Nocturnal Chest Pain

There are many different causes of chest pain requiring medical intervention, some of which can be life threatening. Nocturnal chest pain is one type of chest pain. Possible causes of nocturnal chest pain can be attributed to cardiac, gastric and musculoskeletal causes.

Cardiac Cause
Prinzmetal’s angina or variant angina is a form of chest pain, pressure, or tightness caused by spasms in the arteries that supply blood to the heart. It is a form of unstable angina, meaning that it occurs at rest, often without a predictable pattern. Episodes of chest pain caused by Prinzmetal's angina usually occur in clusters, with periods of frequent episodes lasting for a few months followed by weeks or months with no chest pain episodes. The pain usually occurs between midnight and approximately 8:00 AM. Prinzmetal's angina may have no identifiable trigger, or may be brought on by hyperventilation, exposure to cold or extreme emotional stress.

Generally, nocturnal (nonexertional) chest pain is not common in patients with cardiac disease, but in cases of coronary vasospasm or Prinzmetal angina, symptoms often occur at night and can clearly mimic reflux esophagitis.

Gastric Cause
Nocturnal reflux can be one of the reasons for nocturnal chest pain. At night, the acid dwells longer in the esophagus increasing the likelihood that proximal migration of acid will spill over into the aerodigestive tract and the pharyngeal area. Thus, even a single episode of nocturnal reflux results in significant esophageal acid exposure, and cumulative exposures may lead to esophageal and extra-esophageal manifestations and complications that may sometimes cause chest pain.

Musculoskeletal Cause
Posture-related nocturnal chest pain. They describe chest pain while the patient is sleeping in one position and not another and how patients must arise from bed to relieve their pain. Most commonly, patients also have neck pain and headaches. These patients' conditions are often misdiagnosed as being true angina.

Through structured assessment and nursing intervention, it is possible to identify those at high risk and ensure rapid treatment is provided to patients most likely to benefit from reperfusion treatment. Patients with noncardiac chest pain often will be treated with anti-reflux therapy, such as a proton pump inhibitor (PPI), and are referred to a gastroenterologist for further evaluation. Additionally, postural related nocturnal chest pain may be given analgesics to manage the pain.

References:
http://www.cmecorner.com/macmcm/acg/acg2002_04.htm
Orford JL, Selwyn AP. Coronary artery vasospasm. www.emedicine.com. November 8, 2005. Available at: http://www.emedicine.com/med/topic447.htm, 2007.
Rovai D., Bianchi M., Baratto M., et al. (1997). Organic coronary stenosis in Prinzmetal's variant angina. Journal of Cardiology, 30(6), 299-305.
Tough, J. (2004). Assessment and treatment of chest pain. Nursing Standard, 18(37), 45-55.
Walpin, L. (1980).Physical Therapeutics for Pain and Posture Control. JAMA,243(6), 515.