Complaints of chest pain are among the most common reasons people go to the emergency department, and essentially all of them are wondering, correctly, whether something serious is wrong. Here are some tips of what to look for, from heart attacks on down.
Heart attacks: Heart attacks usually unfold as what is called the “acute coronary syndrome”. The coronary arteries are the vessels that supply the heart’s muscle tissue with blood, and they develop cholesterol buildups that enlarge gradually over your lifetime. These “plaques” usually “rupture”, causing blood to clot and plug the vessel. With no other way of getting blood, the tissue supplied by this vessel dies, and that is the “heart attack”.
“Sudden death” occurs when a sliver of dying heart muscle sends out a series of chaotic electrical impulses that cause the heart to beat erratically and without coordination, and famously this can result in a total loss of actual pump activity and that’s that. You may see an “AED” sign in a gym or auditorium or elsewhere, and these are life-saving devices, and they work by resetting the heart’s electrical activity (essentially a re-boot)and it usually starts beating again.
Symptoms: There are different kinds of pains that come from different parts of the body, and this is extremely important when deciding whether to go to the hospital about it. Organs like the heart (and kidneys and lungs and the liver and spleen) hurt with what is called “visceral pain”, an awful heaviness, or an intense pressure sensation, or a bad dull ache. That is what a heart attack feels like, and it is all the opposites of the sharp and stabbing pains we experience so much of from muscles and joints. Those are pains that are present in an area that you can point to with one finger, whereas with the heart the hurt is regional. And there is, usually, a bothersome radiation of the discomfort into the arms, shoulders, or jaws, or all of these when the heart is what is hurting. Associated shortness of breath is also typical (“It feels like I can’t breathe”). And these are pains most people have never felt before, and they often use the term “indigestion”, all of which should warn anyone involved from the patient to family to emergency staff. Simply, you can’t fool around with these types of symptoms.
Coronary syndromes often have an episodic pattern of warning. Cardiac-sounding discomfort with exertion, for example, is always worrisome. And anyone with an episode of strange chest pain lasting 15-20 minutes out of nowhere, with these features, and maybe a few risk factors, the plan is real simple. We admit you to the hospital and a heart doctor sees you and decides on what further testing is appropriate. This decision is not usually based on abnormal testing in the emergency department, because if one of those arteries is trying to clot, nothing is abnormal until it does. If we don’t like your story, we tell you that you should stay.
Here are some of the tests we do. There is the EKG, which has 12 different “leads”, or electrical pickups. Combinations of three or four of these look at the various regions of the heart, so different ones are abnormal depending on which of the heart’s three main arteries are narrowed or clotted off. There are a number of “minor” abnormalities that raise suspicions, but sometimes further testing gives an “all clear”. There is something called a “STEMI”, where the EKG is wildly and clearly abnormal, and this is cause for immediate intervention, 24/7. At all big hospitals and universities, a staff and cardiologist is always on-call to intervene within 30 minutes of being called. They insert long catheters and using x-rays and dye they can find the blockage and open it up. And sometimes they can’t. For long blockages and diseased vessels, there is no choice but to “bypass” the vessel or vessels with vein grafts from the legs, and you probably know someone who’s had this done.
Other tests. When heart muscle is injured by interruption of blood supply, it eventually dies and falls apart, and this is called “infarction” (heart attack is not a medical term). Within a few hours the proteins that make up cardiac muscle will show up in the blood stream, and we call them cardiac “markers”. Years ago the ones we did took a few days to show up as an abnormal lab, but nowadays it’s a matter of hours. And in some cases, where there have been fairly long episodes of angina (the chest pain that comes from heart muscle starving for oxygen), low positive labs for these markers raises the suspicion for a blockage somewhere. And some are slightly abnormal and nothing is found to be wrong.
An ultrasound of the heart is a helpful study. Cheap, non-invasive, and easy to do, this test looks at the heart’s beating motion, whether there are any parts that are not moving because they have been injured by infarction, and can also tell chamber size. When the heart’s chambers enlarge, that’s bad. They lose strength, and therefore so do you. Heart ultrasounds also look at the valves and their competencies, and can diagnose fluid buildups in the heart’s surrounding membrane, the pericardium. Since ultrasound is essentially an echo phenomenon, this study is called “echocardiogram”, or simple “echo”.
Exercise testing. We do exercise testing in people who we think are OK. Maybe they’re young, their symptoms are weird or “a-typical”, but they have risk factors, and you never know. The concept is simple. We hook you up to the EKG machine and have you run on a treadmill. As your heart speeds up and needs more oxygen, the electricity starts to show it. Very often a radioactive isotope is administered and pictures taken later with a fancy camera, and if a “cold spot” shows up on the test, this could mean a narrowed artery, and an angiogram is then performed. These tests can be falsely negative and falsely positive, so we have to be on our toes that we are doing these tests on the right people. If you’re old enough and the symptoms are scary much at all, an angiogram is the desired test. They’re invasive and slightly dangerous, and a little pricey, but they tell you what you need to know.
Risk factors: Age, family history of heart attacks, and cigarette smoking are big risk factors for heart attacks, and if you’re much over thirty and this is in your family, you’re wise to go to the local ER and be evaluated. And it isn’t like you’re sweating a cancer diagnosis or something, and the consequences can be sudden death and serious loss of energy if something is wrong with the main squeezer. High cholesterol and diabetes are also the ingredients for the development of coronary artery blockages.
So, if there’s one thing to say, if there are any of these features to the symptoms go to the local ER, because there is so much that can be done to check into things further and even stop heart attacks by opening up the blood vessel with miracles of modern technological advancements.
Another worry for chest pain complaints: Blood clots in the lung.
The other big concern for chest pain complaints is blood clots in the lungs. They can be fatal, so we’re hip on them and nowadays can tell you for sure whether you have one. Usually blood clots form in the low pressure veins of the legs (all veins are of low pressure), and the can “break loose” and when they do, the anatomy takes them right through the heart and up into the lung tissue (embolization). Hence they are called “PE’s”, for “pulmonary embolus”. There they result in visceral lung pain (not usually real severe). But since they are plugging up a lung artery, the main complaint is usually marked shortness of breath. Large ones leave patients literally gasping, while smaller ones or s series of smaller ones result more in shortness of breath with exertion, or even at rest.
Risk factors for PE include long flights or drives, where blood may clot in veins due to inactivity, and another is for people with casts or splints on their legs due to orthopedic injury, for the same reason. Paralysis, weakness due to other medical problems, and stroke all raise the risk of developing leg vein clots (deep vein thrombosis, or DVT), and hospitals go to great lengths to prevent them in people admitted with these types of conditions. And there is also a subset of people out there who have a gene where their blood is prone to clotting, and we can test you for these if one develops.
Women who take birth control pills, especially if they smoke and are over 35, are at risk for DVTs and PEs. Young people can have these, so with any calf swelling (sign of leg vein clot), or trouble breathing, fast heart rates, trouble with exertion, these are very dangerous conditions and worth going to the hospital to get checked out. We can screen for both of these conditions with a simple blood test, and more definitive testing can tell us for sure if a clot has developed, or traveled to the lung.
Other Causes of Chest Pain
Chest wall pains—The thorax in all mammals is a bony/muscular box constructed to move air in and out of the lungs, and there are lots of moving parts. So injuries and other conditions can cause soreness and often a very severe sharp and stabbing pain with breathing. Visits to the ER for this account for one the most common reasons people go to the hospital. There is a lot of cartilage in the front and lower chest walls and these are often the source of this decidedly orthopedic pain (sharp, stabbing, and “right here, doc”.) Easily the most common cause of this complaint is anxiety, because adrenaline overdrives the thorax muscles to prepare for the heavy breathing needed for the famous “fight or flight” physiology of high performance. Usually there is an association with chest wall pains and painful breathing of hyperventilation, and the accompanied numbness and tingling in the periphery (face, hands, and feet). And such folks usually are acting nervous, and frightened.
Collapsed lung. Occasionally sharp and orthopedic-sounding chest pain is from pneumothorax (“air in the chest”), and these usually happen spontaneously, especially in young men with flat and broad chests. A simple x-ray tells us if one is present, and they are easily managed usually. Often this pain is felt in the shoulder, like that feeling you get when you run for a while and your chest and shoulder hurt. A pneumothorax can be dangerous, and are yet another reason to make a trip to the hospital for chest pain evaluation.
So remember, you’re never too young to have a heart attack or PE or other serious conditions, so if there is especially a reason to be safe rather than sorry, getting evaluated for chest pain is a sound concept. Especially if you’re a young male and you smoke. And you have a young family depending on you.