Chronic Chest Pain Types Chronic chest pain may not only be life-threatening, but physically, psychologically and

economically debilitating. Many patients have undergone extensive testing, monitoring and treatment, including surgeries, angiograms and even psychiatric care without relief. Mayo treats chest pain patients who fit within two profiles:

people with chest pain, but who have no significant coronary artery disease people with obstructive coronary artery disease who have undergone multiple invasive procedures and are no longer candidates for conventional revascularization such as stents or bypass surgery.

Mayo is one of few medical centers in the world using a true multidisciplinary approach to diagnose and treat chronic chest pain. The Mayo Chest Pain Clinic is a last resort for patients with undiagnosed, misdiagnosed or unresolved conditions, including:

Angina Anxiety or panic attacks Aortic dissection Asthma and other respiratory conditions Atypical chest pain Coronary artery spasm Endothelial dysfunction Gastrointestinal disorders Mitral valve prolapse Pericarditis Prinzmetals Syndrome or Graybiel's Syndrome Refactory angina Sensitive heart Syndrome X or microvascular angina

Angina Angina is one of the most common symptoms of heart disease. It results from the heart not getting enough blood or oxygen. Pain intensity varies from person-to-person. Chest pain may be typical or atypical. Typical chest pain is felt under the sternum or chest bone and is characterized by a heavy or squeezing feeling often caused by exertion or emotions. Angina is usually experienced as discomfort or tightness, or pressure in the chest or in the back, neck, jaw, shoulders and arms (especially the left arm). Anxiety or Panic Attacks Anxiety or panic attacks are characterized by surges of intense anxiety and fear that occur without warning and with no apparent reason. Panic attacks may be accompanied by sharp

and abrupt chest pain, most likely caused by muscle contractions in the chest wall. The chest wall may feel sore for hours or days after a panic attack. Though easily treated with medication and relaxation techniques, anxiety and panic attacks can significantly disrupt an individual's life. Aortic dissection Aortic dissection is a tearing of the lining of the aorta, the main artery from the heart. This condition can lead to heart attack or stroke. Sudden aortic dissection may be accompanied by sudden, severe "tearing" pain beneath the sternum or chest bone. With gradual aortic dissection, tearing of the aorta occurs more gradually, and the pain tends to be less severe and abrupt. When dissection is suspected, the diagnosis is made by ECG test, MRI and CT scan or cardiac catheterization. Read more about treatment of aortic dissection. Asthma and Other Respiratory Conditions Many respiratory conditions can cause chest pain, including asthma, bronchitis, pneumonia and inflammation. Chest pain caused by lung problems can be concentrated or diffuse, constant or increasing with exhaling or inhaling, and mild or severe. Severe coughing can strain chest muscles, leaving them achy for days. An examination by a doctor, including questions about the patient's medical history, will generally reveal respiratory-related sources of chest pain. Atypical Chest Pain Atypical chest pain is experienced outside the chest bone. It tends to be sudden, sharp and short-lived. The causes vary and may originate in the left chest, throat, shoulder, abdomen, back or arm. Atypical chest pain's causes include overexertion, spasms, acid indigestion and headaches. People with lower thresholds for pain are more likely to complain of atypical chest pain and are likely to have greater anxiety and depression. Benign Chest Wall Pain Benign chest wall pain is a common, temporary irritation of the membrane that lines and protects the lungs. This lining is very sensitive to irritation. Most people with benign chest wall pain experience an unexpected, abrupt and sharp pain that interrupts breathing, but then goes away. It is harmless and unrelated to exercise, but often quite concerning to patients. Benign chest wall pain can be diagnosed with a thorough patient history and exam. Coronary Artery Spasm This type of chest pain is caused by ischemia (oxygen starvation) of the cardiac muscle. Coronary spasm is a sudden and temporary narrowing or tightening of a small part of the coronary artery, which supplies blood to the heart. As a result, the heart temporarily does not get enough oxygen and the patient experiences chest pain. Coronary artery spasm can occur anytime, and often occurs at rest. Diagnosis involves a medical history and physical exam. Testing includes an ECG, and often a stress test or cardiac catheterization.

Endothelial Dysfunction Coronary endothelial dysfunction is a disorder in the arteries that supply blood to the heart. The endothelium is a thin layer of cells that lines blood vessels and regulates blood flow. In patients with endothelial dysfunction, a stimulus that would normally cause vessels to expand and increase blood flow fails to do so, and may even cause contraction. Symptoms such as chest pain result. Endothelial dysfunction is a key early sign of coronary artery disease. Gastrointestinal Disorders A variety of gastrointestinal disorders can produce chest pain. Ulcers can cause a burning or gnawing pain near the stomach that extends up to chest. Bloating from gas, esophagitis, reflux or heartburn can also produce chest pain. Alcohol, smoking, caffeine and spicy foods may contribute to these symptoms. In addition to a physical exam and history, the patient may need to undergo an endoscopic procedure (examining the GI tract with a scope), ultrasound or a barium X-ray. Treatments range from lifestyle changes to medication to surgery. Mitral Valve Prolapse With mitral valve prolapse (MVP), abnormalities of the mitral valve cause it to flop back into the left atrium as the left ventricle contracts. This flopping, or prolapse, may be perceived by patients as a form of chest pain. The pain patients describe is often a "catching" discomfort, and often relates to their position (i.e., standing, lying, bending). The physician can diagnose an MVP with a stethoscope exam or an ECG test. Read more about mitral valve disease. Pericarditis Pericarditis is inflammation of the pericardium, the thin sac that surrounds and protects the heart. Pain from pericarditis can be intense and frightening, and usually is confined to the chest area. Patients often experience increased pain during breathing. Diagnosis of pericarditis is usually made through a medical history, a physical exam, blood tests and an ECG. Refractory Angina Refractory angina is characterized by symptoms of chest pain caused by coronary blockage due to advanced coronary disease in which the symptoms are not controlled by medication, angioplasty or bypass surgery. Refractory angina cannot be cured, but in some cases, management of the disease can relieve symptoms and improve the patient's quality of life. Prinzmetals Syndrome or Graybiel's Syndrome Prinzmetals Syndrome or Graybiel's Syndrome is chest pain caused by spasms of coronary arteries. In most patients, there is coronary artery obstruction. In cases where there is obstruction, spasms may occur near the narrowing of the artery. With Prinzmetals Syndrome, chest pain may occur at rest. Some patients experience palpitations. In others chest pain is triggered by exertion. Medications, stents or surgery are

treatment options. Once treated, the patient's prognosis is excellent and severe complications such as arrhythmias, heart attack or sudden death are rare. Sensitive Heart Syndrome Sensitive heart syndrome describes the perception of ongoing generalized chest pain, even without any clinical evidence of coronary blockage or gastrointestinal disorders. In this syndrome, the patient's free nerve endings in the chest (nociceptors) are abnormally sensitive and cause a genuine perception of pain. Sensitive heart syndrome is the subject of ongoing medical research. Syndrome X or Microvascular Angina Syndrome X is characterized by chest pain without evidence of blockage in the large coronary arteries. Syndrome X may be caused by the small blood vessels in the heart inadequately dilating. Because this condition is a small-vessel disease, it can't be seen on an angiogram (an X-ray with dye that identifies blockages in blood vessels). Special imaging tests, such as PET scanning or MRI, may help with the diagnosis in the future. Today, however, syndrome X is usually a diagnosis of exclusion meaning that the patient may be diagnosed with this condition after tests do not identify any other causes of the chest pain. Medications commonly used to treat heart conditions may help relieve pain caused by Syndrome X. The prognosis is generally excellent, but symptoms can be debilitating.