Chest Pain and the Boy Who Cried Wolf

Of all the questions I get, this is probably one of the hardest:

How do I know when to call 911 if I get chest pain?

This usually comes from a patient with prior experience in the world of cardiac illness, someone who already owns a coronary stent who now wonders about every ache and pain he feels in his chest.

This is an especially vexing issue for the patient whose recurrent symptoms turn out to be false alarms.  Patients are often chastised by medical personnel and family members for ignoring the early symptoms of a heart attack, but when they come back to the ER for vague aches and pains that turn out to be noncardiac, they feel like the little boy who cried wolf.

It seems like a normal psychological response to be more sensitive to chest symptoms after suffering a heart attack.  These days when coronary disease is so common and everyone has either a friend or relative who’s had this experience, even healthy persons begin to wonder about chest pain, arm aching, jaw discomfort, and numbness.

A quick survey of online medical sites will lead you to believe that you should dial 911 for virtually any symptom above the naval and below the nostril, but common sense tells you that most pain in the thoracic cavity is not related to clogged-off arteries.

While I never think it’s wrong to call EMS when doubt exists about your symptoms, I also feel that a blanket recommendation to “come to the ER for any chest pain” is overly generalized and therefore not entirely helpful.  With that in mind I decided to elicit the assistance of my partners to give their opinion on what type of symptoms warrant an emergency trip to the hospital.

I presented several scenarios to the dozen and a half members of my cardiology group and asked them to grade each based on how they would react to the symptoms (or how they would advise family members with similar symptoms) by using the following score card:

A. Call 911
B. Drive to ER immediately
C. Go to ER if symptoms worsen or don't improve in a few hours
D. Make routine appointment to discuss with your doctor
E. Ignore altogether

Case 1.  You develop relatively sudden onset of chest pain and abruptly lose consciousness for about 15 seconds.

In the cardiology world this one’s a no-brainer.  The combination of chest pain and loss of consciousness is extremely ominous and generally points toward sudden formation of a clot in a coronary artery.  The downstream heart muscle becomes starved for oxygen and triggers a life-threatening rhythm (ventricular fibrillation) that leads to loss of consciousness.  Your fainting episode is actually cardiac arrest that aborted spontaneously and will likely recur if untreated.  Without exception all the cardiologists answered A on this one.

Case 2. Over a three-week period you develop chest pain with exertion that goes away at rest.

What I am describing here is classic exertional angina.  Unlike case number 1 where a clot forms abruptly and occludes all flow through the artery, exertional angina arises when a blood vessel narrows to the point of impairing adequate flow to the heart only during periods of increasing demand.  On angiography we typically see narrowings of 90% or greater when symptoms get to this point.  Most of my partners answered D for this one, but with the caveat that the patient be seen within the week.  Your doctor may send you for a stress test to verify that your symptoms are indeed cardiac.  If you came to me with these symptoms I’d probably skip the stress test and schedule an angiogram within the next few days.

Case 3. Sudden, squeezing chest pain associated with nausea and sweating.

This is another scenario where you should simply dial 911 (at least that’s what nearly all my partners say).  Like case number 1, this has a high likelihood of representing a heart attack.  The nausea and sweating are triggered by stimulation of the vagus nerve—a response that is common when the right coronary artery becomes obstructed.

Case 4.  Sharp chest pain with deep breathing.

Most of my colleagues chose D for this case (routine appointment) with a quarter suggesting a visit to the ER if the symptoms don’t improve in a few hours.  Heart attacks are rarely associated with sharp pain alone, especially if it comes only with breathing.  This so-called pleuritic chest pain is more commonly seen with either chest wall problems (muscle strains, costochondritis) or irritation of the lining of the lung.  I imagine that the cardiologists who chose C are probably more concerned with pulmonary embolism than anything else.

Case 5. Shoulder pain coming on gradually over the course of hours.

We all know that heart-related pain can travel down the arm and into the jaw, but it’s somewhat unusual for isolated shoulder or arm pain to signal a coronary event.  For this case the answers given were all across the spectrum: two doctors answered A and three answered E, with the rest being somewhere in between.  The fact that some cardiologists recommend a 911 call and others say to ignore it simply illustrates how tough it is to provide generalized guidelines on how to react to unusual symptoms.

Case 6. Jaw pain upon awakening.

Again, isolated jaw or arm pain in the absence of other symptoms is typically not cardiac in origin.  The consensus in my group was on answers C or D.

Case 7. Left back pain with tingling of the left arm for one day.

A lot of Ds and Es are among the answers from my partners on this one.  There are a lot of odd symptoms that can go along with coronary blockage but back pain is a little unusual.

Case 8.  Sudden sharp chest pain coming spontaneously and lasting seconds, periodically over months.

Brief, sharp pain is virtually never related to the heart.  Most of my partners said E with a few Ds.

Case 9.  Dull chest pain for a month but now with shooting pain down the left arm.

The clue with this one is the duration of pain—discomfort lasting longer than a few hours is likely noncardiac.  I was once asked to see a patient who’d had steady chest pain since he was 20 years old (he was 55 when I evaluated him).  Thirty-five years of symptoms makes a cardiac cause a little unlikely.

I’ll close with a couple of summary points.  First, when in doubt there’s never any harm in calling 911 if you think you’re having a heart attack—no one critiques your decision and we’d rather see a false alarm than have you sit at home while your heart suffers.

Second, it’s interesting to note that the answer “B” was almost never given (“drive to ER immediately”).  If you think you need to get to the ER for a suspected heart attack you’d better call 911 and let them take you.  Every one of us can tell stories of patients with chest pain going into cardiac arrest in the passenger seat of the family sedan on the way to the hospital.  Trust me, performing CPR while driving is even more distracting than text-messaging.

Finally, with the exception of case number one, there was no question in my survey that elicited a unanimous response and there were several that prompted answers spanning A to E.  This means that even trained and experienced cardiologists will differ in their opinion when faced with a scenario with limited information.

In the end, the right answer to the question is this: start with common sense, and if there is any suspicion about a heart attack, simply call 911 and let the paramedics, ER doctors, and cardiologists sort it out.