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

Patients with chest pain come to the 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 the clinic with chest pain, the medical provider will have questions about the major factors for heart disease:

  • smoking (the number one preventable risk factor)
  • diabetes
  • high cholesterol
  • high blood pressure
  • age and gender
  • family history of heart disease

The provider 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/heartburn, pleurisy, costochondritis or aortic dissection.
  • Location: Since the heart is on the left side of the chest, 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 a vague, non-localizable pain. If the pain has a pinpoint location, then it is unlikely to be a heart attack. Be aware: because of how nerves in that area of the 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: The duration of heart attack pain can be intermittent or continuous and can last for a few minutes to a few hours. If the patient reports that he has had chest pain continuously for several days, weeks or months, then it is unlikely to be a heart attack.
  • What makes it worse or better:  Heart attack pain is usually relieved by rest since the heart is not as active (unless the heart attack is massive, in which case it will persist with rest). If the 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 the medical provider may look for other non-heart-related causes of the chest pain.
  • Other factors: Although shortness of breath typically accompanies a heart attack type of chest pain, the presence of this symptom may lead the provider to check the lungs as well. Symptoms such as fever and chills and coughing up of yellow-greenish phlegm are not typically associated with heart attacks (unless you have a pneumonia on top of a heart attack).

The challenge of identifying the cause of chest pain can sometimes be complex. If you have chest pain, it's best to seek medical attention immediately rather than checking Google for answers—as matters of the heart are often more than a mouse-click away.


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