Chest pain: What patients need to know

Chest pain is probably the most common, most dangerous, most expensive and most worrisome of all medical symptoms. I believe all patients need to know these ten things about chest pain:

1. Chest pain means heart attack unless proven otherwise:

This is how the system to evaluate chest pain is designed. It does not mean that doctors believe the statement. In fact, most doctors consider it a myth. They still go along because this assumption creates a very effective system to catch certain types of heart attacks early. Is it not possible to know if the chest pains are serious without a thorough evaluation. Most emergency departments have a protocol which dictates that all patients with chest pain must have an EKG done within 5 minutes of arrival.
If the EKG shows a pattern suggestive of heart attack, they need immediate attention. A heart attack with an abnormal EKG is the kind of heart attack where minutes count. The outcome depends on timing of the definitive treatment. Patients’ hearts can be saved by rushing them to definitive treatment as soon as possible. This specific type of heart attack is called STEMI( ST segment elevation myocardial infarction) and it is the reason why chest pain is considered a heart attack unless proven otherwise.
A 55 year old man showing up with pressure-like crushing pain in the middle of the chest with radiation to the left arm is considered to have one of the most typical heart attack symptoms in men. Symptoms of heart attacks in women are, in general, less typical and therefore more likely to be missed. Emergency departments want a system where all people with chest pain could be screened for heart attacks, not just the ones with typical heart attack pain.

2. Some patients with heart attacks do not have chest pain

If all patients with heart attacks had chest pain, we would have caught all heart attacks in the ER. Some heart attacks go undiagnosed because some patients with heart attacks do not have chest pain. Some of them do not have any symptoms in the chest and have true silent heart attacks. Others do feel something but they do not necessarily identify the feeling as chest pain. For example, you may not think twice about a slight pressure in the middle of the chest. When you fail to identify your complaint as chest pain when you first talk to the ER registration desk, your chart will not be processed as chest pain and you will not get an EKG within five minutes.

3. Many patients with chest pain do not have heart attacks

There are several other organs in the chest besides the heart: the lungs, ribs, muscles, major blood vessels, etc. Chest pain can come from abnormalities in any of these organs. In some cases, pain from the stomach and other organs in the abdomen may feel like it is coming from the chest. In fact, the majority of patients visiting the ER with chest pain do not have heart attacks. There are certain situations where you can use your common sense to know that the chest pain is something else. For example, if you had a chest injury from a fall, the sharp chest pain on the left side where you had the injury is not likely to be a heart attack. In that case, your symptoms are more appropriately processed as chest injury symptoms rather than chest pain symptoms.

4. Chest pain from heart attacks can be hard to differentiate from other types of chest pain

There are many articles in the Internet that talk about heart attacks and they describe what kind of chest pain people normally have from heart attacks. Do not be fooled by these simple descriptions. Practically, it is very hard to differentiate chest pain from heart attacks with other types of chest pain. Medical textbooks list the classical symptoms of a heart attack and describe the typical chest pain of a heart attack. In reality, only a fraction of patients with heart attacks have the typical chest pain. When someone comes to the ER with chest pain, it is very hard for a trained ER doctor to definitely dismiss the possibility of a heart attack based on the description of the chest pain. When trained ER doctors cannot do it, I do not advise you to try it. Do not try to judge the cause of a chest pain based on articles you have read or stories you have heard. If you see an article with a headline such as, “Chest pain: How to decide if it could be a heart attack?” or “Chest pain: When do you need to worry about a heart attack?”, do the right thing: ignore those articles. Those articles may give you a false sense of security when your chest pain does not match a pattern they describe. This false sense of security may delay your diagnosis and cause great danger. You may feel like you have anxiety chest pain. You may only have a slight chest pain that comes and goes. You may have a mild pain in the left chest. You may not feel like these chest pains are serious but you can still have a heart attack with unusual chest pain.

5. The ER is still the best place to go if you have chest pain

Emergency rooms today are full of patients with chest pain. Some patients have mild chest pain that comes and goes. Some patients feel like they have chest pain due to gas. Some may have mild dull pain in the center of the chest. Many of them could still have heart attacks. The ER is still the best place when you have a new undiagnosed chest pain. At the end of the day, it may turn out to be nothing and you may feel like you have wasted time and money but hindsight is always 20/20. If you had stayed home and if your chest pain had been from a heart attack, you could have lost your life.

6. Many patients admitted to hospitals with chest pain do not have heart attacks

When you visit the ER for chest pain and they decide to admit you to the hospital, it does not always mean that you have been diagnosed with something bad. Of the hundreds of patients seen in the ER for chest pain, some get diagnosed within a few minutes and get admitted to the hospital, while some eventually get cleared and get discharged home. But there are many patients who fall in between those two extremes. They do not have any definite evidence of major heart attacks but it is hard to rule out minor heart attacks or heart attacks in progress. The majority of patients admitted to the hospital with chest pain fall in this category. If you know someone admitted to a hospital with chest pain and discharged with a “no heart attack” diagnosis, you can share this detailed article with them:

7. Chest pain can be caused by things much more dangerous than heart attacks

Heart attacks are definitely a major concern when you have chest pain but they are not the worst things that can cause chest pain. There are certain diseases that are more dangerous and more fatal than heart attacks, and they also cause chest pain. Aortic dissection, the rupture of the main artery coming out of the heart, can also cause chest pain and it can kill you within a few hours if not treated instantly. A massive blood clot in the lungs can manifest itself as chest pain and it can be fatal too. Sharp stabbing-like chest pain that goes straight to your back is worrisome for aortic dissection. Sharp chest pain that comes and goes with breathing in and out is worrisome for blood clots in lungs.

8. Chest pain is a very expensive symptom to have

An ER visit for chest pain may easily cost you anywhere from two thousand to four thousand dollars. This is true even in cases where everything comes back normal and you get discharged from the ER. Chest pain is definitely a very expensive symptom to have. Despite the cost, you should not stay home and try to figure out how to get rid of chest pain. It is more important to make sure you don’t have heart attacks or other serious life threatening conditions.



9. Ignoring chest pain may cost you more

When you ignore chest pain, you are taking a very high risk. You may turn out to be fine and think about the thousands of dollars you just saved, but you may not always be that lucky. If you happen to have a heart attack or any of the other bad diseases, your condition may get progressively worse. You may faint, you may run out of breath, and you may even collapse instantly. If you only seek help when it is too late, you will end up getting high risk procedures and prolonged hospitalizations. You may end up spending 10 times more money and still have poor outcomes.

10. Chest pain cannot wait until your doctor’s office opens

If you have chest pain on the weekend and are concerned about it, it is not a good idea to wait until Monday morning when your doctor’s office opens. Some patients do that because they trust their own doctors and would not want to be seen by someone else. That may be a good idea when things are not that urgent, but it is very risky to wait for Monday morning when you are having chest pain. Even when your doctor’s office is open, it may be better to call 911 and get to the nearest ER as soon as possible when you have a new undiagnosed chest pain. It is never a good idea to look for ways to get rid of the chest pain instead of getting it diagnosed promptly. There are no home remedies for chest pain.