By Katie Golden, MD

July 21, 2020

Unexplained symptoms and sensations in the body, especially when they are felt in the chest, can be an unsettling source of stress and discomfort. It can be difficult for doctors and patients alike to understand the source of chest symptoms . . . is it anxiety? something wrong with the heart? the lungs? In the present pandemic, especially, we are all challenged with new sources of hardship and stress that may result in physical sensations that are new, which can be further compounded by the difficult question, “Do I need to go see the doctor?”

We know that medical visits can be stressful for many reasons – medical bills, wait times, the fear of a diagnosis or abnormal test result, not to mention concern over potential COVID exposures.  Chest pain, however, is inherently different from an aching hip or knee. It sets off alarm bells in our brain, and for good reason; most of our vital organs are in our chest.  This month, therefore, I wanted to provide our patients with some guidance on when to come to the ER for chest pain.

What are the causes of chest pain?

Chest pain is an incredibly common symptom among all ages, and one of the most frequent reasons patients come into the ER for evaluation. The potential causes for chest pain spans a wide range of conditions and organ systems: heart disease, acid reflux, asthma and allergies, stress and anxiety, strained muscles and rib cages, to name a few. The list is nearly endless. Fortunately, most of these diagnoses are not life-threatening.

As ER doctors, we are trained to recognize and treat the more serious (and less common) causes of chest pain. Some examples of these conditions are a heart attack (a blockage in the coronary arteries that deprives the heart muscle of oxygen), congestive heart failure (when the heart does not pump effectively, leading to a backup of fluid in the body and lungs), blood clots in the lungs, problems with the aorta (the large blood vessel that runs down the chest), pneumonia and infection, a collapsed lung. Rest assured that the large majority of patients who come to the ER for chest pain do not have these serious conditions, their testing is normal, and they are safe to return home.

When do I go to the ER for my chest pain?

The most important message of this article is that you should never hesitate to come to the ER for chest pain that is worrisome to you. It can be hard enough as a doctor, with EKGs and blood tests and chest X-rays, to identify the source of chest pain. You are not expected to make the diagnosis on your own (or find the answer on the internet, which is sure to hijack your brain and convince you that you have a terminal diagnosis).

There are some general guidelines that you can consider when you are trying to decide if you should come into the ER urgently, or if you are safe to wait for a scheduled appointment with a regular doctor. These guidelines generally fall into two categories: 1. high-risk conditions, and 2. high-risk symptoms.

  1. The risk of a more serious cause of chest pain increases as we get older, mainly because many of the more serious conditions develop in later ages. If you are a patient with any of the following conditions, you should not delay evaluation for new pain or pressure in your chest:
  • A prior history of heart disease. This includes heart attacks or heart disease (‘coronary artery disease’), congestive heart failure, problems with your heart valves, prior heart surgeries, or stents in your heart.
  • If you have the risk factors for heart disease, including high blood pressure, high cholesterol, diabetes, a smoking history, obesity, or related family with heart disease.
  • If you are over the age of 45, the age when heart disease starts to become more common.
  1. Symptoms of heart and lung disease can be widely variable from patient to patient, so the following list of higher risk symptoms is not comprehensive. Please note, also, that the presence of these symptom characteristics does not necessarily mean you have a life-threatening condition, only that you should not delay an evaluation:
  • Chest pain that feels so severe that you have to stop what you are doing and sit down until it subsides
  • Discomfort that feels like a heavy, pressure-like sensation (the classic ‘elephant is sitting on my chest’ feeling)
  • Chest pain that is accompanied by severe shortness of breath, profuse sweating or a clammy sensation, nausea or vomiting
  • New swelling in your legs, new shortness of breath with only light exertion (walking from the kitchen to the family room, or going up just a few steps), or inability to lay flat due to shortness of breath
  • Loss of consciousness
  • A severe pain when you try to inhale, preventing you from taking a deep breath

What happens when I go to the ER with chest pain?

I have a formerly published article about what to expect when you come to the ER for chest pain, the tests we typically perform, and then the next steps after your ER visit. Please click here for the article.

At the end of the day, if you are trying to decide whether or not to go to the ER for your chest pain, trust your intuition. No one knows your body as well as you do, so don’t ignore those red flags going off in your head. And if you still can’t decide, then err on the side of safety and come see us to get it checked out. It is most likely that we will be able to provide reassurance, as well as assistance with the next steps in your outpatient follow-up.