Many patients are admitted to hospitals throughout the United Stated everyday for chest pain. At the end of the hospital stay, they will belong to one of the three category:
- Confirmed heart attack: They receive heart attack specific treatment and education.
- Confirmed alternate serious diagnosis: This category include patients diagnosed with conditions such as aortic dissection, pulmonary embolism, pneumonia and so then. They get specific treatment and education about those conditions.
- Negative evaluation: These patients get tested for heart attacks and other things but everything comes back normal. At the end of the hospital stay, they do not know what exactly caused the chest pain.
There are far greater number of patients that fall into category 3 than any other category. These patients are somewhat relieved that they did not have heart attack but they are also baffled and confused about what really happened. Most hospitals have a specific patient education hand-out for these patients. It is usually titled “Non-cardiac chest pain” and lists several possible alternate conditions that may have caused the chest pain.
Many patients diagnosed with this “non-cardiac chest pain” are very anxious and do not know what to make of their hospital stay. Here are some of the questions and thoughts that naturally comes to your mind when you are in this situation:
- Why did they put me in the hospital for the chest if I did not have anything serious?
- I should not have gone to ER for this chest pain, what a waste of my time and money!
- There must be something wrong. Why would they keep me in the hospital for 2 days if everything was fine?
- Are they hiding something from me?
- Why are they sending me home on blood pressure medicine, cholesterol medicine and aspirin if I did not have a heart attack?
- Did I just get hospitalized because of some incompetent doctor who thought I had a heart attack when I obviously did not?
Unfortunately, the answers to those questions are not always straightforward and simple but I will explain the process from the doctor’s perspective. There maybe many doctors involved and many levels of decision making at work.
It always starts with the ER doctor. When you go to ER with chest pain, the ER doctor evaluates you and makes a decision about your hospital admission. This decision making process is very complex and highly subjective. Only a small percentage of the patients have obvious heat attack that can be diagnosed instantly in the ER. The ER doctor has to make a judgement call on everyone else. A normal EKG and normal blood tests in the ER do not mean that you don’t have a heart attack. When all the tests done in ER are normal, the ER doctor makes educated guess about the likelihood of a possible heart attack. Your age, your risk factors for heart disease, your family history of heart attacks, your blood pressure, your history of diabetes, your physical fitness, your exercise tolerance and the description of your chest pain are just a few example of things the ER doctor has to consider in making this decision. Although they have guidelines and algorithms to help make this decision, the final decision is always a subjective judgement call. When they are not sure, they always err on the side of caution and admit you to the hospital for further testing.
The next judgement call is made by the admitting doctor. It is usually a hospitalist like me. It could also be your family doctor or your internal medicine or primary care doctor. The admitting doctor usually waits for three sets of blood tests every six to eight hours apart. When all three tests are normal, the admitting doctor can answer at least one question with a high degree of certainty. The doctor can confirm that you did not have a heart attack. However, the doctor cannot say if there is an imminent threat of a heart attack.
What happens next depends on your overall risks for heart attack. If you do not have any high risk features, the doctor may decide to send you home. If you are in this category of “non-cardiac chest pain”, it means that:
- It was a good idea to have your chest pain evaluated in the ER to make sure you did not have a heart attack. You are at low risk for heart attack but sometimes people with low risk do get heart attacks.
- You were thoroughly evaluated and heart attack was excluded.
- We do not really know what caused your chest pain.
- Keep doing what you are doing to keep your low cardiac risk.
When all the tests are normal but you still have high risk factors for heart attack, you will get a stress test. The goal of the stress test is to see how your heart behaves under stress and find out if you need intervention to prevent heart attack in the near future. If the stress test is positive, you will be evaluated by cardiology for intervention. If the stress test is negative, you may still be diagnosed with a “non-cardiac chest pain”. If you are in this category of “non-cardiac chest pain”, it means:
- You have risk factors for heart disease and need to lower those risks regardless of what happened during this hospital stay.
- You did not have heart attack this time and you may not be in imminent danger of heart attack in the near future.
- The chest pain you had this time was probably not related to your heart but you need to take this as a wake-up call and work with your doctor to avoid heart attacks in the future.
- A negative stress test does not mean that your risk for heart attack is low, it just means you do not have an imminent threat of a heart attack in the near future.
- Your risk for heart attack depends on several factors that are not changed by the result of the stress test. Your regular doctor has tools to calculate your personal risk for heart attack and this is what you need to discuss with your doctor in your follow up visit.