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Chest pain: How a doctor decides it could be a heart attack

Patients with chest pain come to my clinic with a nervous expression and a million-dollar question, "Doctor, is it my heart?"

Such concern is valid. But understanding how medical providers think about chest pain may allay some fear.

If you come to a clinic with chest pain, your provider will have questions about the major factors for heart disease. I will ask if you:

  • smoke (the number one preventable risk factor)
  • have diabetes
  • have high cholesterol
  • have high blood pressure
  • assess your age and gender
  • check to see if you have a family history of heart disease.

I also will be looking to see how closely your symptoms resemble the typical features of a heart attack:

  • Character: Heart pain is a dull, pressure-like sensation—"an elephant sitting on my chest." If the pain is aching, sharp, burning or stabbing, the cause may be a condition like acid reflux or heartburn, pleurisy, costochondritis or aortic dissection.
  • Location: Your heart is on the left side of your chest so any pain in this area is suspect. If the pain is on the right side, then a heart attack is unlikely (unless you have a rare condition called dextrocardia). Pain from a heart attack typically feels like vague and non-localizable. If your pain has a pinpoint location then it is unlikely to be a heart attack. Be aware: because of how nerves in that area of your body overlap, heart-related pain can occur at the left side of the neck and the left arm. We call this referred pain.
  • Timing/duration:  Heart attack pain can be intermittent or continuous. Heart attack symptoms can last for a few minutes to a few hours. If you have had chest pain continuously for several days, weeks or months, then it is unlikely to be caused by a heart attack.
  • Things that make your symptoms worse or better:  Heart attack pain is usually relieved by rest since your heart is not as active during rest (unless your heart attack is massive, in which case it will persist with rest). If your chest pain is aggravated by other factors, such as food intake in the case of acid reflux, or pressing on the affected area in the case of muscular/bony chest wall pain—then your doctor may look for other non-heart-related causes of your chest pain symptoms.
  • Other factors: Although shortness of breath typically accompanies a heart attack, the presence of this symptom may lead your provider to check your lungs as well. Symptoms such as fever, chills and coughing up of yellow-greenish phlegm are not typically associated with heart attacks (unless you have pneumonia on top of a heart attack).

The challenge of identifying the cause of chest pain symptoms can be complex. That's why if you do have chest pain seek medical attention immediately rather than checking Google for answers. Matters of the heart are often more than a mouse-click away.

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