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Chest pain: A heart attack or something else?

MAY 2010

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Tips for telling cardiac chest pain from other types.

That dull burning in your chest doesn't seem to be going away, and even feels like it is getting worse. Is it a heart attack, or something else?

It's a vexing question, one that millions of people — and their doctors — face each year. What's the problem? Chest pain can stem from dozens of conditions besides heart attack, from pancreatitis to pneumonia or panic attack.

More than six million Americans with chest pain were seen in hospital emergency departments in 2009. Only 20% of them were having a heart attack or an episode of unstable angina, a warning sign that a heart attack may happen soon. A small percentage had another potentially life-threatening problem, such as pulmonary embolism (a blood clot in the lungs) or aortic dissection (a tear in the inner layer of the aorta). Some were experiencing "regular" angina, which occurs when part of the heart isn't getting as much oxygen-rich blood as it needs during periods of physical exertion or emotional stress. Most of the six million, though, had a condition unrelated to the heart or arteries.

The other tricky problem with heart attacks is that different people experience them in different ways. Some have classic chest pain. Others have jaw pain or back pain. Still others become breathless, or extremely fatigued, or nauseated.

 

Heart attack warning signs

Chest pain is only one of the possible signs of an impending heart attack. If you notice one or more of the signs below in yourself or someone else, call 911 or your local emergency number right away.

  • Uncomfortable pressure, squeezing, fullness, burning, tightness, or pain in the center of the chest

  • Pain, numbness, pinching, prickling, or other uncomfortable sensations in one or both arms, the back, neck, jaw, or stomach

  • Shortness of breath

  • Sudden nausea or vomiting

  • Lightheadedness or dizziness

  • Unusual fatigue

  • Heat/flushing or a cold sweat

  • Sudden heaviness, weakness, or aching in one or both arms

 

Sorting things out

Doctors use several pieces of information to determine who is, and who isn't, having a heart attack. The most accurate are blood tests for markers that show damage to the heart muscle, such as creatine kinase and cardiac troponin. But since it takes awhile for blood levels of these proteins to get measurably high, the best early methods are an electrocardiogram (ECG) to measure electrical activity in the heart plus your story and description of your chest pain and other symptoms.

Here are some things your doctors will want to know about what you are experiencing:

  • What is it that you are feeling (pain, pressure, tightness, etc.)?

  • Where is the discomfort?

  • When did it start?

  • Has it gotten worse or stayed the same?

  • Is the feeling constant, or does it come and go?

  • Have you felt it before?

  • What were you doing before these feelings started?

Clear answers to these questions go a long way toward nailing down a diagnosis. A stabbing pain or one that hasn't changed for hours is less likely to be a heart attack (see box), while pain centered in the chest that spreads out to the left arm or jaw is more likely to be one.

 

More likely to be a heart attack

Less likely to be a heart attack

Sensation of pain, or of pressure, tightness, squeezing, or burning

Sharp or knifelike pain brought on by breathing or coughing

Gradual onset of pain over the course of a few minutes

Sudden stabbing pain that lasts only a few seconds

Pain in diffuse area, including middle of chest

Pain clearly on one side of the body or the other

Pain that extends to the left arm, neck, jaw, or back (see figure below)

Pain that is localized to one small spot

Pain or pressure accompanied by other signs, such as difficulty breathing, a cold sweat, or sudden nausea

Pain that lasts for many hours or days without any other symptoms

Pain or pressure that appears during or after physical exertion or emotional stress (heart attack) or while you are at rest (unstable angina)

Pain reproduced by pressing on the chest or with body motion

 

Better safe than sorry

Unlike an achy knee or crabby lower back, chest pain isn't something to shrug off until tomorrow. It also isn't something to diagnose at home. Don't play doctor — go see one, fast, if you are worried about pain or discomfort in your chest, upper back, left arm, or jaw; or suddenly faint or develop a cold sweat, nausea, or vomiting. Call 911 or your local emergency number to summon an emergency medical crew. It will whisk you to the hospital in a vehicle full of equipment that can start the diagnosis and keep you stable if your heart really is in trouble.

There are oh-so-many reasons to delay calling for help. I'm too young (you aren't — even 20-somethings can have heart attacks). I'm in great shape (a heart attack is sometimes the first sign of heart disease). I have a family to take care of (all the more reason to get to the hospital fast). I don't want to bother anyone (you'd be a bigger bother with advanced heart failure, or dead).

 

Heart attack pain

illustration of areas where heart attack pain may be felt

Pain from a heart attack isn't confined to the area around the heart. The most typical locations are marked in dark red; light red shows other possible areas.

 

What if it isn't a heart attack? You will be evaluated as if you are having one and, when it is ruled out as the cause of your symptoms, your doctors will look for the real cause. They won't be mad at you for crying wolf. Instead, they should congratulate you for taking action (if they don't, we will) and work with you to get at the root of your chest pain and ease it. If the cause was indigestion, a panic attack, or another possibly recurring condition, the emergency department doctors and your primary care physician can help you interpret what your body is telling you.

Chest pain is serious business. If you think yours might be due to a heart attack, take action right away. The sooner you are checked out, the sooner you can get the kind of artery-opening therapy that can protect your heart from permanent damage.