regime and exercise regularly.
- Have a well-balanced diet and eat at regular intervals.
- Reduce consumption of junk food/spicy food, caffeinated drinks and alcohol.
- Keep a three-hour gap between the last meal of the day and bedtime.
- Avoid smoking.
Diagnosis and treatment
After conducting tests that rule out heart attack, a person with NCCP may be asked to undergo upper GI endoscopy or gastroscopy, wherein a small tube-like device with a light and camera at one end is inserted through the mouth into the food pipe and stomach to check for abnormalities. This test will also detect ulcers in the stomach.
Prescription medications including acid suppressants and proton pump inhibitors may give relief in GERD and other gastrointestinal disorders. Doctors may give pain medication and anti-inflammatory drugs for musculoskeletal conditions. A person may require surgery to treat severe hiatal hernia, lung collapse and serious chest trauma. Behavioural therapy is recommended for stress and anxiety issues.