Pain in upper left chest near collar bone

Signs and symptoms of pericarditis

A common symptom of acute pericarditis is a sharp, stabbing chest pain, usually coming on quickly. It's often is in the middle or left side of the chest, and there may be pain in one or both shoulders.

Sitting up and leaning forward tends to ease the pain, while lying down and breathing deep worsens it. Some people describe the pain as a dull ache or pressure in their chest.

The chest pain may feel like a heart attack. If you experience chest pain, call 911 right away because you may be having a heart attack.

Fever is another common symptom of acute pericarditis. Other symptoms are weakness, trouble breathing and coughing. Palpitations, which are feelings that your heart is skipping a beat, fluttering or beating too hard or too fast, may occur and can be a sign of deeper heart tissue involvement.

Chronic pericarditis often causes tiredness, coughing and shortness of breath. Chest pain is sometimes absent with this type of pericarditis. Severe cases of chronic pericarditis can lead to swelling in the stomach, feet, ankles and legs and hypotension (low blood pressure).

Complications of pericarditis

Two serious complications of pericarditis are cardiac tamponade and chronic constrictive pericarditis.

• Cardiac tamponade happens if too much fluid collects in the sac, putting pressure on the heart. This prevents the heart from properly filling with blood, so less blood leaves the heart, causing a sharp drop in blood pressure. Untreated cardiac tamponade can be fatal.
• Chronic constrictive pericarditis is a rare disease that takes time to develop. It leads to scar-like tissue forming throughout the sac around the heart. As the sac becomes stiff and unable to move properly, the scarred tissue starts to compress the heart and prevent it from functioning well.

Diagnosing pericarditis

A doctor diagnoses pericarditis based on your medical history, a physical exam and test results.

Specialists involved

Primary care doctors, such as a family doctor, internist or pediatrician, often diagnose and treat pericarditis. A cardiologist, pediatric cardiologist or infectious disease specialist may be involved, depending on the patient’s age and medical conditions.

Medical history

Your doctor may ask whether you have had:

• A recent respiratory infection or flu-like illness
• A recent heart attack or injury to your chest
• Other medical conditions

If you have chest pain (angina), your doctor will ask you to describe how it feels, where it's located and whether it's worse when you lie down, breathe or cough.

Physical exam

When the pericardium is inflamed, the fluid between the sac's two layers of tissue increases. So your doctor will look for signs of excess fluid in your chest. A common sign is the pericardial rub. This is the sound of the pericardium rubbing against the outer layer of your heart. Your doctor will listen for this using a stethoscope.

Your doctor may hear other chest sounds that are signs of fluid in the pericardium (pericardial effusion) or the lungs (pleural effusion). Both are more severe problems related to pericarditis.

Diagnostic tests

Your doctor may recommend tests to diagnose your condition and its severity. The most common tests are:

• EKG (electrocardiogram): This detects and records your heart's electrical activity, with certain EKG results suggesting pericarditis.
• Chest X-ray: A chest X-ray takes pictures of the inside of the chest, including your heart, lungs and blood vessels. The pictures can show whether you have an enlarged heart, which can be a sign of excess fluid in your pericardium.
• Echocardiography (PDF): This test uses sound waves to create pictures of your heart, showing its size and shape and how well it's working. It can show fluid build-up in the pericardium.
• Cardiac CT (computed tomography): This X-ray takes a clear, detailed picture of your heart and pericardium and helps to rule out other causes of chest pain.
• Cardiac MRI (magnetic resonance imaging): A cardiac MRI uses magnets and radio waves to form detailed pictures of your organs and tissues. It can show changes in the pericardium.

  Your doctor also may recommend blood tests to find out if you've had a heart attack, the cause of your pericarditis and the extent of inflammation in your pericardium.

Learn more:

• View an animation of angina 

Thoracic Outlet Syndrome

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What is thoracic outlet syndrome?

Thoracic outlet syndrome is a variety of symptoms that happen from a narrowing of your thoracic outlet. This is the space between your collarbone and your first rib. It can result from injury, disease, or a problem you had from birth.

The thoracic outlet is a narrow space between your collarbone (clavicle) and your first rib. Nerves and blood vessels exit from your chest to your arm through this space. This includes:

• The subclavian artery, a very large main artery
• The subclavian vein, a large main vein
• The brachial plexus, a bundle of nerves that serve your shoulder, arm, and hand

Your shoulder muscles normally keep your clavicle raised and in place.

Many health problems can cause your collarbone to slip down and forward. This narrows the thoracic outlet. It puts pressure on the nerves and blood vessels here. This causes the symptoms of thoracic outlet syndrome.

Healthcare providers sometimes categorize thoracic outlet syndrome by its underlying cause. For example, “cervical rib syndrome” is a type of thoracic outlet syndrome that can happen if a person has an extra upper rib. Experts also sometimes categorize thoracic outlet syndrome by the structures compressed. Nerve, vein, and artery compression may all cause different symptoms. But there might be compression on more than one structure.

Thoracic outlet syndrome is not common. Women get it more often than men do. It can happen in people of any age. But it is more common in younger adults.

What causes thoracic outlet syndrome?

Thoracic outlet syndrome results from the compression of nerves and blood vessels between your upper rib and your collarbone. Health problems that can cause this include:

• Having an extra rib from birth
• Having an abnormality in your neck muscles from birth
• Neck injury
• Injury to the first rib or collarbone
• Repetitive overhead arm movements (which may cause inflammatory changes)

Who is at risk for thoracic outlet syndrome?

Awkward postures, often work related, and extreme obesity may raise your risk of thoracic outlet syndrome. People who do repetitive overhead arm movements (like swimmers or pitchers) may also have a higher risk.

What are the symptoms of thoracic outlet syndrome?

Symptoms of thoracic outlet syndrome relate to the compression of blood vessels and nerves. Possible symptoms are:

• Pain. A sharp or dull aching, mainly in the arm or hand. It may occur more often with activity, when raising your arm, or when carrying heavy objects.
• Autonomic and vascular symptoms. Mainly changed sweating, skin temperature, and color, which can occur with swelling. Some people feel that their arm is warm or cold. In extreme cases, poor blood flow to the fingers can lead to gangrene.
• Weakness. Lack of endurance and hand clumsiness, especially when working with the arms over the head or when lifting heavy objects.

Your symptoms may come and go, partly based on your activity level. Overhead activities may worsen your symptoms. The nature and severity of your symptoms may vary by which structures are being compressed. Most people have symptoms on only one side. At times, a problem causes thoracic outlet syndrome on both sides of the body.

How is thoracic outlet syndrome diagnosed?

Your healthcare provider will start with a medical history. He or she will ask you about your past health problems and all your symptoms. You will also need a physical exam. Your healthcare provider may try to reproduce your symptoms, examining your hand and arm in many positions.

Healthcare providers often use a specific test to help diagnose thoracic outlet syndrome. Your healthcare provider may have you raise your arms and then open and close your fist for a few minutes. This often brings on symptoms if you have thoracic outlet syndrome.

Your healthcare provider may also order specific tests to help make the diagnosis. You may need:

• Nerve conduction tests, to see how your nerves are affected
• Doppler ultrasound, to detect blood flow through your arm and hand
• Chest X-ray, to find abnormalities of bone such as an extra rib
• CT scan or MRI, if the healthcare provider needs to see more detail
• CT angiography or MR angiogram (MRA), to get more information about blood flow through your arm

Seeing a specialist is sometimes needed to diagnose thoracic outlet syndrome. Thoracic outlet syndrome is often harder to diagnose than other more common problems of the shoulder.

How is thoracic outlet syndrome treated?

Possible treatments of thoracic outlet syndrome are:

• Physical therapy to help build up your shoulder muscles, improve your posture, and enlarge the thoracic outlet space
• Over-the-counter pain medicines to ease pain and swelling
• Weight loss, if you are overweight
• Changes in everyday activities, including those at work, that bring on symptoms

These treatments ease symptoms in most people. If you still have major symptoms after trying these treatments, your healthcare provider might recommend surgery. For example, your healthcare provider might remove an extra first rib (if present). Sometimes, healthcare providers release an abnormal muscle in your neck or do operations on the blood vessels of the neck. The exact kind of surgery will depend on the anatomy of your thoracic outlet. Surgery eases symptoms in many people.

Healthcare providers do not recommend treatment for people who have an extra rib unless they show signs of thoracic outlet syndrome.

What are possible complications of thoracic outlet syndrome?

Sometimes, thoracic outlet syndrome causes a blood clot to form somewhere in the veins of your arm, blocking the flow of blood. This may make your arm very swollen. The clot may also move to the lungs (pulmonary embolism) or somewhere else. Your healthcare provider might need to treat this with medicines to prevent clotting (blood thinners). You also might need a procedure to remove the clot using a thin tube (catheter) inserted through a vein.

Thoracic outlet syndrome may also cause a blood clot to form in one of the arteries of your arm. This might cause sudden decreased blood flow to your arm. Your healthcare provider may need to treat this clot using blood thinners or a catheter inserted through an artery. Sometimes, healthcare providers may use surgery to remove the clot instead.

Coping with thoracic outlet syndrome

If you have thoracic outlet syndrome, you can ease your symptoms and help prevent them from coming back.

Don't carry heavy bags over your shoulder. This increases pressure on the thoracic outlet. You should also do your physical therapy exercises to help keep your shoulder muscles strong. Doing these regularly may help keep your symptoms from coming back.

When should I call my healthcare provider?

Call your healthcare provider right away if your arm or hand becomes suddenly cool, lighter in color, or swollen. You may have a blood clot. Let your healthcare provider know right away about any other sudden changes in your symptoms, like sudden weakness of your hand. If your symptoms are not getting better with therapy, plan to see your healthcare provider soon.

Key points about thoracic outlet syndrome

• Thoracic outlet syndrome is a variety of symptoms that happen from a narrowing of your thoracic outlet. This is the space between your collarbone and your first rib. It can compress arteries, veins, and nerves in the region.
• The condition can result from injury, disease, or a problem you had from birth.
• You may have symptoms from nerve compression, like pain, tingling, or weakness in your arm or hand. Or you may have symptoms from blood vessel compression, like a swollen arm, or an arm that is pale and cool.
• Most people with thoracic outlet syndrome don't need surgery. Your healthcare provider may prescribe physical therapy, changes in your regular activities, or pain medicines to reduce your symptoms.
• Some people with thoracic outlet syndrome develop blood clots in the veins or arteries of their arm. You might need a medicine and surgery if this happens.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

Medical Reviewer: Luc Jasmin MD

Medical Reviewer: Anne Fetterman RN BSN

Medical Reviewer: Raymond Kent Turley BSN MSN RN

© 2000-2022 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.

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