Is that Cupid's Arrow You Feel, or an Acute Coronary Artery Occlusion?

I seem to be on a cardiac kick lately, with a few recent posts relating to the heart. The heart IS kind of important, and while I had another topic in mind for this week, with Valentine's Day coming up, I thought that I'd stick to the ticker.

Working in an emergency department, I conduct cardiac examinations on every shift. Whether a patient is complaining of palpitations or is unresponsive, we take a close look at the heart. One of the more common symptoms that brings people to the ER is non-traumatic chest pain, so let's talk about that. 

When a patient says that he or she is having chest pain, we immediately try to determine how likely it is that the pain is related to a potentially life-threatening condition or not. 

Before I go any further, I should point out that we, in the medical world, will use the word "pain" as a catch-all for any and all uncomfortable sensations. It could be a pain, a pressure, an ache, or really anything that doesn't feel right. If a person says that they are having "chest pressure," that goes into the "chest pain" category. 

Anyway, some non-serious reasons that a person can have chest pain would be muscle strain or spasm, inflammation in the chest wall, indigestion, or anxiety. I should point out, even if we suspect that the pain is not related to a serious cause, we still check electrocardiograms and other tests such as cardiac blood tests and imaging (X-ray or CT). No one wants to make the wrong diagnosis. 

The initial approach to determining if the chest "pain," is something bad or not includes looking at the patient, his/her age, past medical history, vital signs, and features of the pain.

A few seconds of chest pain in a young person is *probably fine,* while 30 minutes of chest pain that started while doing yard work in a 75yr old person with high blood pressure and diabetes is *probably not fine.* But... if that young person is a smoker on birth control pills with a heart rate of 130 beats per minute, the *probably fine* gets revoked.

Some of the serious conditions that can cause chest pain are:

• acute coronary syndrome (heart attack)
• aortic dissection (body's largest blood vessel tearing apart)
• pericarditis/myocarditis (inflammation of the heart or heart lining)
• pulmonary embolism (blood clot in the lung)
• pneumothorax (collapsed lung)
• esophageal rupture (tearing of the esophagus)

Other conditions include inflammation of the gallbladder (cholecystitis), inflammation of the pancreas (pancreatitis), inflammation and/or bleeding in the stomach (gastritis/peptic ulcer disease), and many more. 

We really focus on what brought the pain/pressure on, and any associated symptoms.

• Chest pain plus vomiting after drinking plenty of alcohol--probably pancreatitis.
• Sudden chest pain in a tall skinny guy with difficulty breathing--probably a pneumothorax

Exertional chest pain is in a class all by itself and is very concerning for a cardiac cause. If you're out riding or running or hiking or just walking, and you're working a bit, maybe going up steep section and you (or anyone you're with), starts feeling:

• Chest pain/pressure/uncomfortable feeling
• Pain or pressure or squeezing sensation in the back, jaw, or arm(s)
• Shortness of breath
• Nausea
• Sweats
• Dizziness

Your day on the trail is done. You need to sit and call 911. If there's no reason not to, take 2-4 low-dose (81mg) chewable aspirin.

Certainly, we don't only worry about those symptoms with exertion, and those same symptoms could occur while watching TV and will still suggest a cardiac cause, but if provoked by exercise, the suspicion is higher. 

There's a semi complicated approach to risk stratification used to determine specifically what tests are needed to definitively exclude a cardiac cause, as a person can have coronary artery blockages that are not identified on an electrocardiogram or on cardiac blood testing, and some types of stress tests can have false positives (test says that heart disease is present) or false negative (tests says no heart disease). 

That's all beyond the scope of this article.

Realistically, I just wanted to emphasize that exertion plus chest "pain," and any of the associated symptoms above would be very concerning and reason to stop, rest, call for a ride in a van with flashy lights and come visit an emergency department. Maybe you'll see me, and you can wish me a Happy Valentine's Day.

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