Pain in the left side of the chest. What to do if it presses in the chest on the right, left or in the middle? Spleen disorders

A common pain in adults is tenderness in the sternum on the left side. It can be of a different nature and intensity: stabbing, sharp, aching, dull, pulling. Often this pain is dangerous and can be fatal. Therefore, it is important, first of all, to consult a doctor and undergo the necessary examination to determine the exact diagnosis.

What can this condition indicate and what to do in this case? More answers to these questions can be found in this article.

Causes of pain in the chest are extracardiac, that is, not related to the heart, and intracardial, namely intracardiac.

It can hurt on the left in the sternum as a result of various pathological conditions. These include primarily diseases of the heart and blood vessels. Such diseases are divided into non-coronary and coronary diseases.

Non-coronary - heart defects, angina pectoris, pericarditis, cardiomyopathy, myocarditis, atherosclerosis, hypertension, thrombosis, mitral canal prolapse, aneurysm. The second group includes such pathologies as myocardial infarction and ischemic disease.

Other causes of pain in the sternum on the left side include:

• Diseases of the digestive organs (acid reflux, esophageal hernia, gastric ulcer, enterocolitis, cholecystitis, esophagitis, narrowing of the esophagus).
• Respiratory diseases (spontaneous pneumothorax, pneumonia, pulmonary embolism, pleurisy, tuberculosis, bronchiectasis, oncology, abscess).
• Neurological pathologies (intercostal neuralgia, neurocirculatory dystonia, psychovegetative syndrome).
• Diseases of the spine (osteochondrosis).
• Tumors in the soft tissues of the chest, localizing on the left.
• In some cases, such pain can be provoked by psycho-emotional overstrain, great physical exertion, and fatigue.

Sometimes soreness in the chest area can occur with various diseases of the ribs or pectoral muscles. In addition, increased sports training and the condition after a cold also affect the development of pain.

Signs and dangerous symptoms

If pain in the sternum is caused by diseases of the vascular heart, then it may be accompanied by the following symptoms:

• Increased heart rate.
• Dyspnea.
• Feeling of fear.
• Nausea.

Typically, such pain has a compressive and pressing character, often radiating to the upper limb or neck.

Respiratory diseases, in addition to chest pain, may have other signs:

1. Cough
2. hyperthermia
3. Dyspnea
4. Hemoptysis
5. General weakness
6. Labored breathing
7. Wheezing and wheezing in the lungs

With pulmonary thromboembolism, pain in the sternum is stabbing, acute, and may be accompanied by loss of consciousness. Without medical attention, death is possible.With pathologies of the digestive organs, the pain intensifies after eating. In addition, heartburn, vomiting, nausea and other disorders are possible.

Pain can provoke a disease of the spine. In this case, the pain is acute, it depends on the change in the position of the body.

In each case, general weakness, loss of working capacity, anxiety and anxiety are characteristic.

Dangerous signs, upon the appearance of which it is necessary to immediately call for immediate help, include loss or clouding of consciousness, hemoptysis, temperature over 38.5 degrees, numbness of the extremities, inability to breathe.

Pain in the sternum on the left should by no means be ignored. After all, this condition can be caused by various diseases that can be fatal.

These pathologies include:

• Aneurysm
• Thrombopulmonary embolism
• Oncological diseases

There are dangerous signs in which you must immediately call an ambulance. If a person has a history of heart muscle pathology, and chest pain on the left does not go away after taking Nitroglycerin, then this fact may indicate a myocardial infarction. With this pathology, there may be vomiting, increased sweating.

Danger also becomes a rupture of the aorta, which has signs of a stroke (limbs and tongue go numb, paralysis of body parts occurs.These pathological conditions are dangerous because they lead to disability or death.

Diagnostic methods

With pain on the left side of the sternum, you may need to consult such specialists as a cardiologist, neurologist, therapist, gastroenterologist, pulmonologist, resuscitator, oncologist, nutritionist.

A mandatory study for various pathological processes is considered to be a blood and urine test.

If a heart attack is suspected, the following diagnostic methods are prescribed:

1. Palpation of the sternum.
2. A blood test for enzymes that produce heart muscle cells.

Also, the diagnostic methods that are used for pain in the sternum on the left include:

• Chest x-ray
• CT scan
• Ventilation perfusion scan
• In diseases associated with blood vessels, angiography may be prescribed.

If there is a suspicion of pathological conditions of the organs of the alimentary tract, then esophagoscopy, fluoroscopy and Bernstein's tests are usually done.The direction for these studies is given by a specialist. It is possible to assign other additional diagnostics.

Treatment Method

Treatment is primarily directed at the underlying cause and depends on the diagnosis. It can be conservative or surgical. Most often, treatment takes place in a hospital setting.

Treatment features:

• For pain in the sternum due to pathologies of the cardiovascular system, it is necessary to call an ambulance and give the patient Nitroglycerin.In a hospital, drugs are used that help unblock blood flow. Usually, Heparin, Aspirin, thrombolytic agents are used for this purpose.
• In the case of pericarditis, anti-inflammatory non-steroidal drugs are given. Beta-blockers are also prescribed, for example, Bisoprolol, Metoprolol, Atenolol.
• Metasone, Morphine, Dopamine, drugs that slow down the heart rate are used as painkillers for aneurysms. In addition, drugs are used that lower blood pressure. These are diuretic drugs: Diroton, Anaprilin or Berlipril.
• In the case of the treatment of diseases of the alimentary tract, obligatory treatment is the observance of a special diet. If the patient has peptic ulcer or acid reflux, then drugs are used to reduce the acidity of gastric juice, for example, Ranisan.
• In some cases, antibiotics, antacids, antifungals, and antivirals may be indicated.
• If the pain began as a result of other causes (with inflammatory processes in the ribs and muscles, or after colds), then anti-inflammatory drugs are usually used, for example, Ibuprofen, Naproxen, Diclofenac, Solpadein. Physical therapy, the use of mustard plasters, warming ointments, and massage are also prescribed.

It is important to remember that with soreness in the chest, self-medication is not allowed. The choice of medications should be carried out only by an experienced specialist. It takes into account the diagnosis, concomitant diseases, the nature and extent of the course of the disease, the individual characteristics of the patient's body.

In severe diseases that are accompanied by pain in the sternum, surgery may be necessary.

In some cases, alternative medicine may be used. However, it is important to remember that they are considered only auxiliary methods, and the possibility of their use must be approved by a doctor.

Forecast and preventive measures

The prognosis depends on the diagnosis of the patient. In case of failure to provide qualified assistance in case of a heart attack, mitral canal prolapse, aortic aneurysm, stroke, a fatal outcome is possible.Death also occurs when treatment of pulmonary thromboembolism and pneumothorax is ignored.

In other cases, with a properly selected treatment method, the prognosis is favorable. It is important to say that the prognosis primarily depends on whether the diagnosis was made correctly or not.

To prevent the development of diseases, a symptom of which is pain on the left side of the chest, it is necessary to follow the general rules for the prevention of pathologies, which include:

1. Refusal of bad habits (alcohol abuse, smoking, drugs).
2. Complete and balanced nutrition.
3. Compliance with the drinking regime.
4. Performing hardening procedures.
5. Sports and exercise.
6. Avoidance of stressful situations.
7. Complete sleep.
8. Avoid overwork.
9. Fulfillment of medical orders.

Preventive measures are also considered annual medical examinations.

You can learn more about the possible causes of pain in the sternum from the video:

The chest is a rather sensitive area, and chest pain from above can indicate both the development of diseases of the internal organs and complications in the work of the whole organism. The chest hurts from above, what kind of symptom is this - the main question posed in this article.

Causes of chest pain

If a woman has a sore left breast after or before the onset of menstruation, then the cause of the discomfort is elementary - hormonal changes in the body. During the onset of menstruation, the woman's body is rebuilt, and therefore a kind of pressure is exerted on the chest, as the most sensitive area of ​​the female body. If the mammary glands also swell a little, increase in size, then the sensation of pain turns out to be stoic and does not disappear for several days. Unpleasant sensations are usually felt on the top of the chest or on the side.

If the left and right breasts hurt, the girl should pay attention to the nature of the discomfort. In the event that the symptom manifests itself only in the process of inhaling air, and in addition to this, the person makes wheezing, then we are talking about diseases of the pulmonary system. A more accurate diagnosis can only be made by a specialist, but usually the cause of the problem lies in bronchitis, tuberculosis and pneumonia. By the way, with bronchitis, pain in the right chest is more often felt, which increases when pressed. The source of pain is localized on top of the chest, because of which the woman is faced with a feeling of constant discomfort.

In the event that a lady has pain in both the right and left breasts from above, the reason may be in the development of mastopathy. This incredibly popular disease now occurs in every third woman. In the process of the development of the disease, so-called cords are formed in the mammary glands, because of which this area begins to ache. First, unpleasant sensations appear in the upper chest, and then they begin to spread.

Mastopathy is a very serious disease, and in order to fight it, a person must immediately consult a doctor. If treatment is not carried out in time, mastopathy can develop, because of which a person will face benign and malignant tumors.

A few more causes of chest pain and an algorithm of actions

If a person has a chest pain at the top, one should not exclude the possibility of developing cardiovascular diseases. Usually, discomfort in this area occurs due to atherosclerosis of the heart vessels or ischemia. It is interesting that men aged 40 to 65 years are more susceptible to the development of such diseases, however, women with unpleasant symptoms may also encounter. If chest pain indicates the development of heart disease, a person will definitely begin to suffer due to high blood pressure, feel a headache with increased stress on the body. You should not ignore such a symptom, because often, by paying attention to pain in the chest area from above, a person can prevent serious consequences for his body.

If a person has a severe pain in the left chest from above, the reason may be more commonplace. So, for example, discomfort at the top of the chest occurs due to anxiety, constant stress and strong excitement. Along the way, a person feels easily dizzy and tingling in the fingertips. If stress is regular, then against its background a person may develop a neurological disease, and chest pains will become a regular companion of the patient.

It is usually quite easy to diagnose chest pain associated with anxiety, because they appear only in stressful moments, and disappear as suddenly as they appeared.

Another common cause of chest pain from above is serious diseases of the musculoskeletal system. So, for example, discomfort can develop against the background of the progress of costal chondritis. Another common cause of discomfort is a broken rib. Such a serious injury sometimes causes very unpleasant painful sensations. By the way, due to a crack in the rib, a person can also feel severe pain from above in the chest, which does not subside even after taking strong medications. Any mechanical injury, strong blows to the chest can cause pain. This area is considered amazingly sensitive in both men and women, and that is why it is always necessary to pay attention to unpleasant sensations that appear suddenly.

What to do if the left breast hurts from above? In this situation, it is necessary to consult a doctor as soon as possible, because the cause of discomfort can be different. So, pain in the left chest most often indicates the development of cardiovascular diseases. Such unpleasant sensations are regular in nature, and are often accompanied by additional unpleasant symptoms. The reason may be in mastopathy, and in mechanical damage to the chest.

The final diagnosis can only be made by a doctor with a thorough examination and sampling. If the specialist has doubts about the cause of the pain, he can conduct an ultrasound of the chest. This procedure helps to identify the source of pain and eliminate it.

The treatment algorithm itself directly depends on the diagnosis. For example, if chest pain from above is due to mastopathy, treatment is limited to taking medication. If the cause lay in a mechanical injury, a person will need to undergo a course of treatment and, possibly, apply a cast. Pain in the upper chest also occurs due to diseases of the cardiovascular or pulmonary system. In this case, treatment involves regular visits to the doctor and the use of the most modern techniques. When diagnosing bronchitis and tuberculosis, a person may be hospitalized in order to monitor the recovery process as closely as possible.

It is almost impossible to make a correct diagnosis on your own at home. Severe chest pain from above is a sign that is too common, indicating many diseases, and therefore a person without special education can easily make a fatal mistake in diagnosing.

Chest pain usually alerts a person immediately, especially if they are strong and appear suddenly. In order to make a correct diagnosis, a person needs to see a doctor, because only a specialist will be able to explain the cause of the deterioration in health and prescribe the appropriate treatment.

The cause of any discomfort in the chest area should be identified in a timely manner. They can occur for various reasons and signal serious illnesses. Pain in the left side of the chest often indicates the presence of pathologies of the heart, musculoskeletal system, abdominal organs or breathing. To determine why the discomfort has appeared, seek medical attention. It is almost impossible to determine the exact cause on your own.

Often, discomfort occurs due to a pinched nerve due to a long stay in an uncomfortable position of the body. Other causes of stabbing chest pain may include:

Main types of chest pain

Based on what symptoms occur in addition to discomfort in the chest area, you can understand what caused it. For example:

• shortness of breath indicates an attack of angina pectoris, and is also a manifestation of diseases of the respiratory system;
• pain that radiates to the upper limbs indicates myocardial infarction or osteochondrosis;
• stabbing pain in the left side of the chest, which increases with deep inspiration, coughing, movement - most likely neuralgia;
• if the discomfort lasts for a long time, this indicates tuberculosis, lung cancer.

No matter what symptoms you have, see your doctor if you experience pain. You need to consult a therapist who, if necessary, will refer you to a specialist.

Chest pain in heart disease

In modern medicine, the main heart diseases that cause chest pain are coronarogenic and non-coronary lesions. The first group includes atherosclerosis and heart attack. The most common non-coronary pathologies are:

• angina;
• pericarditis;
• myocarditis;
• hypertension;
• cardiomyopathy.

Often, pain on the left side of the chest occurs in people suffering from congenital and acquired heart defects.

Diagnosis of pain on the left side of the chest

To understand how to cope with discomfort, it is necessary to undergo a diagnosis. Pain on the left side of the chest cannot appear on its own. Therefore, you should undergo a medical examination. To roughly determine how serious your condition is, a self-diagnosis test on our website will help. It does not replace the advice of a doctor, but it does provide an opportunity to narrow down the range of possible pathologies you may have. It is important to remember that the results of self-diagnosis cannot be used to prescribe treatment. The primary diagnosis of patients who have pain in the left upper chest is carried out by a general practitioner. It begins with an analysis of complaints and anamnesis. Further, if necessary, the doctor directs for examinations or for a consultation with specialists from other areas (cardiologist, neurologist, pulmonologist). Among the procedures that may be necessary for patients with similar manifestations are:

Patients who complain of chest pain may also be scheduled for general and biochemical blood tests. They will allow you to determine the presence of inflammatory processes in the body, as well as enzymes that are produced during a heart attack.

The cost of the examination in case of discomfort in the chest will be from 1000 to 5000 rubles. It depends on the complexity of the case. The initial consultation of specialists will cost 800-1500 rubles.

Which doctor can help?

For pain in the left side of the chest, you should consult a doctor of the following specialty:

After the examination, the doctor will prescribe the necessary diagnostics in your case. Some diseases are difficult to diagnose as they say "by eye". Therefore, you need to trust the doctor when prescribing research. After all the tests, the doctor will be able to draw up the correct course of treatment. Remember: accurate diagnosis and correct diagnosis are already 50% of success in treatment!

Pain in the left side of the chest manifests itself for various reasons, which cannot be independently determined. To facilitate your well-being, you need to contact a specialist to undergo a diagnosis, identify the nature of discomfort and prescribe appropriate treatment. This article will be devoted to these aspects.

To the question why the left side of the chest hurts, only a doctor will competently answer.

Since there are many reasons due to which chest pain develops on the left. The most common are listed below:

The relationship between the cause of the disease and the nature of the pain

When it hurts in the upper left part of the chest, this does not always indicate a life-threatening condition. However, with the development of these symptoms, you need to consult a specialist.

To accurately understand the cause of the development of discomfort, you need to consider the intensity of pain, its localization and diseases that are related to it.

Sharp pain

The development of a sharp pain syndrome is characteristic of the following diseases:

acute pain

Acute pain occurs when:

Pain of a different nature and first aid

Pain in the left side of the aching character is manifested when:

Pain that radiates to the arm is characteristic of:

1. Heart attack. Prolonged discomfort that is given to the left shoulder, arm and neck area is often a harbinger of a heart attack and requires an immediate call to a doctor.
2. Cardiac ischemia is an obstacle to normal blood flow, leads to atrophy of the heart muscle, has signs similar to a heart attack.
3. Angina pectoris is manifested by a sharp discomfort that radiates to the left side of the arm.

Pain sensations that give under the ribs are manifested when:

Discomfort that manifests itself above the chest occurs when:

1. Fibromyalgia, which develops due to regular mental shocks.
2. Mastopathy, which develops due to the replacement of glandular tissue with fibrous tissue and is manifested by pulling, pressing and tingling discomfort.
3. A breast cyst that appears as a liquid capsule due to a hormonal shift. There are times when a cyst develops as a result of injury.

Many women, when pain occurs in the chest area, are worried, associating discomfort with breast cancer. In fact, at the initial stage of oncology, cancer does not manifest itself in any way. Thus, if a woman has discomfort in the left side of her chest, then this is most likely not oncology.

Treatment of pain that has developed in the chest depends on the cause of the disease. It is impossible to take medicines on your own, you must urgently consult a doctor for diagnosis and the appointment of adequate treatment. Before the arrival of the doctor, you can drink painkillers:

• No-shpu;
• Spazmalgon;
• ibuprofen;
• Analgin.

If the discomfort is caused by a heart condition, then the following can be used to reduce the heart rate and relieve the condition:

• Valerian;
• Nitroglycerine;
• Validol.

There are some symptoms that you need to pay increased attention to and immediately call an ambulance, among them:

If the chest hurts on the left, then this can indicate many diseases that cannot be determined independently.

Therefore, if such symptoms appear, you should consult a specialist.

The main causes of pain in the upper chest:

• diseases of the musculoskeletal system: costal chondritis, 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, spasm of the esophagus, gastric and duodenal ulcer, gallbladder disease;
• anxiety states: vague anxiety or "stress", panic disorders;
• pulmonary diseases: pleurodynia (pleuralgia), acute bronchitis, pneumonia;
• neurological diseases;
• uncharacteristic defined or atypical pain in the upper chest.

Pain in the upper chest is not limited to a certain age group, but is more common in adults than in children. The highest percentage is observed among adults over 65 years of age, and in second place are male patients aged 45 to 65 years.

Frequency of diagnosis, by age and sex

No less difficult is the position of the doctor in the initial interpretation of pain, when he tries to connect it with the pathology of one or another organ. 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 likely to be functional. The works devoted to the detailed analysis of pains in the top part of a breast are not numerous; the groupings of pains proposed in them are far from perfect. These shortcomings are due to objective difficulties in analyzing the patient's sensations.

The complexity of interpreting pain in the chest is also due to the fact that the detected pathology of one or another organ of the chest or musculoskeletal formation does not mean that it is the source of pain; in other words, the identification of a disease does not mean that the cause of pain is precisely determined.

When evaluating patients with upper chest pain, the clinician must weigh all relevant options for potential causes of pain, determine when intervention is needed, and choose from an almost limitless number of diagnostic and therapeutic strategies. All this must be done while responding to the distress experienced by patients concerned about the presence of a life-threatening illness. The difficulty in diagnosis is further complicated by the fact that upper chest pain is often a complex interplay of psychological, pathological, and psychosocial factors. This makes it the most common problem in primary care.

When considering upper chest pain, there are (at a minimum) five elements to consider: predisposing factors; description of the attack of pain; duration of painful episodes; characterization of the actual pain; pain relieving factors.

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 according to the nosological or organ principle.

Conventionally, 6 following groups of causes of pain in the upper chest can be distinguished:

1. Pain caused by heart disease (so-called heart pain). These pains 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 "heart pain syndrome", "heart pain", understanding their connection with a particular pathology of the heart.
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 the pathology of the spine, anterior chest wall and muscles of the shoulder girdle.
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 apparent 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" pains include all types of anginal (coronary) pains, pain in pulmonary embolism (PE), dissecting aortic aneurysm, spontaneous pneumothorax. By "non-dangerous" - pain in the pathology of the intercostal muscles, nerves, bone and cartilage formations of the chest. "Dangerous" pains are accompanied by a suddenly developed serious condition or severe disorders of the heart 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 in the upper chest, which are life-threatening:

• cardiological: acute or unstable angina pectoris, myocardial infarction, dissecting aortic aneurysm;
• pulmonary: pulmonary embolism; tension pneumothorax.

It should be noted that the correct interpretation of pain in the upper chest is quite possible with the usual physical examination of the patient using a minimum number of instrumental methods (conventional electrocardiographic and x-ray examination). An erroneous initial idea 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 findings to determine causes of upper chest pain

Cardialgia (non-anginal pain). Cardialgia, caused by certain diseases of the heart, are very common. By its origin, significance and place in the structure of the incidence of the population, 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 as follows:

1. Primary or secondary cardiovascular functional disorders - the so-called cardiovascular syndrome of the neurotic type or neurocirculatory dystonia.
2. Diseases of the pericardium.
3. Inflammatory diseases of the myocardium.
4. Dystrophy of the heart muscle (anemia, progressive muscular dystrophy, alcoholism, beriberi or starvation, hyperthyroidism, hypothyroidism, catecholamine effects).

As a rule, non-anginal pains are benign, as they are not accompanied by coronary insufficiency and do not lead to the development of ischemia or myocardial necrosis. However, in patients with functional disorders leading to an increase (usually short-term) in the level of biologically active substances (catecholamins), the likelihood of ischemia still exists.

Pain in the upper chest of neurotic origin. We are talking about pain in the region of the heart, as one of the manifestations of neurosis or neurocirculatory dystonia (vegetative-vascular dystonia). Usually these are pains of a aching or stabbing nature, of varying intensity, sometimes long-term (hours, days) or, conversely, very short-term, instantaneous, penetrating. The localization of these pains is very different, not always constant, almost never retrosternal. Pain may increase with physical exertion, but usually with psycho-emotional stress, fatigue, without a clear effect of the use of nitroglycerin, they do 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, subfebrile condition, pulse and blood pressure fluctuations), as well as young or middle age of patients, mostly female. These patients have increased fatigue, decreased exercise tolerance, anxiety, depression, phobias, fluctuations in pulse, blood pressure. In contrast to the severity of subjective disorders, an objective study, including using various additional methods, does not reveal a specific pathology.

Sometimes among these symptoms of neurotic origin, the so-called hyperventilation syndrome is revealed. This syndrome is manifested by an arbitrary or involuntary increase and deepening of respiratory movements, tachycardia, arising in connection with adverse psycho-emotional influences. This may cause pain in the upper chest, as well as paresthesia and muscle twitching in the limbs due to the resulting respiratory alkalosis. There are observations (incompletely 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 it is hyperventilation that can cause pain in the region of the heart during exercise testing in individuals 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 in the upper chest, 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 distension of the stomach. These pains can spread upward, behind the sternum, into the neck and the area of ​​the left shoulder blade, simulating angina pectoris. Such pains are aggravated by pressure on the epigastric region, in the prone position, with deep breathing, they decrease with belching with air. With percussion, an expansion of the Traube space zone is found, including tympanitis over the area of ​​\u200b\u200babsolute dullness of the heart, with fluoroscopy - an enlarged gastric bladder. Similar pains can occur when stretching the gases of the left corner of the colon. In this case, the pain is often associated with constipation and is relieved after a bowel movement. A thorough history usually allows the true nature of the pain to be determined.

The pathogenesis of cardiac pain in neurocirculatory dystonia is unclear, due to the impossibility of their experimental reproduction and confirmation in the clinic and experiment, in contrast to anginal pain. Perhaps, in connection with this circumstance, a number of researchers generally question the presence of pain in the heart with neurocirculatory dystonia. Similar trends are most common among representatives of the psychosomatic trend 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 states is also explained from the standpoint of the cortico-visceral theory, according to which, when the vegetative devices of the heart are stimulated, a pathological dominant appears 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 a violation of myocardial metabolism against the background of excessive adrenal stimulation. At the same time, 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 relationship between pain in the region of the heart and emotional influences confirm the role of catecholamines as a trigger for pain. This position is supported by the fact that intravenous administration of izadrin to patients with neurocirculatory dystonia causes pain in the region of the heart such as cardialgia. Obviously, catecholamine stimulation can also explain the provocation of cardialgia with a test with hyperventilation, as well as its occurrence at the height of respiratory disorders with 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 pain in the heart syndrome in neurocirculatory dystonia is played by the flow of pathological impulses coming from hyperalgesia zones in the muscles of the anterior chest wall to the corresponding segments of the spinal cord, where, according to the "gateway" theory, the summation phenomenon occurs. In this case, a reverse flow of impulses is noted, causing irritation of the thoracic sympathetic ganglia. Of course, the low threshold of pain sensitivity in vegetative-vascular dystonia also matters.

In the occurrence of pain, such still insufficiently studied factors as impaired microcirculation, changes in the rheological properties of the blood, and an increase in the activity of the kinincallikrein system can play a role. It is possible that with the long-term existence of severe vegetative-vascular dystonia, its transition to coronary artery disease with unchanged coronary arteries, in which pain is caused by spasm of the coronary arteries, is possible. 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 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 in pericardial lesions is quite understandable, since there are sensitive nerve endings in the pericardium. 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 mid-clavicular line, and irritation of the pericardium in the region of 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 coronary artery disease. Pain in myocarditis is probably associated with irritation of the nerve endings located in the epicardium, as well as with inflammatory myocardial edema (in the acute phase of the disease).

Even more uncertain is the origin of pain in myocardial dystrophies of various origins. Probably, the pain syndrome is due to a violation of myocardial metabolism, the concept of local tissue hormones, convincingly presented by N.R. Paleev et al. (1982) may also 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 essential.

It is necessary to dwell 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-coronary forms). However, under these pathological conditions, in some cases, unfavorable hemodynamic factors occur, causing relative myocardial ischemia. It is believed that the angina-type pain observed in aortic insufficiency depends primarily on low diastolic pressure and, consequently, low coronary perfusion (coronary blood flow is realized during diastole).

With aortic stenosis or idiopathic myocardial hypertrophy, the appearance of pain is associated with impaired coronary circulation in the subendocardial regions due to a significant increase in intramyocardial pressure. All pain sensations in these diseases can be designated as metabolically or hemodynamically caused anginal pain. Despite the fact that they do not formally refer to IHD, one should keep in mind the possibility of developing small-focal necrosis. However, the characteristics of these pains often do not correspond to classical angina pectoris, although typical attacks are also possible. In the latter case, the differential diagnosis with CAD is particularly difficult.

In all cases of detection of non-coronary causes of the origin of pain in the upper chest, it is taken into account that their presence does not at all contradict the simultaneous existence of IHD and, accordingly, requires an examination of the patient in order to exclude or confirm it.

Pain in the upper chest due to pathology of the bronchopulmonary apparatus and pleura. Pain 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 the 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 with bronchoscopy) - afferent fibers from the large bronchi and trachea are part of the vagus nerve. The mucous membrane of the small bronchi and lung parenchyma probably does not contain pain receptors, so pain in the primary lesion of these formations appears only when the pathological process (pneumonia or tumor) reaches the parietal pleura or spreads to large bronchi. The most severe pains are noted during the destruction of the lung tissue, sometimes acquiring high intensity.

The nature of pain sensations to some extent depends on their origin. Pain in the parietal pleura is usually stabbing, clearly associated with coughing and deep breathing. Dull pain is associated with distension 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, pleurisy. With pain associated with pneumonia, dry or exudative pleurisy, auscultation may reveal wheezing in the lungs, pleural friction noise.

Severe pneumonia in adults has the following clinical features:

• moderate or severe respiratory depression;
• temperature 39.5 °C or higher;
• confusion;
• respiratory rate - 30 per minute or more;
• pulse 120 beats per minute or more;
• systolic blood pressure below 90 mm Hg. Art.;
• diastolic blood pressure below 60 mm Hg. Art.;
• cyanosis;
• over 60 years old - features: confluent pneumonia, is more severe with concomitant severe diseases (diabetes, heart failure, epilepsy).

NB! All patients with signs of severe pneumonia should be immediately referred to hospital! 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 respond well 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 severe pneumonia, which requires an urgent referral to a hospital;
• pneumonia should be distinguished from bronchitis: the most valuable symptom in the case of pneumonia is tachypnea.

Pain in case of damage to the pleura almost does not differ from those in acute intercostal myositis or trauma to the intercostal muscles. With spontaneous pneumothorax, there is an acute unbearable pain in the upper chest associated with damage to the bronchopulmonary apparatus.

Pain in the upper chest, difficult to interpret due to its uncertainty 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 CVII and ThI nerves and the brachial plexus almost inevitably and rapidly develops. The pain is localized mainly in the brachial plexus and radiates along the outer surface of the arm. On the side of the lesion, Horner's syndrome (narrowing of the pupil, ptosis, enophthalmos) often develops.

Pain syndromes also occur with mediastinal localization of cancer, when compression of the nerve trunks and plexuses causes acute neuralgic pain in the shoulder girdle, upper limb, and chest. This pain gives rise to an erroneous diagnosis of angina pectoris, myocardial infarction, neuralgia, plexitis.

The need for differential diagnosis of pain caused by damage to the pleura and bronchopulmonary apparatus, with coronary artery disease arises in cases where the picture of the underlying disease is fuzzy and pain comes to the fore. In addition, such differentiation (especially in acute unbearable pain) should be carried out with diseases caused by pathological processes in large vessels - pulmonary embolism, dissecting aneurysm of various parts of the aorta. Difficulties in identifying pneumothorax as a cause of acute pain are due to the fact that in many cases the clinical picture of this acute situation is erased.

Pain in the upper chest associated with the 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 usually has a burning character, is localized behind the fudin, occurs after eating, and is aggravated in a horizontal position. Such usual symptoms as heartburn, belching, and swallowing disorders may be absent or be mildly pronounced, and retrosternal pain, which often occurs during exercise and is 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, arms. With a more detailed questioning, however, it turns out that the pains are more often associated with food, especially plentiful, and not with physical activity, usually occur in the supine position and disappear or are relieved when moving to a sitting or standing position, when walking, after taking antacids, for example, soda, which is uncharacteristic for coronary artery disease. Often, palpation of the epigastric region increases 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; monitoring intraesophageal pH. Endoscopy is important to detect reflux, esophagitis, and to rule out 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. With the perfusion of hydrochloric acid (120 drops per minute through a probe), the appearance of the usual pains for the patient matters. The test is considered to be highly sensitive (80%), but not specific enough, which requires repeated studies in case of fuzzy results.

If the results of endoscopy and perfusion of hydrochloric acid are unclear, monitoring of intraesophageal pH can be carried out using a radio telemetry capsule placed in the lower part of the esophagus for 24-72 hours. indeed a criterion for the esophageal origin of pain.

Pain in the upper chest, similar to angina pectoris, can also be a consequence of an increase in the 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 taking solid food, cold liquids), which, unlike organic stenosis, is unstable. Sometimes retrosternal pains of different duration come to the fore. Difficulties in differential diagnosis are also due to the fact that this category of patients is sometimes helped by nitroglycerin, which relieves spasm and pain.

Radiographically, with achalasia of the esophagus, an expansion of its lower part and a delay in it of the barium mass are detected. However, an 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. Esophageal manometry using a three-lumen probe is more effective. The coincidence in time of onset of pain and increased intraesophageal pressure has a high diagnostic value. In such cases, there may be a positive effect of nitroglycerin and calcium antagonists, which reduce the tone of smooth muscles and intraesophageal pressure. Therefore, these drugs can be used in the treatment of such patients, especially in combination with anticholinergics.

Clinical experience suggests that coronary artery disease is indeed often misdiagnosed in esophageal pathology. In order to make a correct diagnosis, the doctor must look for other symptoms of esophageal disorders in the patient and compare the 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 this pathology is often combined with angina pectoris, which is confirmed by bicycle ergometry. Thus, despite the use of various instrumental methods, the differentiation of pain sensations is still very difficult.

Mediastinitis and tumors of the mediastinum are infrequent causes of pain in the upper chest. Usually, the need for differential diagnosis with coronary artery disease arises at pronounced stages of tumor development, when, however, there are still no pronounced symptoms of compression. The appearance of other signs of the disease greatly facilitates the diagnosis.

Pain in the upper chest in 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 region, in which there is pain, sometimes similar to angina pectoris. This pathology is widespread, since changes in the spine are often observed after 40 years. With damage to the cervical and (or) upper thoracic spine, the development of a secondary radicular syndrome with the spread of pain in the chest area is often observed. These pains are associated with irritation of the sensory nerves by osteophytes and thickened intervertebral discs. Usually, bilateral pains appear 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, accompanied by a feeling of shortness of breath due to the impossibility of deep breathing. Taking into account the advanced age of patients in such cases, the diagnosis of coronary artery 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 coronary artery disease, which also requires a clear distinction between the pain syndrome. Perhaps, in some cases, angina pectoris against the background of atherosclerosis of the coronary arteries in patients with spinal lesions occur reflexively. The unconditional recognition of such a 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 in this case are completely insufficient for diagnosis, since these changes can only accompany IHD and (or) not be clinically manifested. Therefore, it is very important to find out all the features of pain. As a rule, pain depends not so much on physical activity as on changes in body position. Pain is often aggravated by coughing, deep breathing, may decrease in some comfortable position of the patient, after taking analgesics. These pains differ from angina pectoris in a more gradual onset, longer duration, they do not go away at rest and after the use of nitroglycerin. Irradiation of pain in the left hand occurs along the dorsal surface, in the I and II fingers, while with angina pectoris - in the IV and V fingers of the left hand. Of certain importance is the detection of local pain in the spinous processes of the corresponding vertebrae (trigger zone) when pressed or tapped paravertebral and along the intercostal space. 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 to the other side. With bicycle ergometry, pain in the region of the heart may appear, but without characteristic ECG changes.

Thus, the diagnosis of radicular pain requires a combination of radiological signs of osteochondrosis and the characteristic features of pain in the upper chest that do not correspond to coronary artery disease.

The frequency of muscular-fascial (muscular-dystonic, muscular-dystrophic) syndromes in adults is 7-35%, and in some 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 muscular-fascial syndromes (Zaslavsky E.S., 1976): functional (reversible) and organic (muscular-dystrophic). In the development of muscular-fascial syndromes, there are several etiopathogenetic factors:

1. Injuries of soft tissues with the formation of hemorrhages and sero-fibrinous extravasates. As a result, compaction and shortening of the muscles or individual muscle bundles, ligaments, and a decrease in the elasticity of the fascia develop. As a manifestation of an aseptic inflammatory process, connective tissue is often formed in excess.
2. Microtraumatization of soft tissues in some types of professional activity. Microtraumas disrupt tissue circulation, cause muscular-tonic dysfunction with subsequent morphological and functional changes. This etiological factor is usually combined with others.
3. Pathological impulsation in visceral lesions. This impulse, which occurs when the internal organs are damaged, is the cause of the formation of various sensory, motor and trophic phenomena in the integumentary tissues, innervationally associated with the altered internal organ. Pathological interoceptive impulses, switching through the spinal segments, go to the corresponding affected internal organ - connective tissue and muscle segments. The development of musculo-fascial syndromes associated with cardiovascular pathology can change the pain syndrome so much that diagnostic difficulties arise.
4. Vertebrogenic factors. When 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 various reflex responses at a distance - in the area of ​​integumentary tissues, innervationally connected with affected vertebral segments. But far from all cases, there is a parallelism between the severity of radiographic changes in the spine and clinical symptoms. Therefore, the radiographic signs of osteochondrosis cannot yet serve as an explanation for the development of muscular-fascial syndromes solely by vertebrogenic factors.

As a result of the influence of several etiological factors, muscular-tonic reactions develop in the form of hypertonicity of the affected muscle or muscle group, which is confirmed by electromyography. Muscle spasm is one of the sources of pain. In addition, impaired microcirculation in the muscle leads to local tissue ischemia, tissue edema, accumulation of kinins, histamine, and heparin. All these factors also cause pain. If muscular-fascial syndromes are observed for a long time, then fibrous degeneration of muscle tissue occurs.

The greatest difficulties in the differential diagnosis of muscular-fascial syndromes and pain of cardiac origin are found in the following syndromes: shoulder-scapular periarthritis, scapular-costal syndrome, anterior chest wall syndrome, interscapular pain syndrome, pectoralis minor syndrome, anterior scalene 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 vegetative chain and leads to degenerative changes in the corresponding formations. This syndrome in persons with a known healthy heart may be due to traumatic myositis.

More rare syndromes, accompanied by pain in the anterior chest wall, are: Tietze's syndrome, xifoidia, manubriosternal syndrome, scalenus syndrome.

Tietze's syndrome is characterized by severe pain at the junction of the sternum with the cartilages of the II-IV ribs, swelling of the costal-cartilaginous joints. It is observed mainly in middle-aged people. Etiology and pathogenesis are unclear. There is an assumption about aseptic inflammation of the costal cartilages.

Xifoidia is manifested by a sharp pain in the upper part of the sternum, 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, stomach.

With manubriosternal syndrome, acute pain is noted above the upper part of the sternum or somewhat laterally. The syndrome is observed in rheumatoid arthritis, but occurs in isolation, and then it becomes necessary to differentiate it from angina pectoris.

Scalenus syndrome - compression of the neurovascular bundle of the upper limb between the anterior and middle scalene muscle, as well as the normal I or additional rib. Pain in the region of the anterior chest wall is combined with pain in the neck, shoulder girdle, shoulder joints, sometimes there is a wide area of ​​irradiation. At the same time, vegetative disorders are observed in the form of chills, pallor of the skin. Difficulty breathing, Raynaud's syndrome.

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 specific weight in the differential diagnosis of angina pectoris.

Differentiation is necessary in the initial period of the disease (when they first think 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, pains of this origin can be combined with true coronary artery 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 affect both treatment and prognosis.

Pain in the upper chest due to diseases of the abdominal organs and pathology of the diaphragm. Diseases of the abdominal organs are often accompanied by pain in the region of the heart in the form of a syndrome of typical angina pectoris or cardialgia. Pain in peptic ulcer of the stomach and duodenum, chronic cholecystitis can sometimes radiate to the left half of the chest, which causes 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 region of the heart and behind the sternum. The occurrence of these pains is explained by reflex effects on the heart during lesions of internal organs, which occur as follows. Interorgan connections were found in the internal organs, through which axon reflexes are carried out, and, finally, polyvalent receptors were found in blood vessels and smooth muscles. In addition, it is known that, along with the main borderline sympathetic trunks, there are also paravertebral plexuses that connect both borderline trunks, as well as sympathetic collaterals located parallel and on the sides of the main sympathetic trunk. Under such conditions, afferent excitation, heading from any organ along the reflex arc, can switch from centripetal to centrifugal paths 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 on the periphery.

As for the causes of reflex pains in the region of the heart, it is assumed that a long-term 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 impulsation leads 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 irritations is carried out 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 through the sympathetic fibers reach the vasomotor receptors of the heart.

Diaphragmatic hernias can also be causes of retrosternal pain. The diaphragm is a richly innervated organ mainly due to the phrenic nerve. It runs along the front inner edge 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. The most common hernia of the esophageal opening of the diaphragm. Symptoms of diaphragmatic hernias are varied: usually it is dysphagia and pain in the lower parts of the chest, belching and a feeling of fullness in the epigastrium. When the hernia is temporarily introduced into the chest cavity, there is a sharp pain that can be projected onto the lower left half of the chest and extends into the interscapular region. The 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. Given the paroxysmal nature of the pain, its appearance in middle-aged and elderly people (mainly in men), a differential diagnosis should be made with an attack of angina pectoris.

Pain can also be caused by diaphragmatic pleurisy and much less often by subphrenic abscess.

In addition, when examining the chest, shingles can be detected, palpation can reveal a fracture of the rib (local tenderness, crepitus).

Thus, in order to find out the cause of pain in the upper chest and make the 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.