Chest pain is a frightening symptom that can affect individuals of all ages. In an older person the degree of pain may be less vivid than in a younger person and therefore may go unnoticed. Chest pain is either acute (sudden) or chronic (longstanding). Acute chest pain has many causes, including illnesses affecting the heart, lungs, and the muscles and bones of the chest and spine. The type of pain often tells the physician the underlying cause.
A common cause of acute chest pain is a heart attack (myocardial infarction, coronary thrombosis). Typically, but not necessarily, the pain starts suddenly and is felt behind the breastbone. It is characterized by a pressing or heavy feeling that sometimes travels to the back or to the shoulder and wrist. Occasionally, it is felt in the neck and jaw. You may experience a pain in the lower chest and mistake it for indigestion. I know of many older people who postponed a visit to the physician because they assumed they were suffering from indigestion when, in fact, they had experienced a heart attack.
Often the pain of a heart attack is less typical in the elderly. One woman came to my office complaining of indigestion, a problem she had had for many years. While she was waiting, the nurse noticed that she was burping frequently, and seemed to be uncomfortable. An electrocardiogram showed that she had suffered a myocardial infarction. At no time had she complained of the chest pain that usually accompanies a heart attack.
Other causes for the sudden onset of chest pain are a pneumothorax (collapse of a lung), pulmonary embolism (blood clot in the lung), or an acute lung infection (pneumonia). Usually, symptoms such as shortness of breath, cough, phlegm, or fever indicate a lung problem. Acute chest pain can also result from spontaneous fractures of the spine and ribs. Some older people have a tendency to experience spontaneous fractures of their spine. Sometimes this causes pain in the chest, rather than in the back, because nerves are pinched as they leave the spine and wrap around the chest.
An elderly woman was urgently admitted to the hospital because she had acute pain in her lower chest and upper abdomen. She could not find a comfortable way to lie in bed. An electrocardiogram failed to show evidence of a heart attack to account for her pain. Nitroglycerin did not alleviate the pain. An X-ray of her spine showed that she had fractured three vertebrae (spinal bones), which probably pressed on the nerves going to the front of her chest. I found that treatment with analgesics and heat to her back relieved her pain, which eventually subsided as the fractures healed.
Chronic chest pain occurs for the same reasons as acute pain. It can come from muscle and bone disorders, such as arthritis, that affect the spine and ribs, or occasionally from bone tumors affecting the spine or ribs. But the most common cause of chronic chest pain is angina pectoris, and it occurs when physical activity or emotional stress strains the heart. The pressure or heavy pain in the chest disappears when the exertion or stress is stopped. A common trigger of anginal pain is walking into a cold wind.
A common imitator of angina pectoris in older people is a hiatus hernia with reflux of stomach juices. Even though the pain typically has a burning quality, which is different from angina pectoris, it can sometimes be indistinguishable from anginal pain. It occurs especially when bending over and at night. Diagnosis often requires X-rays of the stomach and occasionally gastroscopy, which shows whether gastric juice is coming from the stomach and irritating the esophagus.
At times, the exact cause of chronic chest pain is difficult to determine, especially if more than one factor plays a role in its production. Your physician may have to use various drugs in sequence and in combination in order to relieve pain that has multiple and elusive causes.
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