From Richard N. Fogoros, M.D.,
Your Guide to Heart Disease.
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How should chest pain be evaluated?

If the chest pain is acute in onset: When you arrive in the emergency room with chest pain, doctors can usually get to the root of your problem quite rapidly by 1) taking a directed medical history, 2) performing a physical examination, 3) getting an ECG and cardiac enzymes. If the diagnosis is still in doubt, further testing will be needed, depending on which conditions are being considered.

The first order of business is to rule out a potentially life-threatening cardiac problem – 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 heart attack is especially important since immediate treatment can significantly limit the heart damage that occurs, and can prolong overall survival. Almost as important is the diagnosis of unstable angina, since rapid and aggressive treatment of this condition is also necessary to prolong survival.

Once a life-threatening problem is ruled out, most emergency room doctors will make a presumptive diagnosis (i.e., “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 problem: Angina due to coronary artery disease is the chief concern here. Often, stress testing with thallium will be needed to rule out this diagnosis, and not infrequently a cardiac catheterization will also be necessary. The importance of diagnosing angina is not to relieve your pain, but instead to deal with the long-term implications of angina. Namely, the coronary artery disorder that causes angina is a progressive disease process that gets worse over time, and – if untreated – often leads to heart attacks, disability, and death. It is vitally important to make the diagnosis so that treatment can be optimized not only to relieve the pain, but also to slow or halt the progression of the underlying coronary artery disease.

When something other than “routine” coronary artery disease is causing your chest pain a diagnosis also needs to be made before the pain can be adequately treated. Depending on which problems might be suspected by your doctor, you may need x-rays, endoscopy of your GI tract, or pulmonary (lung) function tests.

When is chest pain an emergency?

As we have seen, 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 cardiac disorder - 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.

On the other hand, chest pain is relatively unlikely to represent a dangerous cardiac disorder - and is less likely to be a medical emergency - if any of the following are true:

• The pain changes with changes in body position.
• The pain worsens with a deep breath or with coughing.
• You have had similar pains in the past, and a cardiac disorder was ruled out.

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