Diagnosis of Chest Pain
Initial Evaluation of Chest Pain
Physicians and emergency room technicians do several things to determine the probable cause of a patient's chest pains, including the following:
- An evaluation of the patient's description of his or her pain.
- What does the pain feel like?—As discussed above, the characteristics of the chest pains often are helpful in determining a possible cause. Typically, the physician will ask the patient to describe his or her chest pains, with an eye toward identifying particular characteristics that may suggest a cause.
- Does the pain occur with exertion?—This is highly suggestive of a fixed blockage in one or more of the coronary arteries.
- Does the pain radiate to the neck, jaw, and/or arms?—Such pain also suggests angina, the pain caused by insufficient blood reaching the heart.
- Does the pain have a "squeezing" or "tightness" quality?—Is it accompanied by shortness of breath, sweating, a feeling of "clamminess," nausea or indigestion? These symptoms strongly suggest angina due to a blockage in the coronary artery.
- If the pain is anginal in nature, does it last more than 15 to 30 minutes?—This may suggest the coronary artery is totally blocked and a heart attack is occurring.
- Can the pain be reproduced by movement of the arms or torso or by pushing on a certain area of the chest?—This may suggest a musculoskeletal cause.
- Did the pain come on suddenly? Is it sharp, perhaps the worst the patient has ever experienced?—This may suggest aortic dissection, pneumothorax (collapsed lung), or pulmonary embolus (blood clot in the lung). The sudden onset of sharp pains combined with shortness of breath strongly suggests a pulmonary embolus or pneumothorax.
- Is the pain made worse by deep breathing?—This may be caused by a musculoskeletal injury or by any lung disorder (pneumonia, pleuritis, pneumothorax, pulmonary embolus).
- Is the pain brought on by eating or lying down? Is it relieved with antacids?—This may suggest acid reflux or an ulcer.
- Electrocardiogram (EKG)—Whether the chest pains are evaluated in a doctor's office or an emergency room, an EKG is almost always performed. The EKG can show changes which suggest a blockage in a coronary artery that is compromising blood and oxygen flow to part of the heart. In some cases, an EKG indicates that a person is actually having a heart attack. It is important to understand that while a "normal" EKG may indicate a patient's chest pain is caused by something other than a blockage in a coronary artery, it does not conclusively rule blockage out as a cause.
- Blood Tests—In a heart attack, part of the heart tissue is deprived of the oxygen it needs and dies. As heart tissue dies, it releases certain chemicals—creatine phosphokinase (CPK) or troponin—into the bloodstream. Elevated levels of these chemicals in the bloodstream strongly suggest that a heart attack has occurred and are tested for in the emergency room and then during the next 6 to 24 hours.
- Chest X-Ray—A chest x-ray takes a picture of the lungs, the heart, and the bones of the rib cage. It is used to detect signs of lung infection, fluid in the lungs, or a collapsed lung.
- Blood Oxygen Levels—The degree to which the blood is adequately oxygenated can be determined by a monitor placed on the patient's finger. More complete measurements of oxygen and other related levels can be obtained by analyzing arterial blood gas (ABG). An ABG is obtained by drawing blood through a small needle inserted into an artery, usually in the wrist. Lower than normal levels of oxygen in the bloodstream can suggest a lung problem such as pneumonia, pulmonary embolus (blood clot in the lungs), or pneumothorax (collapsed lung). A major heart attack, with subsequent accumulation of fluid in the lungs, can lead to abnormally low blood oxygen levels.