Chest Pain

Since becoming a father I’ve had intermittent chest pain. Not sure why, but it’s worse when I lie on my left side and sometimes hurts with deep breaths. All gone when I go running however. I’m not worried (and neither should you be mom), but it got me typing.

I’ve had a few calls now from people having chest pain also. I usually lead with some version of “I’m sorry, but I have to say this… If you’re having chest pain, I’d be crazy to not point you toward an ER or 911 (…pause…) but if you’d like to have more of a conversation about how we think about chest pain, then I’m happy to have a chat.”

Unfortunately chest pain can be anything from a bent-up burp to a rupturing aorta. Probably every doctor has been surprised by findings (or lack thereof) on EKGs, chest X-rays, CTs, and blood tests. Heartburn? – nope – heart attack. Pregnancy dyspnea? – nope – pulmonary embolus. Sore ribs from a hard football hit? – nope – pneumothorax.

Red flags and happy words are useful when thinking about chest pain, as they are for any other problem. But patients really should have access to these, because they, possibly more than even their doctors, should be their own best advocates here. I’ve referred to the “principal agent problem” a few times in the past, and in this case the agent (doctors) have very strong forces pushing the principal (patients) toward every study under the sun. When doctors make mistakes with chest pain it’s more than life and death. It’s life, death, guilt, shame, paper work, lawsuits, etc.

Red Flags:

• Past heart attack
• Past coronary artery bypass
• Past pulmonary embolus
• Past spontaneous pneumothorax
• Past thoracic aneurysm surgery … (notice a trend?)
• Pacemaker
• Diabetes
• High cholesterol
• High blood pressure
• Smoking
• Family history of early heart attacks (sub age 60 gets me interested)
• Recent travel
• Known clotting disorder
• Recent cocaine, meth or other stimulant use
• IV drug use +/- endocarditis
• Never had this pain before and getting worse
• Elderly/frail
• Out of breath
• Pain radiation to the jaw or down the arms
• Fevers
• Irregular heart beat
• Lost consciousness

Happy Words

• “Like past heartburn pain that also got better with Pepcid.”
• “I’ve been studying all night and I’m really nervous about my final tomorrow.”
• “I just had a cold and this cough is really bothering me.”
• “It’s usually worse after I eat fatty or spicy foods.”
• “Feels better sitting up.” (pericarditis?)
• “Only hurts when I take a deep breath.” (pleurisy/pleuritis?)
• “Hurts to move my arm around and especially when I’m bench pressing.”
• “Goes away with exercise.”
• “One spot on my chest hurts… o yeah!… when you press there that’s it!” …(Sometimes I’ll inject these spots with lidocaine. If the pain goes away completely, we’re golden.)
• “My doctor says I have anxiety. If you’d just listen to my chest, I’d feel a lot better.”
• “Sleep deprived new dad.”

If you go to an ER or urgent care with chest pain, welcome to the jungle. EKG is inevitable within minutes. If no EKG then either you’ve done this 5 times in the past 7 days, or you’ve been labelled something derogatory. Hospitals actually track “door to EKG” times so an EKG is just inevitable. This test is simple and tells us about your rhythm, and whether or not you need to be whisked to a cath lab. Mind you, a normal EKG doesn’t rule out a heart attack. It just means there’s a little more time to think.

Unless you lay on some very happy words, prepare for rapid triage and evaluation with subsequent chest Xray and blood tests (CBC, Chem 7, CK, CKMB, Troponin, Lipase, D-Dimer, BNP). Maybe you’ll get a pregnancy test if there’s any sliver of a chance. For a select few we may even do drug screens to see if meth, cocaine or amphetamines could be factors.

If you show up too soon after the pain starts, you may be watched for 4, 8 hours, maybe overnight, to see if your troponin “bumps.” If your D-Dimer is microscopically above normal you may be offered a chest CT. We love these because they rule out many many problems like emboli, pneumothoraces, pneumonias, aneurysms, esophageal ruptures, cancers, etc. However, they come with considerable radiation and expense, not to mention you get to sit in an ER a few more hours. An echocardiogram could be in your future to assess your heart valves and heart function, or for clots. If you have a pacemaker we’ll probably have it “interrogated” to check for any abnormal events.

In parallel, we may try to thin your blood a bit with aspirin, and we’ll strive to kill your pain quickly with nitroglycerin, maybe morphine. We may try to knock down your blood pressure with metoprolol. If we’re real worried this could be heart or embolus related you may even receive a heparin drip, the merits of which I’ve heard debated since the late 90s.

As noted above, if the first EKG looks concerning you may be whisked to the nearest cath lab. If you’re in a rural ER or on the high seas, you may instead receive a ~$1000+ clot busting thrombolytic… (Which could also kill you via hemorrhage).

I spent about 4 years at the New Mexico Heart Hospital where most ER patients had either chest pain, shortness of breath or palpitations. It was a chest pain wood chipper. Everyone got the “cardiac panel”… (Everyone except my one disoriented cage fighter with lacerations all over his forehead).

In summary, if you’re worried, find an ER and buckle up. If you’d like some time to chat, call Pre-R. I won’t tell you what to do, but we’ll talk about the workup you may expect.

Seriously mom… I’m fine!

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