Chest pain: Is it always an emergency?

By Linda Lombroso;12:08 a.m. EST January 31, 2014

Dr. David Brogno, chief of cardiology at Nyack Hospital, is an interventional cardiologist who specializes in cardiac catheterization, angioplasty and stenting. The issue of chest pain, he says, is quite complex. Obviously not all chest pains represent a serious health problem requiring a trip to the emergency room, says Brogno. The flip side of that statement is that not all serious cardiac problems present with chest pain. So how is a patient to know when it is OK not to go to the ER? There are a few rules of thumb. ? If there is an obvious, non-heart-related cause that is not serious. For example, you just got hit in the chest with a baseball, you have a bruise and it hurts where you have been hit. In that situation the pain is certainly not coming from the heart, and unless the ball was hit by A-Rod, it is unlikely that you have even sustained serious rib trauma. You most likely have a bad bruise that your primary doctor can handle in the office. ? The pain lasts for less than a few seconds, is sharp not dull, and/or migrates from spot to spot. Generally those types of pain are caused by irritation of the muscles, bones, joints or nerves in the chest wall and usually go away on their own. If they continue to occur over several days, your doctor may want to treat you with an antiinflammatory drug. ? Likewise pain that gets better with activity is most likely musculo-skeletal in origin, not cardiac. ? If the chest pain is made worse by taking a deep breath in, it is likely caused by an irritation of the inside lining of the chest wall (the pleura) rubbing against the outside surface of the lungs. This is a condition called pleuritis and, although it is not a heart problem, it can be associated with certain types of infections, sometimes even pneumonia. If you are otherwise feeling well, and can see your doctor within the next 24 hours, you can probably avoid a trip to the ER. What types of chest pain should be handled in the emergency room? ? Any severe, unexplained chest pain that persists for longer than a few minutes, especially if it is associated with shortness of breath, nausea or vomiting, lightheadedness, or a cold sweat. ? Chest pain that gets worse with exertion, or chest pain occurring at rest now that previously had only been occurring with exertion. ? Any chest pain preceded or followed by a fainting spell. ? Severe, persistent chest pain that goes straight into your back. Unfortunately, a lot of times the symptoms of heart disease arent easily classified as chest pain or even pain per se. ? Many folks who are having a heart attack describe their symptoms as gas or an upset stomach. They often attribute it to something they ate. It can sometimes be very difficult for even the emergency room doctor to figure out if someones symptoms are due to a heart problem or a gastrointestinal problem. Figuring that out is best done in an emergency room setting where specialized testing can guide us. ? Sometimes the symptoms of a heart problem can be so subtle that a patient might be barely aware of them. Patients have described a feeling of fullness or aching, or even just a sense that something isnt right in their chest. The bottom line is that persistent, unexplained chest symptoms need to be investigated, and sooner is better than later. Thats what emergency rooms were made for. Dont worry about feeling foolish if nothing wrong

is found. Eight out of 10 emergency-room patients with chest pain will turn out not to have any heart problem, and thats OK. We accept that so we can find the two out of 10 who need our immediate help. One other note: Patients often ask me if they should drive themselves or have a family member drive them to the emergency room if they are having chest pain. My feeling is that they are better off calling 911 and being transported by medical professionals just in case something bad should happen on the way to the ER. Ambulances and EMS personnel are equipped to handle these situations en route to the ER family members are not. Play it safe, not sorry. More from Dr. Brogno on heart health Blocked arteries can cause heart attacks. Is there some way to screen for blockages in the arteries, even if you dont have any symptoms? Unfortunately, there are people who do have coronary disease and dont have any symptoms from it, says Brogno. The patients who seem to be most at risk for this are diabetics. Stress testing for the general population is of limited value, but diabetics are one group in which it can actually prove quite helpful, especially if they have other risk factors, like high cholesterol, smoking, high blood pressure or a family history of coronary disease. Certain types of CAT scans have also been used to detect coronary blockages, but those scans arent very good at determining how tight the blockages are, and they dont help us decide what to do if the patient has these blockages on the CAT scan but doesnt have any symptoms. Believe it or not, the best test for detecting heart disease is a detailed medical history taken by your doctor. Many things that a patient might not think are symptoms can actually be indicators of heart disease, and your doctor knows what questions to ask in order to tease that information out. If that sounds like an advertisement for your local physician, so be it. The most important diagnostic equipment is still between your doctors ears. What are some of the best ways to improve heart health? Quitting smoking is the one lifestyle change that has the biggest impact on reducing the risk of heart disease, head and shoulders above all others. Beyond that, research has clearly shown that a sedentary lifestyle (and in particular, long periods of sitting) is highly associated with development of cardiovascular disease. Obviously, daily exercise for at least 30 minutes would be ideal, but just moving around is important even if it is just getting out of your chair to stretch or get a glass of water. And make sure you get a good nights sleep. That may sound a little wacky, but research shows that lack of sleep leads to obesity, which can cause diabetes and high cholesterol, and those are two big causes of cardiovascular disease.

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