A patient of mine had a really scary experience the other night. An obese woman in her 50s who takes medication for high blood pressure, she'd had a few episodes of chest pain over the previous two days. Then, she woke with a terrible sense of chest pressure and burning at 4 am and, when it lasted until daylight, she came to the emergency room. After many hours in the emergency room during which she had several blood tests and EKGs, she was sent home on antacids.
In 2012, isn't there any less expensive and less traumatic way to diagnose heartburn?
Every year, Americans make over six million visits to emergency rooms with chest pain. The vast majority will be discharged, as my patient was, with a diagnosis of something that isn't life-threatening, such as heartburn (also called GERD, or gastroesophageal reflux), or even a negative diagnosis: "non-cardiac chest pain."
The challenge in diagnosing chest pain, as I discussed in a past column, is that while most conditions that cause it aren't too serious (e.g. heartburn and inflammation of the joint between the ribs and the sternum, or "costochondritis"), a few of the causes are life-threatening: myocardial infarction (heart attack), dissecting aortic aneurysm, and pulmonary embolism (blood clot in the lungs).
How do doctors distinguish between the less serious and the more serious causes of chest pain? Less easily than you would imagine or than we would like, actually.
The classic trio clinicians use to evaluate chest pain, and particularly to rule out the most common dangerous cause--a heart attack--is:
The EKGs, The Enzymes, and The Story.
The EKG (electrocardiogram, sometimes called ECG) is abnormal in 80% of people who are having a heart attack and can be abnormal in people with pulmonary embolus and other acute heart or lung problems. But many factors, including an abnormal EKG at baseline, can make the EKG difficult to interpret. Still, serial EKGs are usually obtained over a period of up to 24 hours to look for changes characteristic of myocardial infarction if MI is suspected.
The Enzymes are the serial blood tests for proteins that can leak from a damaged heart muscle when someone is having a heart attack. The most reliable indicator is troponin. When someone is having a heart attack, levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and return to baseline over 5-14 days. But a negative test doesn't exclude a serious medical problem or, necessarily, nail down the timing of a heart attack--a crucial piece of information in deciding on treatment.
The Story is the most important part of the evaluation of chest pain, because it will determine whether you'll be sent home, kept in the emergency room, or even admitted to the hospital. The Story has two parts: 1) how great is your personal risk of having a heart attack? and 2) what diagnosis does your description of your symptoms best fit?
The risk factors for having a heart attack are: age, male gender, family history, smoking, high blood pressure, diabetes, obesity, and high cholesterol (more details here).
You can estimate your own risk of having a heart attack in the next 10 years by using this calculator.
The classic symptoms of a heart attack are pressure in the middle of the chest with pain in the left arm or jaw, plus sweating and shortness of breath, brought on by physical exertion or emotional stress and lasting at least several minutes. But many people have different symptoms or even no symptoms and women, particularly, are unlikely to come in the the ER with "classic" symptoms.
When someone has lots of risk factors and typical symptoms, it's a no brainer that they need further evaluation. When someone has few risk factors and atypical symptoms (a 20 year old with pain and tenderness over the ribs, for example), it's also easy--they're discharged relatively quickly.
But when someone like my patient comes in with chest pain, it's tricky. She does have some risk factors (obesity, high blood pressure) but she also has a history of heartburn which can feel an awful lot like a heart attack, and aspects of her story did not sound cardiac--especially the fact that her pain lasted for several hours.
Various new protocols including imaging techniques are being studied to see if we can't get better and faster at diagnosing chest pain.
Meanwhile, my patient did the right thing in coming to the ER, and the nurses and doctors who saw her did the right thing in keeping her there until they were sure she was okay.
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