Deciphering Chest Pain

Many people would have experienced this symptom sometime in their life. This can cause a great deal of anxiety. How is it possible to determine if this is a serious symptom and what are the causes?

Cardiac chest pain

This is most important to rule out given the potential threat to life. What are the typical symptoms/clues that this originates from the heart?

  1. Central, squeezing, compressing, heavy, fullness sensation.
  2. Exertional symptoms – pain that occurs with exertion (eg walking, straining) and then gets relieved by rest. This is termed classic angina and occurs due to blockages in the heart arteries. Some patients may report that symptoms improve after rest and then they can walk or exert more subsequently – this is called ischemic pre-conditioning and could also be a symptom of coronary artery blockages.
  3. Postprandial symptoms – chest pain when walking after eating is also suggestive of coronary artery blockages.
  4. Episodic chest pain that may be associated with cold weather or early morning may point to coronary vasospasm – contraction of the coronary arteries which transiently reduce blood flow to the heart.
  5. Radiation of the pain – when the pain radiates to the jaw, shoulder, neck, face and arm or between the shoulder blades – this is also possibly cardiac related.
  6. Sharp tearing pain which radiates to the back may be caused by tears in the aorta ( large blood vessel) – this should be evaluated early.
  7. Pain that changes with posture or worsened with breathing may suggest inflammation of the membrane that covers the heart – we call this pericarditis. In this condition, pain tends to be worse lying down ( supine), and improved with sitting upright and leaning forward.
  8. Presence of associated clues such as concomitant symptoms of breathlessness, palpitation, dizziness, fatigue. Presence of risk factors such as diabetes, hypertension, high cholesterol or smoking. Known history or family history of cardiac or aortic disease. Patients with diseases such as Marfan syndrome or a known dilated aortic root.

Do patients always have the above symptoms?

Unfortunately, many patients do not present with the classic symptoms that we describe. This is especially so in patients with diabetes and also in women with coronary artery disease. In these cases, the symptoms may be intermittent and non-specific and may warrant testing to determine if these are truly cardiac.

How do I know if this pain is a heart attack?

The common heart attack signs are

  1. New onset pain or discomfort in the chest, jaw, neck or back
  2. Progression of previous angina episodes
  3. Lightheadedness, nausea or vomiting
  4. Discomfort in the pain or shoulder
  5. Shortness of breath
  6. Cold sweat

The symptoms may last for more than a few minutes and may occasionally go away only to return. Pay close attention to your symptoms and call for an ambulance to the hospital to have this checked out even if you are unsure. Minutes matter when it comes to a heart attack and early help can significantly increase the chance of survival.

Cardiac test which are done to evaluate chest pain

  • Electrocardiogram – This is necessary to quickly determine the probability of heart attack or blockages.
  • Chest – X Ray – This is done to assess the cardiac size as well as lung or other causes of chest pain.
  • Echocardiogram – A non-invasive test which could help determine if there are signs of reduced heart function, clues to inflammation to the membrane lining the heart (e.g pericarditis), size of the aorta and the valves within the heart.
  • Blood tests – These include cardiac enzymes such as serum troponin which can be used to detect for the presence of cardiac injury ( e.g. due to a heart attack or myocarditis).
  • Computed tomography – enables one to rule out blockages of the heart arteries, and can also help assess other adjacent structures in the chest.
  • Stress testing – This is done in patients to determine if the patients may be at risk of having coronary artery blockages (Treadmill, Stress echocardiogram, myocardial perfusion imaging). These test are not done in patients suspected of having heart attacks
  • Cardiac MRI – To assess for structural heart disease, myocarditis (inflammation of the heart), heart function or congenital heart disease

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