What would you do if . . . you develop chest pain?

You’re 45 years old.  You’ve been healthy – at least you think so.

But suddenly, you awaken in the middle of the night with chest pain.

You can’t call your doctor – nor any other.  You climb out of bed, trying not to disturb your family.  They’ve had enough nightmares already.  You pace the floor, but the pain is no better.  Fortunately, it isn’t any worse either.  You wonder if you’re breathing is a little short or if it’s just your imagination.

You ask yourself, was all the preparation worth it, if you’re just going to die of a heart attack?

What in the world should you do?

* * *

Dr. Koelker replies:

Because the above scenario is common in 2011, it will likely be in 2012 and beyond.  Health professionals as well as laymen will encounter many patients frightened by chest pain.

Doctors look for patterns of illness.  What patterns might occur in a 45-year-old?

For a woman, 45 is quite young to consider heart disease – for a male, heart problems would be higher on the list of potential problems . . . but still not as high as other conditions, such as acid reflux, bronchitis, pleurisy, pneumonia, or musculoskeletal chest pain. Still, it behooves a doctor to rule out the most serious causes first, if at all possible.

What are the serious causes of acute chest pain?

• Heart attack
• Heart rhythm problem
• Pulmonary embolism (blood clot to the lung)
• Pneumothorax (collapsed lung)
• Leaking aortic aneurysm
• Perforating gastric ulcer

At 45, none of these is especially common, but a quick mental run-through is always a good idea.

Heart rhythm problems are fairly easy to eliminate – take your pulse, or listen to your own heart.  If it’s regular, there shouldn’t be a problem. Our patient, SC, has a regular, steady heartbeat.

Next, are there any abdominal symptoms? If not, an ulcer is unlikely, though not impossible. SC poked his abdomen – nothing to complain about there.

Third, is there a likely source for a blood clot to the lungs? These would usually stem from a clot in a  deep leg vein, which may cause the affected leg to swell, hurt, or become inflamed.  If your legs are OK, it’s probably not a blood clot, especially if you’re not significantly short of breath, and the pain is not worsened by breathing deeply. Although SC’s mother had suffered from swollen legs for years, SC never had.

Could it be a dissecting or leaking aortic aneurysm? Almost for sure not.  Very uncommon.  But if it is, unless you have a thoracic surgeon handy, there’s little worth worrying about the possibility.  SC wasn’t sure what an aneurysm was, so he wasn’t worried about this possibility.

Does it hurt when you take a deep breath? This could point to a collapsed lung, but lacking a history of trauma, it is quite unlikely. It hurt when SC took a deep breath – but no worse than when he was breathing normally.

That leaves us again with the question of a heart attack.  Could it be?

Heart attack symptoms vary, from absent to severe.  The so-called “silent MI” occurs with no recognized symptoms.  That’s not to say symptoms haven’t occurred, but they’ve gone unrecognized – perhaps a little indigestion, or fatigue, or palpitations, attributed to spicy food, or excess work, or anxiety.  Severe symptoms are harder to miss:  extreme left-sided chest pain, radiating to the neck or jaw, accompanied by sweating, shortness of breath, nausea, and fatigue.

SC, the example in our case history, reports only chest pain and perhaps a little shortness of breath, possibly imagined. If this is a heart attack, it would appear not to be a “bad” one.  However, patients who smoke or have a positive family history of heart attack at a young age might want to consider taking an aspirin until things get sorted out.  The odds of aspirin causing significant harm are low, though aspirin can certainly worsen acid reflux associated chest pain.  SC did not have an EKG handy and didn’t know how to interpret one anyone.  He took an aspirin, anyway, like he’d seen advised on TV – back when there was television.

SC’s beer-drinking buddies would have suggested trying an antacid.  Many of my patients have made the mistake of taking an acid-reducer rather than an antacid (Pepcid, Zantac, Prilosec, Prevacid, etc).  The problem here is these take at least 30 to 60 minutes to become effective, whereas a true antacid will neutralize stomach acid on contact – temporarily, that is.  The quickest-acting antacids are in liquid form, such as a few teaspoons of baking soda in water, or liquid Maalox, or Mylanta.  If ingesting any of these are immediately successful in eliminating the pain, the problem can be attributed to acid reflux. The relief from an antacid may last all night or only half an hour.  If you have one of the acid-reducers mentioned above, you may want to take one to prolong your symptom relief so you can sleep.

The hero of our story wasn’t so lucky. SC tried the baking soda without result.  Growing a little more anxious, he took a big breath, but thought perhaps the pain was a little worse.  But what does this mean?

Chest pain on inhalation points to either the pleura or the chest wall itself. The pleura is the lining of the lungs, which can become irritated by pneumonia, pleurisy, a blood clot, or fluid around the lung.  Any of these may cause shortness of breath or a fever.  But he’d had no cold symptoms, no fever, no leg swelling to suggest phlebitis or thrombus, no cough, no wheeze. He tried his daughter’s inhaler anyway, but the albuterol did nothing except make him cough.

What about the chest wall then? SC started to wonder if he’d strained a muscle, carrying load after load of firewood.  But he’d been doing this for months now, without ill-effect.  The long hours of physical labor seemed to agree with him.  Plus, he’d remembered no momentary strain or sore muscles.  Poking and prodding himself, he found no sore ribs, or muscles, or tenderness over his sternum (breast bone).

Still no answer.  What to do? This places our patient in the situation many doctors find themselves.  They don’t know exactly what’s wrong, but on the other hand, nothing serious has been uncovered.  The pain has persisted a few hours without relief – but neither has it worsened.

How about taking some pain pills? There are few conditions that taking pain medication would obscure.  Aspirin or ibuprofen might make acid-related symptoms worse, but the therapeutic trial of baking soda has suggested acid-reflux is unlikely.  Anything you’ve taken before without side-effects may be worth a try:  Tylenol, more aspirin, ibuprofen, tramadol, Vicodin, or Aleve.

Our hero took two Aleve and returned to bed. It helped enough to allow him to doze off and on, but eight hours later, the pain was as bad as ever.  Still no new signs, though.  The pain remained on the left side, in the front of the chest and over toward the side.

With more firewood to gather, he spent the day lugging it inside. Strangely, the pain was no better, nor worse, with any of this.  Not wanting to worry his family, he spoke not a word but went straight to his work.

The next evening, as he took off his shirt, his wife pointed to his chest.

“What’s that, SC?” she asked.

SC looked at his chest.  Just off to the side was a cluster of pimple-like blisters.  Touching, them, he winced, afraid.

“I don’t know,” he whispered.  He still hadn’t told her about the pain.

“I bet that’s shingles – like Grandma had,” his wife replied.  “Doesn’t it hurt?”

“What’s shingles?” SC asked worriedly.

“It’s like chicken pox – they live in the nerves, and just come out in one spot.”

“Nah, it doesn’t hurt,” SC lied, his relief overriding his earlier concern.

“You’re lucky, then.  Grandma thought they’d kill her, they hurt so bad.”

“What did she do?” he asked, still a little worried.

“Oh, nothing, they just went away in a few weeks.  You’ll be fine,” she answered.

And that’s exactly what happened  [. . . and this could be a true story.]