Chest Pain

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Questions to Ask Your Cardiac Care Team
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Diagnosis

Initial Evaluation of Chest Pain
Physicians and emergency room technicians do several things to determine the probable cause of a patient's chest pains, including the following:

• An evaluation of the patient's description of his or her pain.
  • What does the pain feel like?—As discussed above, the characteristics of the chest pains often are helpful in determining a possible cause. Typically, the physician will ask the patient to describe his or her chest pains, with an eye toward identifying particular characteristics that may suggest a cause.
  • Does the pain occur with exertion?—This is highly suggestive of a fixed blockage in one or more of the coronary arteries.
  • Does the pain radiate to the neck, jaw, and/or arms?—Such pain also suggests angina, the pain caused by insufficient blood reaching the heart.
  • Does the pain have a "squeezing" or "tightness" quality?—Is it accompanied by shortness of breath, sweating, a feeling of "clamminess," nausea or indigestion? These symptoms strongly suggest angina due to a blockage in the coronary artery.
  • If the pain is anginal in nature, does it last more than 15 to 30 minutes?—This may suggest the coronary artery is totally blocked and a heart attack is occurring.
  • Can the pain be reproduced by movement of the arms or torso or by pushing on a certain area of the chest?—This may suggest a musculoskeletal cause.
  • Did the pain come on suddenly? Is it sharp, perhaps the worst the patient has ever experienced?—This may suggest aortic dissection, pneumothorax (collapsed lung), or pulmonary embolus (blood clot in the lung). The sudden onset of sharp pains combined with shortness of breath strongly suggests a pulmonary embolus or pneumothorax.
  • Is the pain made worse by deep breathing?—This may be caused by a musculoskeletal injury or by any lung disorder (pneumonia, pleuritis, pneumothorax, pulmonary embolus).
  • Is the pain brought on by eating or lying down? Is it relieved with antacids?—This may suggest acid reflux or an ulcer.
• Electrocardiogram (EKG)—Whether the chest pains are evaluated in a doctor's office or an emergency room, an EKG is almost always performed. The EKG can show changes which suggest a blockage in a coronary artery that is compromising blood and oxygen flow to part of the heart. In some cases, an EKG indicates that a person is actually having a heart attack. It is important to understand that while a "normal" EKG may indicate a patient's chest pain is caused by something other than a blockage in a coronary artery, it does not conclusively rule blockage out as a cause.
• Blood Tests—In a heart attack, part of the heart tissue is deprived of the oxygen it needs and dies. As heart tissue dies, it releases certain chemicals—creatine phosphokinase (CPK) or troponin—into the bloodstream. Elevated levels of these chemicals in the bloodstream strongly suggest that a heart attack has occurred and are tested for in the emergency room and then during the next 6 to 24 hours.
• Chest X-Ray—A chest x-ray takes a picture of the lungs, the heart, and the bones of the rib cage. It is used to detect signs of lung infection, fluid in the lungs, or a collapsed lung.
• Blood Oxygen Levels—The degree to which the blood is adequately oxygenated can be determined by a monitor placed on the patient's finger. More complete measurements of oxygen and other related levels can be obtained by analyzing arterial blood gas (ABG). An ABG is obtained by drawing blood through a small needle inserted into an artery, usually in the wrist. Lower than normal levels of oxygen in the bloodstream can suggest a lung problem such as pneumonia, pulmonary embolus (blood clot in the lungs), or pneumothorax (collapsed lung). A major heart attack, with subsequent accumulation of fluid in the lungs, can lead to abnormally low blood oxygen levels.

Further Evaluation of Chest Pains
If the cause of a patient's chest pain is uncertain but believed to be a blockage in a coronary artery, the attending physician may order one of several tests. Which of these tests is performed depends on several factors, such as the degree to which coronary artery disease is suspected, the status of overall health, the ability of a patient to walk on a treadmill, and the results of the initial evaluation, including the electrocardiogram.

1. Cardiac Exercise Stress Test (Treadmill Test)—During a cardiac exercise test on a treadmill, the patient is connected to a monitor that continuously displays the electrocardiogram. The speed and uphill gradient of the treadmill increases every 3 minutes. As the test progresses, the patient's heart must work harder, which increases its need for oxygen and causes the heart rate and blood pressure to rise. In patients with one or more blockages in the coronary arteries, an insufficient amount of oxygen is delivered to parts of the heart as oxygen demand increases. This can result in the development of chest pains and/or certain diagnostic changes on the electrocardiogram.

   The cardiac stress test is imperfect: A "positive" test does not definitively diagnose the presence of coronary artery disease, nor does a "negative" test absolutely rule it out. Positive or negative findings only indicate the likelihood that blockages are or are not present.

2. Nuclear Imaging Studies—A cardiac stress test typically is performed in a hospital nuclear medicine department. It involves injecting a minute amount of a radioactive substance into the patient's bloodstream. The two most commonly used nuclear substances are thallium and sestamibi. The radioactive substance flows to the heart, accumulating in healthy parts of the heart. Pictures are then taken to display where the substance has concentrated in the heart. This is done by scanning the patient's chest during a period of stress and again during a period when the heart is not being stressed. The stress is produced by having a patient walk on a treadmill or by injecting certain substances into the bloodstream that affect the blood flow within the heart. Pictures of the heart obtained during and after stress are then compared. It can be then determined if parts of the heart are receiving insufficient blood flow during stress. Such a finding suggests a significant blockage in one or more of the coronary arteries.

3. Cardiac Stress Studies or "Dobutamine" Echo Studies—During a cardiac stress study, sound waves are used to take pictures of the heart before and during periods of physical stress. As with nuclear imaging studies, stress can be induced by exercising on a treadmill or by infusion of a chemical. The chemical usually used in echo testing is dobutamine, an agent that causes the heart to beat more vigorously and, to some extent, faster. The pictures obtained before and during stress show how well different parts of the heart are contracting. By comparing how well different areas of the heart contract at baseline and with stress, areas receiving inadequate blood flow due to blockages in the coronary arteries can be identified.

4. Cardiac Catheterization—In cardiac catheterization, a straw-like tube is inserted in an artery in the patient's groin. Differently shaped catheters are inserted through this tube and threaded up into the heart. An iodine-based dye is injected through the catheter into the coronary arteries, and pictures of the coronary arteries are obtained. These pictures can show partial or total blockages in the coronary arteries.

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