Is That Chest Pain Serious? Tools To Help You Decide When You Should Worry.

Have you ever had chest pain and wondered if it was anything serious? Were you unsure whether you needed to see a doctor? Have you ever wondered what your risk is of having a heart attack?

Keep reading and you will find out that there are a number of tools you can use to help you understand your own risk.

This article will help you recognize when your pain could be more dangerous and when you can breath easier, so to say.

The Problem

Chest pain is a very common symptom and can be caused by a whole slew of conditions. It accounts for 5-20% of all emergency department visits across the country.

Most causes of chest pain are benign, ranging from musculoskeletal pain to heart burn. But for a minority of patients, it can be very serious.

As a physician, there are a number of elements in the patient’s story and on physical exam that can be used to help us decide whether there may be a high risk or low risk for a serious disease.

Unfortunately physicians have been historically poor at identifying those patients who could have more serious disease. So in the past most patients were admitted for further testing in the hospital (usually stress tests). Most of these tests were negative. This is a huge amount of time, resources, and money for a very low yield.

Luckily, the recent advent of a number of evidence-based decision tools have helped us refine our risk assessments. This article will not only show you tools that can be used but also the way doctors think about chest pain and the elements of a presentation that drive our decisions.

Serious Causes of Chest Pain

#1: Heart Attack

One of the most anxiety provoking conditions for patients is the risk of heart attack. This is why most people come into the emergency department who have chest pain. There are certain elements that make me more concerned for a heart attack and some that help to belay the risk.

• Age – The older you are, the more risk. Generally under 30 is a very low risk for heart attack. Other causes listed below are certainly possible in the right setting in younger patients. As patients age above 30, I have seen some significant heart attacks and I always make sure to dot my i’s and cross my t’s. Above 40 could be anything and certainly above 50 gets a full workup. If you are 40 or older with chest pain, there is no excuse – GO TO THE ER!
• Time course – How long the pain has been going on is important. If it has been 1 hour and has progressively worsened, this is a bit more concerning. However, if it has been a week or so of pain, then the likelihood of a heart attack, even though possible, is less likely.
• Intensity of pain – Needless to say, those patients who appear in significant pain tend to have something more significant. While those with mild pain are less concerning.
• Quality of pain – Is your pain sharp and you can pinpoint the exact location, or is it a pressure, like an elephant is sitting on your chest? The pressure type feeling is much more typical of a heart attack than sharp and should potentially be investigated further.
• Radiation of pain – More concerning symptoms would be pain that travels to the left arm, jaw, or back. Less concerning would be no travelling of pain or moving towards the right arm.
• Shortness of breath – Though patients with asthma can have chest pain, shortness of breath along with pain can be more concerning. Patients who have shortness of breath or pain with exertion but are better when they rest are automatic full workups for me…that is unless they are young with a more probable cause.
• Nausea – Nausea without diarrhea, especially in the setting of chest pain, is concerning. Pain can cause nausea, but if a patient has that much pain to start with, then it should raise some red flags.
• Sweating – Sweating along with chest pain has been associated with worse conditions such as heart attack. When I hear that a patient broke out in a sweat, my warning light always blinks.

#2: Pulmonary embolism – A blood clot in the lung

A blood clot in the lung can certainly cause pain and can also cause shortness of breath. In some cases, patients can have a minor increase in temperature. The pain can be more pronounced when taking a deep breath, called pleuritic pain. Sometimes one of the legs can be swollen and be a source from where the blood clot came.

Recent surgery, immobilization like a long airplane ride, or being on hormone supplements like birth control, can increase your risk. There are some good decision tools (see below) to help you determine your risk of having this condition.

#3: Aortic dissection – A tearing of your major blood vessel

This condition is rare but is very serious when it occurs. The typical symptoms are that of a tearing sensation and a sharp pain going from the chest to the back. This condition can also cause some strange neurological symptoms like numbness/tingling or weakness, usually on one side of the body or in one extremity.

High blood pressure increases the risk of this condition. However, it is very difficult to diagnose and takes an experienced clinician to suspect the condition.

#4: Pneumothorax – A dropped lung

This is caused by a small hole in the lung that causes air to get trapped between the lung and the inner wall of the chest. When this happens, the air can cause pressure to build up on one side of the chest, which in turn can be very serious.

This condition can occur in trauma, such as a car accident, but usually takes a lot of force in this situation. However, a pneumothorax can also occur spontaneously. The typical scenario is a tall lanky male patient in their teens or early 20s with a sudden onset of pain on one side of the chest with some shortness of breath.

This condition can cause a sharp pain and can also be worse with deep breaths. A simple chest x-ray or ultrasound can diagnose this condition quickly. It is relatively easy to fix with a small tube that relieves the air from the chest cavity while the lung heals.

#5: Esophageal rupture – A tearing of your esophagus

This is extremely rare but usually occurs with forceful vomiting. If pain develops suddenly and severely in the chest after vomiting, it’s important to think about this condition.

#6: Pneumonia

Simple, yet a common cause of chest pain. If there is history of coughing, fever, or other upper respiratory infection symptoms, pneumonia could be the cause.

Risk Tools

I hope I haven’t caused too much worry now that you know a number of the serious causes for chest pain. Let’s take a deep breath and get to your actual risk of serious disease, which for most people is fairly low.

As already discussed, if you are less than 30 years old and you have chest pain without the serious features I mentioned, chances are your pain is nothing to be worried about and will likely resolve on its own.

There are some decision tools that help physicians determine risk. All decision aids generally involve some form of gestalt (intuition). With experience and using the elements listed above, physicians get a feeling whether a patient’s chest pain is concerning or not.

You’re thinking, but I’m not a physician – how can I have intuition about my chest pain? I would venture to say that you as a patient have a rather good third eye (when you take the time to listen to and think about your symptoms).

When I discharge patients, I usually tell them to return if anything worsens. They ask me what to look out for. I give them some symptoms but I always say “you will know if something isn’t right.” Rule of thumb – if something doesn’t feel right and you are concerned, then you should be checked out as soon as possible.

I will mention that all of the tools available use certain tests only found in a clinic or hospital to aid in determining risk. You may have some of this information or may not. If you use MDCalc, a website containing a plethora of medical calculators and tools, you can plug and play to see what your risk may be.

The rules that I highlight have the ability to help you understand your risk for a heart attack or blood clot in the lung. Unfortunately there aren’t other decision tools yet to help with other causes of chest pain. The information above is the best way to help you identify other possible causes for your chest pain.

Emergency Department Assessment of Chest Pain Score (EDACS)

Th EDACS can certainly help predict your risk of having a heart attack while having chest pain. If evaluated in the emergency department, it is recommended that you also have an EKG and troponin blood test (enzyme measured in blood that shows if there is any damage to the heart) completed to be thorough. If these tests are negative, then discharge with primary care follow up is an appropriate course of action.

The tool uses your age, sex, and a number of symptoms to determine risk, many of which I mentioned above.

For those experiencing chest pain at home, this can be helpful to understand your risk of having a heart attack while experiencing chest pain. However, the score can not be used alone without other testing to help guide your decision.

HEART Score

The HEART score is another fairly recent decision aid that was created to help physicians decide a patient’s risk of a complication within 30 days from their visit in the ER. It consists of 5 elements. Unfortunately again, 2 of the elements are tests that cannot be done at home currently, similar to the EDACS. Nevertheless, the other 3 do give an idea to help determine your risk.

In the emergency department this score is one of my favorites. With a score of 3 or less, studies have determined that a patient is safe to be discharged and follow up with their doctor for outpatient testing. This has revolutionized our care of chest pain patients. Rather than overnight admissions for everyone to have a stress test in the morning, many patients can safely be discharged after some basic testing.

Framingham risk

This is a longitudinal study of men and women which started in 1948 and continues today. These patients are followed over a lifetime to study the risk factors that can cause heart disease.

Using this simple calculator, you can determine your risk of having a heart attack in the next 10 years. Not only this, but you can also learn your relative heart age to see if it correlates with your actual age.

This is a great way to understand your risk now and decide if you should make any lifestyle adjustments to prevent your chances of a heart attack in the future. Higher scores, aka higher risks should prompt you to see your doctor to discuss how to improve your health.

Wells’ Criteria

The Wells’ Criteria are a set of rules to help decide whether you might have a pulmonary embolism (PE) or blood clot in the lung. These criteria are very helpful in determining risk for this condition.

Generally it is accepted with a modified score that 4 points or less is considered low risk, though the original study used 0 and 1 point as markers for low risk while 2-6 points is considered moderate risk. This score cannot be used alone to determine whether further testing can be avoided but gives an idea of risk to help providers decide on the next step.

PERC

A crowd favorite, the PERC rule or Pulmonary Embolism Rule-Out Criteria, gives a specific set of criteria that you can use to determine whether another test may be necessary to rule out a blood clot in the lung, or whether no other testing is necessary.

• Age <50 years old
• Heart rate <100 beats per minute
• Oxygen saturation >94%
• No prior blood clots
• No recent trauma or surgery (within 4 weeks)
• No coughing up blood
• No estrogen use (such as birth control pill)
• No clinical signs of blood clot in the leg or arm (like swelling or pain)

The great thing about this rule is that almost every criteria can be done at home, except for oxygen saturation. Generally speaking, if a patient is seen in the emergency department and none of these criteria are present, further testing to look for a blood clot is not necessary.

Conclusion

Chest pain is a difficult symptom. Though there are certain elements that increase our suspicion for more serious disease, my own gestalt has been wrong in the past. If you have some of the symptoms above and/or elements that can increase your risk, there’s no harm going to the ER to be checked out.

The little time and testing to get the reassurance that you’re healthy is loads better than the risk of death or disability from a cardiac arrest. If your intuition tells you something isn’t right, your best bet is to see a doctor right away.

On the other hand, if you don’t have chest pain but realize your risk is higher than you thought, now is the time to make an appointment and see your doctor to make sure your lifestyle and risk factors are adjusted to maximize your health and longevity.

 

What do you think about using this information to understand your risk? Is there any additional information patients should know? Comment below.