When Is Chest Pain Really Heart Pain?

One of the most difficult problems for people is to separate “real” chest pain from “copycat” chest pain.

Of course, all chest pain is “real” in that it really hurts! But, for doctors and patients, identifying the sort of chest pain that signals an impending heart attack is the critical first step. Early identification of a coming heart attack can lead to prompt treatment, less heart damage, and a longer life.

I find that the signs and symptoms of a heart attack commonly confuse my patients. When should you be concerned about chest pains? What should you do first? And when should you seek medical attention?

I sat down with Payal Kohli, MD, a cardiologist at the University of California San Francisco, to discuss one of the great challenges in medicine—chest pain!

Dr. Blaha: Why is it important to identify “real” chest pain early?

Dr. Kohli: Chest pain can be one of the earliest signs of a heart attack. Estimates say that from the onset of their symptoms, most patients wait for a median time of about 2.5 hours before they finally seek medical care. This is way too long! We have a saying that “Time is heart muscle!” This means that with each minute wasted, more heart cells are damaged. Therefore, it is critical to try to recognize the symptoms of a heart attack early on, so that you can call 9-1-1 and get to the hospital quickly.

Dr. Blaha: What causes a heart attack?

Dr. Kohli: A heart attack is caused by a rapidly progressing blockage in the blood vessels (arteries) that supply the heart muscle. Heart cells need oxygen to live, and these blood vessels supply that oxygen. These blockages are more common in people with risk factors such as diabetes, high blood pressure, and high cholesterol, as well as in those who are overweight and have kidney problems. However, heart attacks can also occur in young people without these classical risk factors. You may have heard of “silent” heart attacks—these are somewhat rare and, more commonly, there are warning signs, as the heart is being deprived of oxygen. Many times, a “silent” heart attack is actually the result of warning signs or symptoms that were ignored!

Dr. Blaha: What are the characteristics of “real” heart pain, which is called angina?

Dr. Kohli: While a few heart attacks present in unusual ways, angina remains the most common sign that the heart muscle is lacking proper blood flow. Usually, the chest pain is in the middle of the chest or on the left side of the chest, and this pain can go up into the neck, the back, the shoulders, or down the left arm. Commonly, the pain feels like an ache or dull pressure or heaviness on the chest (some people say it’s “as if something is sitting on the chest”), but it can also feel like a squeezing pain. It grows worse when the person exerts him- or herself (as when walking), and it can cause shortness of breath (or a feeling of being “winded”), and sometimes sweating. Although this is the classic type of chest pain, people sometimes just complain of having unusually severe indigestion and there may not be any pain, per se. Importantly, you should seek medical care immediately if:

  • the pain or symptoms come on suddenly
  • there is something unusual or different about them
  • they last more than 20 minutes without relief

Dr. Blaha: Do men and women experience chest pain differently?

Dr. Kohli: Interestingly, new research shows that men and women sometimes use different words to describe their discomfort, but that women do probably have the same classic angina symptoms as men. Most women have chest pain and shortness of breath before a heart attack, and so they need to be equally vigilant!

Dr. Blaha: Let’s talk about the kind of chest pain that isn’t caused by heart attack. What are some causes of “copycat” chest pain?

Dr. Kohli: The lungs, the esophagus (the food pipe connecting the mouth and stomach), the lining around the heart, the muscles, and the bones in the chest can all cause chest pain. But these causes can have features that differ from classic angina, such as pain when the person takes deep breaths, pain associated with different body positions, or pain that can be reproduced by pressing on the chest. Since it can often be difficult to distinguish “copycat” pain from “real” pain, you should seek medical care regardless of your symptoms and allow your doctor to order additional tests to try to sort it out.

Dr. Blaha: If your doctor says that you did not have a heart attack, are you in the clear?

Dr. Kohli: That depends. Your doctor will do a series of tests, including a chest x-ray and an electrocardiogram (also known as an "EKG"), as well as some blood tests, to try to determine what is causing your pain. Even if the tests are normal, your doctor may still say that you are at high risk. In that case, you should be on the alert because some heart attacks are preceded by sputtering chest pain over a few days to weeks. If you are told that you are high risk, the most important thing you can do for yourself is to try to prevent a heart attack before it happens by talking to your doctor about lifestyle changes and other prevention strategies.

Dr. Blaha: What is the most important message for our patients?

Dr. Kohli: The most important thing is to “Act Fast"—don’t delay seeking medical care after the onset of unusually troubling symptoms. Chew and swallow a full-strength aspirin (325 mg, available over the counter) and get help right away. The sooner you get diagnosed, the better your chances of thwarting damage to your heart. And please don’t be embarrassed if it turns out to be just indigestion. Doctors see thousands of cases of chest pain and it always makes us relieved when it turns out to be just a false alarm!

©1996-2013, Johns Hopkins University. All rights reserved. Disclosure: The information provided here is compiled by The Johns Hopkins University School of Medicine with editorial supervision by one or more of the members of the faculty of the School of Medicine pursuant to a license agreement with Yahoo! Inc. under which the School of Medicine and its faculty editors receive licensing fees and payment for services rendered within the scope of the License Agreement. Johns Hopkins subscribes to the HONcode principles of the Health on the Net Foundation.

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