Volume 3  Number 5  June 22, 2006
Second Opinions

Chest Pain: Am I Having a Heart Attack?

Chest pain is the second most common medical reason for Emergency Room (ER) visits, and for most patients, the first question is "Is It My Heart?"

Two General Classifications of Chest Pain

Even though most heart attacks (myocardial infarctions or "MIs") are accompanied by chest pain, up to one third of them are silent, that is, without pain. This happens mostly in elderly patients and those with diabetes who may complain instead of atypical symptoms like fainting, collapse, or weakness. See this page. Still, since most heart attacks are preceded or accompanied by chest pain, a common complaint associated with many other conditions, the question of distinguishing causes of chest pain becomes critical.

How do we distinguish between the various causes of chest pain? Fortunately, the chest pain of coronary (heart) disease, anginal pain ("angina pectoris") due to insufficient supply of oxygen rich blood to the heart, has several characteristic features. This is in general unlike most other types of chest pain, which is called nonanginal pain.

A. Typical Angina and its Variants have several features, among which are generally three or more of the following:

  1. Heaviness, squeezing, tightness or a crushing sensation felt in the front of the chest substernally (behind the breastbone) or between the shoulder blades.
  2. Pain may be precipitated by exertion, meals, cold, or emotional stress
  3. Prompt relief with rest or nitroglycerine.
  4. Pain frequently radiates to the shoulders, mid back, arms, upper abdomen, face, neck or jaws or any combination thereof.
  5. When present, the pain usually causes the patient to stop all activities and remain at rest.
B. Nonanginal Chest Pain. Any type of chest pain other than that described above is called nonanginal:

  1. It may occur anywhere in the chest, but usually does not radiate.
  2. The pain is not related to exertion, and almost always lasts less than 10 seconds or more than 10 minutes.
  3. It almost never causes the patient to stop his activities.
  4. There is NO consistent relationship between rest or nitroglycerine and pain relief.

Nonanginal or "no sweat" chest pain is much more common than anginal chest pain, even in older patients, although anginal pain increases in frequency with age and male sex. Only about one out of ten patients presenting to their doctor with chest pain has coronary disease or another serious medical condition. (See below).

The TYPE of chest pain described is one of the most important keys to diagnosis. Angina is a powerful indicator of coronary disease, while nonanginal chest pain is strongly in favor of a non-coronary cause. Following are four clinical histories to illustrate the two main categories.

Anginal Chest Pain (Angina Pectoris) Indicating Coronary Artery Disease

Case 1. A 72 year old man, an avid tennis player began developing a squeezing or "heavy" sensation in the front of his chest "right under the breast bone" coming on after mild to moderate exertion playing doubles. He noted the pain-which only occurred "from time to time,"-disappeared completely within a minute of two when he rested between games. After several episodes of pain in the course of a month, he gave up tennis. In order to keep active, he began taking walks up a short hill near his home, but the same type of chest discomfort began to recur after a week or two, this time occasionally radiating to the back, and again subsiding completely after a brief rest. Since the pain did not occur every time he walked, he tended to downplay its significance. After urging from his wife, he finally consulted his physician who promptly referred him to a cardiologist who ordered a stress test followed by a cardiac catheterization.

Comment: New angina always calls for immediate medical consultation. A certain percentage of patients are initially "in denial" about their symptoms, and indeed in some cases angina can be capricious in its presentation, and often without noticeable progression, described as "stable angina." Typical or atypical angina may be recurrent and not consistently provoked by exertion. It may be present for some time before the patient is diagnosed, particularly in women in whom the symptoms may not be as clear-cut. Moreover, stable angina may become unstable or crescendo by increasing in frequency or severity, often leading to an MI. Approximately half of all heart attack or MI patients have experienced warning symptoms like anginal chest pain days, weeks, or even months prior to the attack.

Anginal Chest Pain Associated With a Heart Attack

Case 2. A 63 year old man is brought to the ER with a history of two hours of persistent frontal chest pain with nausea which he self-diagnosed as "a bad case of indigestion." When questioned further he admitted to a heavy, almost a crushing sensation, in the front of the chest spreading to the shoulders and neck, sweating, and extreme weakness. His cardiogram and other findings were typical of an acute coronary ("AMI for "acute myocardial infarction.")

Comment: Anginal chest pain as in the above case, lasting more than 10-15 minutes, poorly or unresponsive to rest or nitroglycerine, should raise the immediate suspicion of an acute coronary or MI (heart attack). Frequently patients describe the pain, particularly if accompanied by nausea or vomiting as "indigestion." or "heartburn." (A history of relatively chronic recurrent angina precipitated by exertion, meals, stress, etc., and relieved by rest or nitroglycerine should not be confused with the persistent anginal pain of a heart attack.)

Nonanginal Chest Pain

Nonspecific Chest Pain

Case 3. A 42 year old woman visited her physician on and off for 5 years because of recurrent aching over her left chest "under the heart" coming on unexpectedly every few weeks or months, and lasting anywhere from minutes to hours. Sometimes she complained of sudden sharp poorly localized stabbing chest pains appearing "out of nowhere." She was high strung and admitted that sometimes the pain was related to stress, sometimes not. There was no relief with rest or nitroglycerine. She also complained of frequent sighing, and occasionally the feeling of a "lump in the throat." The lady was subjected to a search and destroy diagnostic strategy with endless, cardiograms, three stress tests, two upper GI endoscopies, and ultimately a coronary angiogram. All tests were normal.

Comment: This is a typical example of "nonspecific chest pain syndrome" a leading cause of non-coronary chest pain This type of pain is often described as stabbing or knife-like, prolonged, dull, or aching, can last for moments, hours, or days, but may present with many faces. Its cause, usually unknown, may be related to stress, emotions, or hormonal influences, but in most cases is obscure.

Case 4. A 25 year old woman was brought to the Emergency Room by her terrified boyfriend who informed the receptionist," Shes having a heart attack, shes gotta be seen immediately." The patient was pale, talking hesitantly, and between short rapid breaths, complained of chest pain, difficulty breathing, and numbness about the mouth. On examination she appeared anxious, had a rapid pulse and respiratory rate, with a normal blood pressure. While the intern was attending her, a resident passing by, quickly assessed the patient, and calling for a paper bag, bunched up the end , asked the patient to hold her fingers around the opening and breathe in and out the bag. Within minutes she felt better, the chest pain gone, and after some reassurance and medical information, she was discharged.

Comment: This case can be classified as "panic disorder" or "hyperventilation syndrome." It is one of the many presentations of nonspecific chest pain. .Brought on by acute, unconscious or unrecognized anxiety, the patient, often a young female, begins taking short, rapid breaths. If this state of overbreathing continues more than several minutes, the patient can lower blood calcium, causing a cascade of frightening symptoms, including chest pain or pressure, numbness of the lips, etc. Rebreathing from a paper bag reverses the process by restoring blood calcium to normal.

Gastrointestinal (GI) Chest Pain

Various common conditions of the esophagus, and stomach are the second most common cause of nonanginal chest pain, accounting for up to a third of all cases. Esophageal conditions causing chest pain include the very common gastroesophageal or "GE reflux" caused by regurgitation of stomach acid, commonly called "heartburn." Sometimes disorders of swallowing may be related to chest pain. Other common causes are ulcer disease and ulcer symptoms without ulcer. Rarely, gall bladder disease causes this kind of chest pain.

Other Non-Coronary Causes of Chest Pain

A number of other conditions cause chest pain. Overall, they account for less than 15%-20% of all cases. Important among these are inflammation of the rib cartilage, fractures, pneumonia, blood clot to the lung, and serious abdominal conditions, such as abscess and appendicitis. Among the most common causes of chest pain, particularly in children, is muscle strain.

Summary

Chest pain, a common medical complaint, and a leading cause of ER visits and hospitalizations for heart attack, has many causes other than coronary disease. I have tried to simplify the understanding of chest pain by describing the principal differences between serious and "no sweat" chest pain, and by stressing two of the most common causes of the latter: nonspecific chest pain, and problems arising in the upper gastrointestinal tract. However, the diagnosis in patients with chest pain can be much more difficult than I have outlined, especially in older women or when anginal and nonanginal pain coexist.

I firmly believe that the informed patient is far better off than the medically unsophisticated. Yet I continue to tell my patients, no matter how much they know:

ANY TYPE OF UNEXPLAINED CHEST PAIN ALWAYS CALLS FOR IMMEDIATE MEDICAL ATTENTION

Martin F. Sturman, MD, FACP

The above revised article, is reprinted with permission from Radius Magazine, March 2006, a division of Nightingale Publishing, Inc.

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