Understanding Chest Pain: When to Worry, When to Act, and How Doctors Decide

Welcome back to Cardiovascular Therapeutics Unplugged, where we demystify the world of heart treatments with real, honest conversations. Today’s episode tackles one of the most common and often terrifying reasons people rush to the emergency room: chest pain. Millions experience it every year, but while some cases are true emergencies, many are not. The real challenge? Most people can’t tell the difference.

Dr. Mehra to breaks down how doctors distinguish urgent heart issues from less serious causes of chest pain. They cut through the fear, decode the clinical guidelines, and share what every patient actually needs to know about chest pain when to act, when to stay calm, and how to advocate for your health. Whether you or a loved one has experienced chest discomfort or you’re just looking to be prepared, this episode brings clarity to one of medicine’s most anxiety-provoking symptoms.

00:00 Evaluating chest pain in emergencies

06:34 Evaluating severe chest pain causes

10:22 Identifying heart attack symptoms

13:33 Recognizing atypical heart attack symptoms

15:33 ER triage for chest pain

18:34 Understanding microvascular heart conditions

22:42 Cardiac health diagnostic options

28:09 2021 medical diagnostic guidelines

29:23 Understanding chest pain and diagnosis

33:02 Closing remarks and thank you

Transcript

SPEAKER_00 0:00

After injuries, chest pain is the second most common reason for adults to present to the emergency room in the United States. When a patient is having chest discomfort, it is the most dangerous thing or a scary thing that they've encountered. The number one thing we look for is to make sure it's not something that's gonna hurt you. Some pains can be very, very severe and ripping in nature. Some people don't feel anything, unfortunately. Their body doesn't give them the signs of a heart attack, and they end up having what's called a silent MI or silent myocardial infarction. So when you're having symptoms, call 911. Don't wait, get to the hospital. If you're wrong, it's okay. But at least you got to the emergency room, you got treatment, there's no reason to suffer damage.

SPEAKER_01 1:10

And while many are facing something urgent, many are not. And the problem is most people can't tell the difference. They either panic when they shouldn't, or far more dangerously, they wait when they should act immediately. So what actually causes chest pain? And when is it a sign of a heart attack? And when is it something far less serious? And how do cardiologists and emergency physicians really sort through it in real time? Welcome back to cardiovascular therapeutics on plant, real conversations about heart treatments that change lives. Dr. Marad, today we're cutting through the fear and getting to what patients actually need to know. Such an important conversation. But before we hop in, so it's great to see you. Um are you excited for this episode? And how are you doing? I haven't talked to you in a in a week or so.

SPEAKER_00 1:51

Yeah, I'm doing great, Layla. Thanks once again for hosting this episode. It's a very exciting time to kind of talk about chest pain today. Uh, we have, again, I've been discussing a variety of guidelines. So I'm gonna refer to the guidelines once again. We have guidelines from 2021 that were revised, and so I'm gonna allude to those guidelines to explain what is chest pain, why it creates panic in patience, and what to do, what not to do. So we'll dive a little bit deeper into this topic so we can alleviate some of the fears and at the same time educate everyone about chest pain evaluation.

SPEAKER_01 2:31

Absolutely. And like like I touched on in the beginning, chest pain is one of the scariest things that someone can feel, especially without really knowing whether it's urgent or an emergency or not. So it's such an important conversation to have. And speaking about the chest pain and how it sends so many people to the ER, I think it sends millions of people to the emergency room every year, but not all of it is actually emergency or a cardiac emergency. So, from your perspective, what makes chest pain so uniquely anxiety-provoking? And how does that fear actually affect patient outcomes?

SPEAKER_00 3:03

So, like you said, after injuries, chest pain is the second most common reason for adults to present to the emergency room in the United States. It accounts for about 7 million visits, which is about 5%, approximately 5% of all ED visits that take place in the United States. Chest pain also itself just leads to 4 million outpatient visits to doctors' offices annually. So it it remains a huge burden on healthcare as well as a diagnostic challenge in the emergency room as well as the outpatient setting. Like you said, not all chest pain is dangerous, but when a patient is having chest discomfort, it is the most dangerous thing or a scary thing that they've encountered. So an adequate diagnosis and workup is paramount to getting to the right treatment modality. So let's discuss, you know, what uh to do when somebody has chest discomfort and how do cardiologists or emergency physicians think about chest pain. For this, we're gonna look for guidance to the 2021 guidelines that I mentioned. There was a lot of clinical pathway-driven protocols that were formulated in those guidelines so that people have kind of homogenous approach to chest discomfort instead of just haphazardly doing workup that may or may not lead to the correct diagnosis. What are we looking for? Let's say what is the most important thing an ER physician or a cardiologist looks for. The number one thing we look for is to make sure it's not something that's gonna hurt you. Is it is it the heart? Is it is it an aortic pathology, meaning your great vessels are affected? Is it the lungs? Is it a pulmonary embolism? Those are the things that cross our minds in general. So we're looking for the the things that are immediately gonna be very harmful or or or possibly fatal for for somebody. So, you know, uh and and and it varies in distribution from a young person presenting to the ER with chest discomfort, an 18-year-old versus a 65-year-old smoker with diabetes. So those are the things that make us triage patients and work them up accordingly. So what are the things that we're looking for? So I'm just gonna break it down into some general categories. First, we look at the nature of the chest pain, right? We're looking to see if this is angina. Angina refers to chest discomfort coming from decreased blood flow to the heart, possibly leading to a myocardial infarction or a heart attack. So anginal symptoms are usually the classic way that they are described as or retrosternal or substernal, meaning right here in the middle of the chest, a pressure-like sensation or heaviness that possibly could suggest underlying heart disease. We look at onset and duration. Is it something fleeting? Is it something that happened after somebody just picked up something heavy? Uh, or is it a sustained pressure-like sensation that comes on with exertion and is relieved with rest? Those are the kind of things we look at to identify whether it's muscular pain or is it cardiac pain, for instance. The location of the pain, the radiation of the pain, pain going from the chest to the back, or chest to the jaw, again suggests a cardiovascular pathology. The severity of the pain. Some pains can be very, very severe and ripping in nature, right? Some people walk into the ER and say, This was the worst pain I experienced in my life. When it's sudden and onset, we start thinking about a heart attack or a what's called an aortic dissection, a tear in the big vessel. Or if it's related to deep breathing, is it a pulmonary embolism? Is it occurring after a long flight? Do we suspect a clot from the legs, which is called a deep vein thrombosis? Did a clot travel to the lungs? Is that what's causing the chest discomfort? These are the three things we want to rule out. The other things we look at is precipitating factors. Is it coming on, like I said, with exertion? Is it positional? Those are the things that point us in the right direction. So yeah, chest pain protocols have been developed. One of the things that guides uh the approach that I wanted to mention that ER physicians use is going by the letters, chest pain, C H E S T, P-A-I-N-S. So that refers to C refers to chest pain. Uh is it, you know, more than just the fleeting sensation in the chest? We look at H, which we measure blood enzymes called high sensitivity troponins, to see if there's leakage of those enzymes in the blood. E, we want, we want to give patients early care. So ER physicians are looking to see when somebody shows up to the ER. We want an EKG done within 10 minutes. We want that patient with chest discomfort evaluated very quickly. These are certain quality standards that every hospital has to live by, that somebody with chest discomfort is evaluated very quickly, especially if they're accredited by the American College of Cardiology for taking care of chest pain patients or if they have a cardiac catharization lab which is going to perform an angioplasty if necessary. E, like I said, is early care. S is sharing the decision-making process. So discussing it with cardiologists, and if the ER physician is evaluating, quickly discussing the patient with a cardiologist. T stands for testing, whatever routine testing needs to be done for the chest discomfort evaluation. And the pains part refers to pain pathways, uh, I mean clinical decision pathways that need to be followed. Accompanying symptoms need to be looked at, identifying what may be going on with the patient and what the patient might benefit from in as far as further testing is concerned. N is looking at non-cardiac etiologies of chest discomfort or causes of chest discomfort. And then S stands for structured risk evaluation and assessment. So that's the, you know, kind of the way that we think about protocol-driven way in approaching a patient who ha who presents with chest discomfort either in the ER or in the outpatient setting.

SPEAKER_01 9:34

No, that's a great way to remember it too. And from a patient standpoint, I'm sure patients want to know, we would all want to know, how can they tell whether their chest pain is an emergency? And what are the signs that should make someone act immediately versus patterns that suggest something that may be less urgent and can maybe wait, be waited on?

SPEAKER_00 9:54

So again, the number one thing that patients are concerned about when they have chest discomfort while they're sitting at home or doing something, is this a heart attack? Do I need to go to the hospital? What do I do? So things that are concerning and point more towards ischemia, meaning decreased blood flow to the heart versus a non-cardiac cause are things like central pressure. Having pressure in the middle of the chest that is sustained, is not going away. A squeezing sensation that points more towards a cardiac etiology. People describe it as a gripping sensation sometimes, a heaviness or a tightness. All these things point towards the same kind of discomfort that people have when they're having decreased blood flow to the heart. If they're having symptoms that have been going on for a few days or a few weeks, sometimes people ignore them, but they realize that it's getting worse. Doc, I used to be able to play tennis on a regular basis, and now, you know, I can't do what I was doing, or I'm tired very quickly. Or I used to be able to, you know, walk upstairs to my bedroom from my house very easily. Now every time I get up there, I've got this tightness in my chest. So those kind of things point towards ischemia, so or decreased blood flow or cardiac-related problem. So related to exertion is one thing. If it's left sided, if it's dull, if it's an aching sensation, if it's a stabbing sensation, these are the words that people use. All these things point more towards a cardiac etiology. If it's non-cardiac, usually it's transient, it lat doesn't last that long, it's positional in nature. It could be cardiac, but not necessarily ischemic, meaning that it could be an inflammation of the heart or something if it's positional. So those things point more towards a non-cardiac cause. And just as a side, we used to use prior to the 2021 recommendations, we used to use the word atypical cardiac chest discomfort very often. That was done with, and you know, they said atypical is a very it's not the right terminology. So either we use cardiac causes or non-cardiac causes to keep it very simple as far as what workup needs to be done to come up with a diagnosis.

SPEAKER_01 12:18

And from all those different uh discomfort feelings you mentioned, another one I think that we hear a lot is crushing. I think we hear about the classic crushing chest pain. So what about the patients whose symptoms don't look like textbook? Women, diabetics, older adults. What are clinicians trained to watch for those patients might not expect?

SPEAKER_00 12:38

Yeah. So, you know, some people don't get the classic discomfort in the chest. And you have to go, again, dive a little deeper and make sure that you're doing the risk assessment for the patient in the correct manner. A diabetic might not get classic symptoms because they've got what's called autonomic dysfunction, or they're they they have neuropathy and they don't feel the crushing chest chest discomfort. They might have just sometimes people just have some sweating. Sometimes people just feel a little nauseous. Some people have discomfort in the abdomen, epigastric discomfort. Some people just shortness of breath. And some people don't feel anything. Unfortunately, their body doesn't give them the signs of a heart attack, and they end up having what's called a silent MI or silent myocardial infarction. So those things, you know, again, if somebody shows up with these atypical symptoms out of the blue, we still work them up. We have to have a higher index of suspicion so that you don't miss anything. They still need to get their cardiac enzymes and their blood checked. They still need to get their EKG. So a higher index of suspicion based on their risk factors. So if a diabetic shows up having some nausea and epigastric discomfort, then they deserve to have an EKG. They deserve to be worked up properly so that, you know, heart attack is not missed.

SPEAKER_01 13:59

Absolutely. And I also think for a lot of patients, an ER visit itself is intimidating. I think a lot of people get nervous about going to the ER at all. So can you walk us through what actually happens when someone comes in with chest pain and what tests are ordered? I know you mentioned some right now, like EKGs and things like that, but what are clinicians looking for and how quickly can things really escalate?

SPEAKER_00 14:21

Yeah, so, you know, when when somebody presents to the ER, like I said, very quickly they're triaged. They first walk into the ER, they meet either a triage nurse or a receptionist or a medical assistant who's sitting there at the desk and the patient says, I'm having chest discomfort, they're very quickly in most emergency rooms whist away into the chest pain uh kind of area and get their EKG done very quickly and are evaluated by an ER physician very quickly. The EKG needs to be done and interpreted within 10 minutes so that if there are acute changes in the EKG, you know, pathway, clinical decision pathway is taken. If you end up seeing EKG which is consistent with a heart attack, you know, an interventional cardiologist or a cardiologist is called and the patient is appropriately treated for a possible heart attack with the right medications, they might end up going to the cardiac atherization suite and you know, have uh if they're having what's called a ST elevation myocardial infarction, and they'll get treated immediately in the hospital with possible angioplasty and stencer, or if if they have significant further even multivessal disease, they might be referred for bypass surgery. If they're not having an immediate, you know, myocardial infarction on the EKG, then they will be worked up and risk stratified, and then they go down the pathway of getting further workup done for possibly underlying heart disease based on their risk factors. And this again, based on whether they're low risk, intermediate risk, or high risk, they would get either a stress test or an echocardiogram or a cardiac CTA to further make sure that they're not having uh underlying corneary disease. If they're non-cardiac causes, then they're worked up for things like infections or pulmonary embolisms, aortic dissections. Everything then goes down that non-cardiac pathway, and you can look for other etiologies of chest discomfort. Again, they're going to be risk certified based on their age. If, for example, an 18-year-old walks in with chest discomfort, it'd be very different from how an 80-year-old is, you know, your index of suspicion is very different for the two age groups.

SPEAKER_01 16:42

Right, of course. Well, some patients go through the full workup and undergo a coronary angiogram and they're told everything looks normal, but sometimes they actually had a real intense chest pain. So what's actually happening in those cases? And how do you explain that to a patient that the chest pains were painful but really break down what was happening?

SPEAKER_00 17:04

So the again, there are different algorithms that could explain that. If somebody, for example, has chest discomfort but no underlying corneartery disease, they might have things like vasospastic angina, meaning that they have spasm in their blood vessels. They could have what is called microvascular corneartery disease, just not in the big vessels, epicardial vessels, but the smaller vessels, and that can be assessed with different modalities such as cardiac MRI or cardiac PET scans, which look at corneary flow reserve and microvascular blood flow to the heart. Those are things that some people need further assessment if they're having discomfort, even if even if their stress test is normal and their cornea angiogram are normal, sometimes people can have microvascular disease that leads to a stable chest pain or chronic angina. So if you have spill of cardiac enzymes in the blood, but you don't have any kind of underlying corneartery disease, then you could suspect what's called my oca, myocardial infarction in non-obstructive cornear artery uh disease. So that's an entity that was described. So for that, you know, you can you can look at again corneary blood flow reserve, or you can do what's called invasive corneary function testing to look and see if there is significant microvascular disease.

SPEAKER_01 18:30

And we're talking about chest pains in, I feel like almost a way that happens not so often, maybe an emergency visit. But for some patients, chest pain isn't just a one-time event. It becomes a recurring long-term issue for some people. So, how do you approach patients who are stuck in that cycle and what options exist beyond the initial workup?

SPEAKER_00 18:51

You know, a lot of patients have very severe cornearity disease. Even after revascularization, meaning they've had bypass surgery or they've had stents placed, they continue to have what's called chronic stable angina. The treatment is basically optimizing medical therapy there using the drugs that we have available, such as beta blockers or anti-anginal agents, to optimize their function and keeping them chest pain free. Chronic angina is a very difficult thing to treat in clinical practice on a regular basis. It's it's a challenge for physicians and cardio, you know, and especially cardiologists, because you could fix everything and some people still continue to have discomfort. Of course, we have to rule out other causes of discomfort, making sure that there's nothing else going on besides underlying corneartery disease. But yeah, chronic angina can be a chronic problem. And, you know, you have to you have to deal with it with uh the appropriate medications that we have. Yeah.

SPEAKER_01 19:54

Absolutely. And if someone is listening right now who has experienced chest pain and either ignored it or felt dismissed by the system, what's the most important thing that you really want them to walk away knowing?

SPEAKER_00 20:06

I hope that people are not dismissed, you know, by by the system. I hope that there's somebody listening to them. They have to seek out the right physician, they have to seek out the right person who they're talking to, whether it's their primary care physician or it's their cardiologist. You know, this is something that should not be missed and deserves the right um uh workup. So based on your risk factors, there's a lot of modalities that are available. Seek help, get, you know, based on your risk factors, get a stress test or an echocardiogram. And these days there's more and more emphasis on doing corneal artery calcium scoring. You could probably have a CCTA or a cornea, which is a cornea angiogram CT CAT scan. That that can tell you, you know, where you stand if you're if you're concerned about underlying corneartery disease. There's a variety of uh diagnostic studies that we can do, but the most important thing is speaking to the right physicians and making sure that you yourself are not ignoring your symptoms. A lot of people, you know, brush their symptoms aside. They think that it's nothing. And like we mentioned earlier, a lot of symptoms can be not the typical crushing chest discomfort. So don't dismiss if you there's a change in your clinical status. If you're if you were able to walk on the boardwalk here at the Jersey Shore, you were able to walk, you know, five miles last summer, and this summer you're you feel like, oh, I uh you know, I can't walk the dog for even half a mile and something's changed. It deserves a workup. Listen to your body, have somebody else really take a look, a professional take a look into your symptoms. We can work things up, we can treat things effectively these days. So there is no reason to be left untreated and undiagnostic. Diagnosed.

SPEAKER_01 22:00

Absolutely. And speaking with that in terms of timing and going back to what we were saying, how people naturally assume that chest pain is a heart attack, or they might assume it's something severe, but maybe not severe enough for the ER, but it's recurring and keeps happening. When do you think they should schedule a proper medical evaluation? What like what time frame is that like? Is it like the second time it happens, the first time it happens, or like you said, when they notice that change?

SPEAKER_00 22:26

Yeah, I mean, there's no correct number of times that you need to experience a symptom to seek help. I mean, if if I think you have to be in tune with your body, I mean, some people know exactly what's going on. I just don't feel right. They come in the first time I see it and practice on a regular basis. They'll show up. I I just don't feel right. And, you know, most of the time, you know, they're correct. They listen to their bodies. So there's no correct number of times that you need to have a symptom. But um, yeah, I mean, if you're having recurrent chest discomfort, it becomes a pattern, don't dismiss it. Every time I play now, I'm getting a tightness in my chest and I have to sit down. Whereas I could play pickleball for, you know, two hours without without any issues, and now I can't do that. I hear that all the time. So and that's the you know, just just listen to your body. If something's changed, something's new that you don't like, get it checked out.

SPEAKER_01 23:25

Absolutely. And I think that also many people experience chest tightness during stress or panic or anxiety, and they tend to worry that something's seriously wrong. But how do how would you think about this? Like how do you how does stress and anxiety create real physical chest symptoms?

SPEAKER_00 23:42

Yeah, well, a lot of things can mimic chest discomfort, which is which we get concerned about. So you could have acid reflux that is causing you to have chest discomfort. You've you could have muscular pain that is causing you to have chest discomfort. You could have, like I said, uh lung pathology that can cause you to have chest discomfort. You could have asthma that, you know, people with asthma or breathing issues can have chest tightness and they could feel like their lungs are closing up and they're they can't breathe, of course. And is it cardiac? They don't know. And anxiety and panic can do the same thing. People can have palpitations, their heart could be racing, they could have tightness in their chest, and they could feel like they're having a heart attack. You know, that is something that it we we take seriously as well. We want them to not go through a battery of cardiac tests. We, you know, again, it's it's your clinical evaluation that then takes them into treating their underlying anxiety so that they're not miserable and somebody is not putting in stents where where you needed to treat the anxiety or depression or panic disorder. But so, yeah, I mean, a lot of things can mimic chest discomfort or angina, but you have to again look at the right things and come up with the right clinical diagnosis.

SPEAKER_01 24:59

Absolutely. And this is such an important conversation to have and share because it really gives a lot of clarity to people who who doesn't may happen to which is essentially everyone. But before you wrap up with this episode, do you have any other final thoughts or anything that you wanted to add in at all?

SPEAKER_00 25:14

Yeah. So what happened in the 2021 guidelines was there was there was a wide spectrum of diagnostic pathways that were very divergent and different when people worked up patients when they showed up to the ER or they showed up to a doctor's office. But there was a consensus in these guidelines to to follow certain clinical decision pathways. If somebody has this chest discomfort, you go down this pathway. If somebody has this chest discomfort, for example, stable underlying corneartery disease, what do you do? How do you treat them? If they have a cornea angiogram, like you mentioned, but there are no blockages and they're having discomfort, what do you do? You look for microvascular disease. So that gave us really a lot of information on how to work out these patients and eventually go down the right treatment pathway. So that's why the 2021 guidelines gave us, you know, guidance as to what to do. The top 10, I would say, take-home messages of the guidelines were were the follows. One, chest pain means more than just pain in the chest. Um, chest pain could be pressure, it could be tightness, it could be discomfort in the in in the shoulders, it could be in the arms, it could be in the neck, it could be in the back, it could be in the abdomen. So all those things can be what are called anginal equivalents. Number two, when somebody shows up, you know, we do blood work, we move towards using what are called high sensitivity troponins, their cardiac enzymes that give us an idea of whether there is cardiac injury or myocardial injury in the in the blood, and that starts a pathway of diagnosis and treatment very quickly. Those things are very quickly available when somebody shows up to the ER. Like I mentioned, early care, number three, early care for acute symptoms. Go ahead, you know, if if you're having symptoms, first of all, this starts at home. When you're having symptoms, call 911. Don't wait. If you feel like something is wrong, don't wait. Seek medical help early. So time is muscle. You get to the hospital. If you're wrong, it's okay. But at least you got to the emergency room, you got treatment, there's no reason to suffer damage. Number four, share the decision making. Patients and doctors need to talk and see what's going on and share in the decision-making process. Number five, for low-risk patients, we don't need the majority of the time, we don't need testing. So that testing is not needed. Number six, again, like I mentioned, clinical decision pathways become a very, very important thing in the evaluation of chest pain in the emergency department as well as outpatient doctors' offices. Number seven, look for accompanying symptoms. What else is going on in a patient with chest discomfort, nausea, shortness of breath, dizziness, swelling in the legs. Number eight, identify patients who are going to benefit from further testings. The low risk patients are one category, but then in the intermediate and the high-risk patients, you want to go down the right clinical diagnostic pathway. Number nine, non-cardiac patient, and you know, we want to call pain non-cardiac. We don't want to call it atypical. Atypical pain is out. It is a misleading kind of description of the pain. Non-cardiac pain is what we want to use to qualify pain that is not coming from the heart. And ten, a structured risk assessment should be used. You have to assess these patients and assess their risk in a very structured manner. So you're going down the right diagnostic and the treatment protocol. So those are the top 10 take-home messages from the 2021 guidelines. And those are the ones that I employ regularly in my clinical practice.

SPEAKER_01 29:04

Because there's such good takeaways. Definitely, definitely valuable for everyone listening. And thank you so much, Dr. Murray, for helping patients, families, and our listeners really replace that fear with clarity that they actually need and that everyone needs. And chest pain is definitely one of medicine's most complex tries problems, I would say, because the stakes on both ends of the spectrum are real. So understanding what it actually means and when it's a man's immediate action can really make all the difference. So thank you so much for this episode. And this is Cardiovascular Therapeutics Unplugged. Real conversations about heart treatments that change lives. And make sure to follow and share this episode so you don't miss any future conversations and make sure to share it with anyone who can really benefit from it. So thank you again, Dr. Mara. It's great speaking with you as always. And I can't wait for our next episode.

SPEAKER_00 29:53

Thanks, Leila. Have a great day.