Tightness in the chest

                   Feeling of tightness in the chest raises an alarm in every body, irrespective of age. Even though tightness in the chest is not always serious, it is necessary to get evaluated for ruling out some of the life threatening conditions.

Chest tightness could be due to a possible heart attack, angina, pericarditis, asthma attack, pleurisy, tearing in the wall of aorta, gastroesophageal reflux disease, anxiety or a muscle sprain. A qualified doctor would only be able to suggest whether this tightness in the chest is related to which condition and is it alarming or not.

You should check for the following things mentioned below, as your doctor would ask for the same to reach to an initial conclusion of what your condition is.

RED FLAG SIGN:

Tightness in the chest if accompanied by crushing, squeezing sensation with pressure in the chest with pain and pain radiating to the back or arm it is most likely to be related to a cardiac cause. If you notice any of these signs, you should get in touch with the ER immediately.

SELF DIAGNOSIS:

Access if you have the following:

• Sudden pain in the chest upon coughing or taking a deep breath > in that case the most possible diagnosis is Pleurisy(Pleuritic chest pain)
• Persistent tearing kind of sensation with tightening sensation in the upper back and lower chest > If you notice these symptoms which are most likely due to a tear in the wall of aorta(Aortic dissection), it is important to get in touch with the ER.
• Sharp pain on one side of the body with tightness in the chest accompanied by a feeling of stretching from chest to back is mostly due to Shingles virus activation.
• If you notice tightness in the chest that does not last more than ten minutes after a stressful event or trauma it could be attributed to Anxiety.
• Pain in the chest that is more pronounced while lying down with burning sensation and lasting for a long time is mostly related to GERD.
• Simple reasons like Muscle sprain can also cause pain in the chest of low intensity.

AGGRAVATING FACTORS AND RELIEVING FACTORS:

• Aggravated with activity and relieved with rest in the initial stages, but upon progressing pressure and pain can be felt even at rest > mostly due to coronary artery disease(Angina, Heart attack)
• Aggravated due to exposure to allergens like dust, chemicals, seasonal changes or certain food items and relief is with treatment(Asthma).  
• High blood pressure, which in turn is a result of underlying medical conditions can aggravate Aortic dissection. 
• GERD is usually aggravated with consumption of spicy foods, huge amount of alcohol, caffeine, stress etc. Relief is with use of antacids.

Most causes that lead to tightness in the chest are due to certain underlying conditions or risk factors for ex., cardiac conditions(atherosclerosis, high blood pressure), lung conditions(pneumonia, emphysema), for anxiety(trauma, stress) etc.

WHAT TO DO NEXT IF YOUR SYMPTOMS MATCH WITH ANY CONDITION

                       There is no reason to panic and reach to a conclusion, as there can be a lot of over lapping of symptoms and physical examination by your doctor along with certain investigations help confirm the diagnosis. You need to schedule an appointment with your doctor for this.

But before that make a note of what kind of pain you are experiencing, it’s duration, associated symptoms and pre-existing medical conditions for which you are taking treatment(as your doctor may ask you about all these factors). 

Your doctor would conduct a physical examination(auscultation of lungs, heart valve murmurs, check of blood pressure, pulse difference in both arms etc) and advise for further investigations listed below for concluding on the cause for tightness in the chest with pain.

WHAT INVESTIGATIONS ARE REQUIRED

Depending upon the findings of your clinical examination, your doctor might suggest some of the investigations listed below for concluding the cause for your symptoms and treatment for the same.

• ECG – Helps to find out changes during a heart attack or angina or pericarditis.
• Chest X-Ray – Helps in identifying pneumonia, emphysema, pleuritis)
• Measurement of cardiac enzymes – Blood tests showing changes which are common after a heart attack.
• Pulmonary function tests
• 2D Echo -  Specialized ultrasound examination of the heart which helps in better visualization of the heart and it’s chambers(valve abnormalities, functioning of the heart can be assessed).
• Computerized tomography – This generates cross sectional images of the organ examined. Contrast can be used during this procedure to better visualize heart, aorta and blood vessels.
• Magnetic resonance angiogram – This test is useful for looking into blood vessels applying magnetic field and pulses of radio wave energy to make images of the body(useful in diagnosing aortic dissection).
• Transesophageal echocardiogram -  This procedure involves the insertion of a ultrasound probe into the esophagus which lies close to the heart and aorta helping in better visualization of heart and it’s vessels(useful in diagnosing aortic dissection).
•  X Ray with barium swallow – This procedure involves drinking of chalky fluid and taking x rays after that, which allows better visualization of esophagus, stomach and duodenum.
• Test to check esophageal motility – Pressure and movement in the esophagus is measured by inserting a tube through nose into the esophagus.
• Endoscopy – A procedure in which a tube is inserted  down the throat equipped with a camera and light to visualize the upper gastrointestinal tract and to obtain a specimen for biopsy if required.

TREATMENT

• Treatment of angina is with nitroglycerin, along with management of underlying conditions like hypertension and diabetes.  Heart attacks are managed conservatively with aspirin, thrmbolytic drugs, antihypertensive medication followed by diagnostic angiogram. Depending upon the findings PCI with stenting or CABG is considered accordingly.
• For respiratory conditions like pleurisy underlying cause should be treated along with procedures to remove fluid from the cavity(thoracentesis) or insertion of chest tube(in case of pus accumulation), or pleurodesis depending upon the cause. Asthma is managed with beta agonists, corticosteroids and leukotriene modifiers. 
• Aortic dissection is treated with surgery (grafting or stenting) and use of medication like beta blockers and soium nitroprusside. Medications are mainly used for preparing the patient for surgery.
• Treatment of anxiety is with combination of drugs, cognitive-behavioural therapy, psychotherapy and relaxation therapy. Antidepressants and anxiety reducing drugs are useful in this situation. Cognitive-behavioural therapy involves making a person recognize and change troublesome thought patterns and behaviours.
• GERD is managed conservatively initially with medications such as antacids, H2receptor blockers, proton pump inhibitors and prokinetic agents. In case of no relief with use of medicines surgery is to be considered. Various procedures are employed depending upon the requirement in the patient. Common procedures used for this purpose include Nissen fundoplication(to reinforce lower esophageal sphincter),surgery to create a barrier for preventing the backup of stomach acid, stretta procedure(to form scar tissue in the esophagus), surgery to strengthen lower esophageal sphincter.

TIPS FOR PREVENTING TIGHTNESS IN THE CHEST

• Prevention of heart attacks or angina is done by maintaining healthy weight, quitting smoking, limiting alcohol and keeping blood pressure , diabetes and cholesterol levels under control.
• Attacks of asthma can be prevented by avoiding triggering factors which can induce an attack like dust, chemicals etc. In case of pleurisy, underlying conditions that can lead to pleurisy should be treated promptly to prevent it.
• Maintaining an ideal weight, avoiding smoking and keeping blood pressure under control can prevent acute cases of aortic dissection.
• Healthy , balanced diet avoiding caffeine, smoking with some amount of physical activity helps you stay calm, hence prevents anxiety attacks.
• Measures to prevent GERD are avoiding triggering foods like acidic foods(orange juice, tomatoes), caffeine products, eating small frequent meals. Avoid lying down immediately after a meal. Head end elevation while sleeping also helps. Limiting alcohol and avoiding smoking also helps.