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Chest Pain - Part 2

Evaluating the Cause of Chest Pain

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Updated May 16, 2014

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

When Is Chest Pain An Emergency?

The most important decision in evaluating chest pain is yours - should you behave as if your chest pain as an emergency, and seek immediate medical help?

As we have seen in Part 1 of this article, the term “chest pain” encompasses many different kinds of symptoms and many different kinds of medical disorders. Some of these disorders are quite benign and trivial, but some are dangerous and life-threatening. So when you have chest pain, how do you know when to treat it as an emergency?

There are no hard and fast rules here. Sometimes even minor chest symptoms can turn out to be due to coronary artery disease (evidenced by the fact that up to 30% of heart attacks are accompanied by symptoms so trivial that the patient does not notice them). And you should tell your doctor about any chest pain you experience. But here are some general guidelines that are useful for deciding whether you need to go to the emergency room.

Chest pain is relatively likely to represent a dangerous condition - and should be treated as an emergency - if any of the following are true:

  • You are 40 years old or older, and have one or more risk factors for coronary artery disease (family history, smoking, obesity, sedentary lifestyle, elevated cholesterol, diabetes).
  • You are any age and have a very strong family history of early heart disease.
  • The pain can best be described by the terms tightness, squeezing, heaviness, or crushing.
  • The pain is accompanied by weakness, nausea, shortness of breath, sweating, dizziness or fainting.
  • The pain “radiates” to the shoulders, arms, or jaw.
  • The pain is more severe than any you have had before.
  • The pain is accompanied by the uncontrollable feeling that something is horribly wrong (this is often called by doctors, “a sense of impending doom”).
  • The pain gets continually worse over the first 15 or 20 minutes.
  • The pain is new – you have never experienced anything like it before.
If any of these conditions pertain to your chest pain, you should treat it as an emergency.

Chest pain is relatively unlikely to represent a dangerous cardiac disorder if any of the following are true:

  • The pain reliably and reproducibly changes with changes in body position.
  • The pain is momentary or fleeting.
  • You have had identical pains in the past, and a cardiac disorder was ruled out.
If your pain seems reasonably likely to fit into the "dangerous" category, get yourself to an emergency room. Otherwise, at the very least, let your doctor know about your symptoms.

Evaluating Chest Pain in the Emergency Room

If you decide you need immediate attention for your chest pain, in general the safest thing to do is to call 911 and be taken to a nearby emergency room. The responding EMTs or paramedics will be able to do a rapid baseline evaluation, and help to stabilize your medical condition (should you need it) even before you arrive at a medical facility.

Once you are in front of a doctor, the doctor's first evaluation will typically be to determine whether the chest pain is brand new (acute), or if it represents a more chronic problem.

If The Chest Pain Is Acute In Onset:

If you are being evaluated for acute onset chest pain, the doctor can usually get to the root of your problem quite rapidly by 1) taking a brief, directed medical history, 2) performing a physical examination, 3) getting an ECG and cardiac enzymes. This evaluation most often will determine whether you are dealing with a cardiac emergency. If after this initial evaluation the diagnosis is still in doubt, further testing will be needed, depending on which medical conditions seem likely to your doctor at that point.

To reiterate, the first order of business is to rule out a potentially life-threatening cardiac problem – acute coronary syndrome (ACS), with or without an actual myocardial infarction (heart attack), usually being the main concern. (Aortic dissection - a tearing of the wall of the aorta - is also life-threatening, but far less common.) Rapidly diagnosing a heart attack is especially important since immediate treatment can significantly limit the amount of permanent cardiac damage that occurs, and can save lives. Almost as important is the diagnosis of unstable angina, since rapid and aggressive treatment of this condition is also necessary to avoid permanent cardiac damage.

If ACS is strongly suspected, you will probably be admitted to an intensive care unit and medical treatment will be instituted. Your doctors may also want additional studies to be performed right away, in order to pin down the diagnosis - possibly including an echocardiogram, a thallium scan, a CT scan, or cardiac catheterization.

On the other hand, if a life-threatening problem has been ruled out, most emergency room doctors will then make a presumptive diagnosis as to what actually is the cause of your chest pain (that is, they will say something like, “This is probably what’s causing your pain,”) and refer you to your own physician for follow-up evaluation and treatment.

If the Chest Pain is a More Chronic, Recurrent, or Non-acute Symptom

If your chest pain is something you've had before, your doctor's main concern will be whether you have angina. Angina is usually caused by typical coronary artery disease, but can also be produced by less common cardiac conditions such as coronary artery spasm or cardiac syndrome x. Depending on his or her level of suspicion, the doctor in the emergency room may consult a cardiologist immediately, or (if you are quite stable and angina is strongly suspected) may begin medical treatment for presumed angina, and refer you to your own doctor (or to a cardiologist) for a definitive diagnosis. When something other than angina is thought to be causing your chest pain, a firm diagnosis also needs to be made so that appropriate therapy can be started. Depending on which medical problems your doctor suspects to be the cause, you may need x-rays, endoscopy of your GI tract, pulmonary (lung) function tests, or other testing to pin down the diagnosis. Most typically, an emergency room doctor will refer you to your own doctor (or to an appropriate specialist) to make the final diagnosis.

Summary

As you can see, the first order of business in evaluating chest pain is to make sure you are not going to die, or suffer permanent cardiovascular damage. Accomplishing this goal depends on two things. First, you yourself need to make an appropriate decision about seeking immediate medical care. (When in doubt, do so.) And second, the doctor needs to perform an expeditious evaluation to make sure there is no ongoing or impending cardiac catastrophe, or any other truly life-threatening medical emergency.

Once this is done, assuming a life-threatening condition has been ruled out, you likely will be referred for an evaluation outside of the emergency room setting.

Sources

Gibler WB, Cannon CP, Blomkalns AL, et al. Practical implementation of the Guidelines for Unstable Angina/Non-ST-Segment Elevation Myocardial Infarction in the emergency department. Ann Emerg Med 2005; 46:185.

Pope JH, Ruthazer R, Beshansky JR, et al. Clinical Features of Emergency Department Patients Presenting with Symptoms Suggestive of Acute Cardiac Ischemia: A Multicenter Study. J Thromb Thrombolysis 1998; 6:63.

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