Chest pain: an overview

The National Institute for Health and Care Excellence (NICE) presents 1-2% of primary care consultations and 5% of visits to Accident and Emergency departments in the United Kingdom (UK) to account for chest pain.

Chest pain is the primary sign of discomfort in the centre or left side of the chest, which can last for more than a few minutes. It may then disappear and recur.¹ This discomfort will feel like squeezing, fullness, or uncomfortable pressure, along with pain, and may result in a heart attack. 

Evaluating associated cardiac and non-cardiac chest pain plays a major role in hospital admissions and appropriate treatment planning in a timely manner, as many non-cardiac causes may also result in chest pain.²

Understanding cardiac and non-cardiac chest pain

Cardiac chest pain is a condition in which an individual experiences chest pain due to preexisting heart conditions, such as:^2,3

• Acute coronary syndrome – a medical condition due to a blocked artery
• Inflammatory conditions of the heart muscles, like pericarditis and myocarditis
• Mediastinitis – infection or inflammation of the chest (containing the heart)
• Tachyarrhythmias – a medical condition with an irregular heartbeat rhythm
• Pericardial tamponade – pressure inside the pericardial sac (covering the heart and the main blood vessels) from fluid retention
• Acute aortic dissection – a condition with an injured aorta, the main artery that delivers oxygen-rich blood to the body
• Pulmonary embolism – a condition with a blood clot in the lung(s) affecting its blood and oxygen supply
• Myocardial ischaemia – reduced blood supply to the heart muscles, affecting their oxygen supply

Non-cardiac chest pain involves the onset of chest pain with pre-existing conditions such as:^2,3

• Musculoskeletal causes – including chest wall trauma, rib fracture, and muscle strains
• Gastrointestinal causes – including gastroesophageal reflux disease (GERD), oesophageal spasm, and pancreatitis (pancreas inflammation)
• Psychiatric causes, such as panic disorder, anxiety, and depression
• Inflammation/ infections

Understanding Tietze syndrome

Tietze syndrome (TS) is a rare condition in which a person experiences unexplained chest pain with tenderness and swelling near the second and fifth rib cartilage – structures that connect the ribs of the rib cage to the chest bone/sternum, providing elasticity for expansion during respiration.⁴

It is a painful benign condition with one-sided swelling that majorly affects the costochondral joints – joints between ribs and rib cartilages that support the ribcage. Individuals with TS may have substantial discomfort with dull and aching pain even at rest. However, the condition can resolve on its own without aggressive treatment.^4,5

What causes Tietze syndrome?

The exact cause of TS remains unknown. However, some studies have speculated that multiple minor injuries to the anterior chest wall (in front) can result in TS.⁴

Other assumed conditions, such as falls, car accidents, and conditions resulting in excessive cough, like sinusitis (sinus infection), laryngitis (inflammation of the voice box), vomiting, viral/bacterial infections, or any previous history of thoracic surgery, may result in the development of TS. TS is mostly associated with psoriatic arthritis or inflammatory arthritis.⁴

Symptoms of Tietze syndrome

The majority of the symptoms associated with TS involve pain and may develop gradually or have a sudden onset. TS, most commonly seen in a healthy younger population, presents with the following symptoms:⁴

• Dull chest pain even at rest
• Pain during movement/position change
• Sharp and stabbing pain radiating to the neck or arms, and shoulders
• Spindle-shaped swollen area overlying the upper rib cartilage 
• At times, the swollen area looks erythematous or red and warm
• At times, the pain escalates during twisting of the torso (movement of the upper body), coughing, sneezing, or deep breathing
• The pain worsens with the movement of the arm on the same side as the swelling or chest pain

Differentiating Tietze syndrome and cardiac-related chest pain

The following symptoms differentiate TS from cardiac-related chest pain:^5,6

Evaluation of Tietze syndrome

Healthcare professionals identify the TS with the following diagnostic procedures:⁴

• Electrocardiogram – identifying the acute chest pain cause
• Lab tests – inflammatory markers like erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
• Biopsy of the costal cartilage
• Ultrasound – the most effective modality in identifying soft tissue inflammation
• Nuclear magnetic resonance (NMR)/magnetic resonance imaging (MRI) – identifies inflammation, especially the thickened soft tissue swelling, inflammation-related alterations in bone marrow and fat tissue
• Computed tomography (CT) reveals a slight focal swelling
• Positron emission tomography (PET) visualises hypermetabolic activity with dense calcifications at affected joints

Management of Tietze syndrome

The cornerstone of Tietze syndrome treatment involves conservative therapy, resolving within a few weeks, months or up to a year. First-line management of TS includes:^4,7

• Oral and topical anti-inflammatory agents
  • Non-steroidal medications (e.g., ibuprofen)
  • Oral steroids (e.g., hydrocortisone)
  • Steroid injections (e.g., hydrocortisone)
• Analgesic agents – medications that relieve pain (e.g., aspirin)
• Local anaesthetic injections
• Warming pads for the tender, non-purulent, swollen area 

Summary

Chest pain, the most common discomfort experienced by individuals, involves both cardiac and non-cardiac causes. Tietze syndrome (TS) is a condition where a person experiences unexplained chest pain with swelling and tenderness around the rib cartilage. It is a self-limiting condition, worsening with movement around the swollen area, coughing, sneezing, and deep breathing. The sharp stabbing pain radiates to the arm and shoulder on the same side of the body. Cardiac chest pain differentiates itself from TS based on the localisation of pain, physical characteristics of the swollen area, pain extension, and other associated symptoms. 

Understanding the characteristics of chest pain and staying informed helps to identify the underlying reason for chest pain and receive treatment on time.