Angina That Gets Worse When Lying Down

Overview

It is widely known that chest pain can be alarming, as it can indicate severe cardiac conditions such as a heart attack. Chest pain is also present in other heart-related conditions, such as angina (severe chest pain) and pericarditis (painful swelling of the outer covering of the heart). However, did you know that chest pain is not only caused by heart-related problems? Other conditions that can cause noncardiac chest pain include gastroesophageal reflux disease (acid reflux, GORD), muscle and bone disorders, psychological problems and lung-related problems. Knowing the differences between the symptoms of these chest pains can help you identify the cause of your chest pain and when to seek medical attention.  

Causes of Chest Pain

Heart Attack

A Heart attack (or myocardial infarction) happens when the heart muscles are not getting sufficient oxygen for a prolonged period of time due to blockage in the arteries supplying the heart. The intense chest pain during a heart attack happens because the heart muscles get damaged or die due to insufficient oxygen and nutrients for a prolonged period of time (more than a few minutes).

If you have a heart attack, you may experience sudden chest pain that extends to the neck, arms or back and may last longer than 15 minutes. The chest pain may feel like a sharp, squeezing pain, aching or heaviness in the chest that lasts for several minutes.¹  For some people, heart attack chest pain can present as just a dull pressure and discomfort in the chest. Some other symptoms that you may experience if you have a heart attack:

• Nausea i.e., a feeling of vomiting 
• Shortness of breath
• Sweating
• Abnormal heartbeat

People with the following risk factors are at a higher risk of heart attack than the normal healthy population:¹

• Age of 65 years and above
• High blood pressure
• High cholesterol
• Obesity
• Diabetes
• High alcohol consumption 
• Drug usage  
• Smoking

Heart attacks can be fatal and you should immediately seek medical attention if you experience any of the above symptoms. 

Pericarditis

Our heart is surrounded by a two-layered sac called the pericardium; this protects the heart by decreasing the friction with the chest wall and surrounding organs. 

Pericarditis is a condition in which the pericardium is inflamed (swollen and painful). It can be caused by infections (viruses, bacteria, fungi and parasites) or non-infectious causes (trauma to the chest, autoimmune diseases, kidney failure, and cancers).² Most pericarditis cases are idiopathic, which means the cause is unknown. 

If you have pericarditis, you may experience a sharp chest pain that increases when you lie down but improves when you sit up.² This pain can extend to your neck, left shoulder and left arm.² Some patients also experience shortness of breath. If it is caused by infections, you may also have a fever. 

You should visit your doctor if you experience these symptoms, especially if you are unsure of the cause of the chest pain or when you start having a fever. This can get dangerous if a large amount of fluid builds up quickly in your pericardial sac, leading to a condition called cardiac tamponade, where your heart is compressed by the fluid. 

Depending on the cause of pericarditis, different treatments could be used. Non-steroidal anti-inflammatory drugs (NSAIDs) are usually prescribed for uncomplicated cases to decrease chest pain, inflammation and fever.²

Angina

Angina is defined as chest discomfort or pain that lasts for less than 10 minutes.³ Angina is usually due to reduced blood flow and oxygen to the heart as a result of a blocked artery. 

Angina chest pain can be triggered by exertion and stress.³ Many people have described angina chest pain as a dull pain, discomfort or heaviness in the chest that may radiate to the arms, jaw, neck and back.  

You should visit the doctor as soon as possible if you experience angina chest pain because angina is often a warning sign of underlying coronary artery disease (disease of the arteries in the heart). If left untreated, angina may worsen and lead to a heart attack. 

GORD

Gastroesophageal reflux disease (GORD) is a condition of the gut in which stomach content moves up into the oesophagus (food pipe), and because this stomach content is acidic, it can cause damage to the inner lining of the oesophagus. GORD can cause chest pain because the nerves that extend to the oesophagus also extend to the heart for sensing.⁴ So, when the oesophagus inner wall becomes damaged, the pain that it causes can feel like the pain caused by heart-related conditions. GORD can also cause inflammation in the oesophagus.

What Can Cause Chest Pain That is Worse When Lying Down?

Angina, pericarditis, and non-cardiac-related chest pains can feel worse when you lie down.  

What is Angina?

Angina is a type of chest pain that happens when the heart muscle is not getting enough blood flow and oxygen to meet its demands. Angina chest pain usually lasts for less than 10 minutes and can spread to the shoulders, arms, jaw and back.

Types and Symptoms

Angina can be categorised as:

Stable angina

Stable angina is characterised by chest pain that is usually triggered by physical exertion (e.g. exercise), psychological stress, a large meal or cold weather, and tends to get better when you take a rest. Stable angina typically lasts for 2-5 minutes and is a more common form of angina compared to unstable angina.⁵

You might also have these symptoms if you are experiencing stable angina: ⁶

• Nausea (feeling of vomiting)
• Shortness of breath when you are exerting yourself
• Fatigue
• Dizziness

If you have been diagnosed with angina but your angina chest pain increases in frequency or intensity, you should seek medical help immediately as it might mean that your angina has worsened.⁷

Unstable angina

Unstable angina usually causes chest pain that can initiate suddenly without exertion and can last for a different duration every time. Unstable angina is more dangerous as delayed diagnosis and treatment can lead to a higher risk for heart attack.

The other accompanying symptoms of unstable angina include:

• Nausea
• Dizziness
• Sweating
• Palpitations - an irregular heartbeat, like racing or pounding 

Causes and Risk Factors

The main cause of both stable and unstable angina is reduced blood flow to the heart muscles due to blocked or narrowed arteries. The demand for oxygen in the heart exceeds the supply temporarily during angina. 

Atherosclerosis is a common cause of blocked arteries. It causes the narrowing of heart arteries due to plaques formed from cholesterol and fatty deposits. 

Exacerbating factors 

People with high cholesterol are at a higher risk of angina because cholesterol accumulates and forms plaques that narrow the heart arteries. Besides that, people with the following risk factors are also more likely to experience angina:⁸

• Obesity 
• Diabetes
• High cholesterol
• Lack of exercise
• Smoking
• Drug usage
• Autoimmune disorders
• Family history 

Prevention is better than cure. Angina can be prevented by reducing the risks of coronary artery disease. It is highly recommended to maintain a healthy lifestyle and have a balanced diet, especially for people with a high risk of angina. 

What is Non-Cardiac Chest Pain (NCCP)?

Recurrent chest pain may be diagnosed as non-cardiac chest pain (NCCP) when all other cardiovascular-related chest pains, such as angina, are ruled out by the doctor. NCCP is commonly caused by problems affecting the gastrointestinal tract, muscles, lungs, infections and stress levels.⁹ While cardiac-related chest pains may be more common among adults, NCCP can happen in both children and adults. Burning or squeezing chest pain is a common complaint of people experiencing NCCP. This chest pain may extend to the neck, arms, jaws and even to the back.

Examples of Causes 

Gastroesophageal Reflux Disease (GORD)

About 30-60% of patients who have NCCP are diagnosed with GORD.¹⁰ GORD happens when stomach acid and stomach content travel up the oesophagus, causing a condition called acid reflux. This reflux can cause inflammation in the inner wall of the oesophagus and lead to chest pain in GORD, but patients can experience chest pain even without inflammation. 

People with the following conditions or lifestyle habits are more at risk for GORD:^11,12

• Obesity
• Diabetes
• Lack of physical activity
• Irregular meal times
• Irregular sleep schedules
• Cigarette smoking
• High consumption of fatty or acidic foods
• High levels of psychological stress

Psychiatric causes

Depression, anxiety, panic disorders and psychological stress are all psychiatric causes that can lead to chest pain. Chest pain caused by psychiatric disorders is usually triggered when you experience emotional distress. This chest pain generally feels like a stabbing pain or discomfort in the chest accompanied by a racing heartbeat.

Musculoskeletal chest pain

Musculoskeletal chest pain is chest pain that originates from chest muscles or bone-related abnormalities, and this type of chest pain may account for 36-49% of NCCP cases.¹³ Rib fractures, strained chest muscles, and costochondritis (inflammation at the joint of ribs and breastbone) are common causes of musculoskeletal chest pain.

Symptoms

Gastroesophageal Reflux Disease (GORD)

GORD causes heartburn, a burning pain in the chest that may radiate toward the mouth. This chest pain is usually worsened when lying down because acid reflux happens more easily without gravity pulling the stomach acid down, like when you are in a sitting or standing position. Sometimes, patients may also have a sour taste in the mouth or vomit because of the reflux of stomach content up the throat. 

Some other symptoms of GORD include:^4,12

• Chronic cough mainly at night
• Sore throat
• Gingivitis - inflammation of the gums
• Laryngitis - inflammation of your vocal cord or your vocal box
• The feeling of a lump in the throat

You should contact your healthcare provider if you experience these symptoms. If GORD is left untreated, the oesophagus lining can get damaged and narrow, causing difficulties in swallowing. In more serious cases, GORD may lead to oesophageal cancer due to long-term damage and inflammation in the oesophagus.¹² 

Psychiatric causes

Panic attacks and anxiety can cause shortness of breath or hyperventilation, together with chest pain. It may also be useful to take note of the location of the chest pain as panic attacks tend to cause pain that stays in the chest, while chest pain caused by a heart attack, for example, can spread to the neck, shoulders and arms. If you have a panic attack, you may also feel very anxious and scared when the chest pain happens and begin sweating, shaking and feeling dizzy. 

Cognitive behavioural therapy (CBT) is an effective way to improve the chest pain caused by psychiatric disorders because the therapist can help patients to identify and tackle the causes of their chest pain.¹⁴

Musculoskeletal chest pain

If your chest pain is caused by chest muscles or bone-related problems, this chest pain may be reproduced by palpation, which means examining by touching. Your chest pain may also feel worse when you are taking a deep breath or when you move your chest in a rotation. Musculoskeletal chest pain is generally described as a sharp pain, aching, or pressure in the chest.¹⁵

Rib fractures can cause pain that spreads to the neck and also swelling and tenderness (discomfort when touched) in the chest. Muscle strains can also cause tenderness in the affected muscles.¹⁵ 

How to Tell the Difference Between Angina, NCCP and Other Causes

It may be difficult to identify if our chest pain originates from the heart or not since other causes of chest pain can also have similar symptoms. Here are some of the questions you can ask yourself to identify the likely cause of your chest pain:

1. Does my chest pain last longer than several minutes and spread to my arms, jaw or back? Is my chest pain accompanied by shortness of breath, dizziness, and sweating?

If your answer to this question is yes, you are probably having a heart attack and should call the ambulance immediately.

2. Does my chest pain usually happen when I exercise, feel stressed, have a large meal, or feel cold? Does my chest pain subside after resting?

If your answer to these two questions is yes, then it is likely that you have stable angina.

3. Does my chest pain feel worse when lying down?

If your answer to this question is yes, you are likely to be experiencing pericarditis, angina or NCCP chest pain (especially GORD).

4. Is my chest pain accompanied by a sour taste in the mouth, coughing, or a lump in the throat? Does my chest pain happen more frequently after meals or at night time?

If your answer to these questions is yes, you might have GORD.

When to Call for an Ambulance

You should seek medical attention immediately if you are experiencing chest pain that spreads to your arms, jaw, and back and lasts for longer than 10-15 minutes because you may be having a heart attack. 

For other types of chest pain, it is worth visiting your doctor to get a proper diagnosis of the cause of chest pain and get treatment as soon as possible.

Summary

Cardiac chest pain can be caused by a heart attack, angina and pericarditis. Noncardiac chest pain is commonly caused by GORD, musculoskeletal disorders, psychiatric disorders, lung-related problems and infections. Both cardiac and noncardiac chest pains can have similar symptoms, which can be worrying. You should take note of how long your chest pain has been going on and if you have other accompanying symptoms. It is best to get a diagnosis for your chest pain from the doctor as soon as possible because it can be dangerous if the cause of your chest pain is associated with the heart or other severe conditions.