Chest Pain

Chest pain is a very common symptom in people of all ages. Young children all the way up to the elderly may experience chest pain.  The older an individual becomes, the more likely that chest pain is due to a problem with the heart.  Fortunately, chest pain due to heart problems is fairly rare in children.

Atherosclerosis

To understand chest pain in older people, it is important to first understand atherosclerosis.  Atherosclerosis refers to the process by which cholesterol and fat deposits in the arteries throughout the body (“plaque” build-up).  This causes a gradual decrease in the opening of the artery which slows the flow of blood.  This can ultimately result in a near or complete blockage of the artery.  If this happens in one of the arteries feeding the heart muscle with blood, it is termed a myocardial infarction or “heart attack”.  A person experiencing a heart attack may feel chest pain due to the heart muscle not receiving enough blood.

The process by which plaque builds up in the arteries is an extremely slow one. Atherosclerosis begins at a microscopic level during the childhood and teenage years.  However, it takes at least 20-30 years for it to get to the point where it can cause a significant blockage.  It can be accelerated by problems such as high blood pressure, diabetes, and elevated blood cholesterol levels, all relatively uncommon problems in children. Therefore, for all intents and purposes, chest pain and heart attacks due to atherosclerosis almost never occur during the childhood or teenage years.  When one hears in the news about a young person having a “heart attack” during an athletic event, it is almost never due to atherosclerosis.  Instead, it is usually due to an excessively thickened heart muscle or some other congenital disorder of the heart.

Chest pain in the young

Because atherosclerosis is primarily a disease of middle-aged and elderly people, we can rest assured that chest pain in a young person is rarely if ever due to blockage of an artery to the heart muscle. There are other potential heart related causes of chest pain in young people; however, they are fairly rare. They include inflammation of the lining of the heart, an abnormally thickened heart muscle, or a congenital abnormality of a coronary artery. Inflammation of the lining of the heart usually produces a constant, severe pain that is accompanied by other signs of sickness such as a high fever. An abnormally thickened heart muscle as well as a congenitally abnormal coronary artery can produce exertional chest pain. Both causes can usually be ruled out with an ECG and echocardiogram.

If an evaluation reveals a normal heart, then what is producing the chest pain in a young person? In many cases it is musculoskeletal (muscle or bone related). Musculoskeletal chest pain is typically sharp, well localized, and lasts for a relatively short period of time. It can occur both at rest as well as with activity. Other potential causes of chest pain in young people include gastrointestinal or respiratory pain. Gastrointestinal pain such as gastroesophageal reflux can cause chest pain by the reflux of stomach acid into the esophagus. Respiratory type chest pain is often due to asthma. It typically causes a feeling of chest tightness or discomfort with exercise. In many cases the exact cause of chest pain cannot be exactly identified. However, understanding that chest pain in young people is rarely caused by heart related problems is reassuring to most patients. Many families come to the doctor afraid that their child's chest pain is a warning sign of impending danger or risk. Fortunately this is usually not the case.