Published in Panorama
Chest Pain or Heart Attack?
Sam was ravenous after his tennis session. He sat down to a hearty meal. Soon he experienced pain and discomfort in the chest area. Faced with the unexpected chest pain, Sam’s reaction was normal – he feared the worst - Heart Attack or Myocardial Infarction, as the medical fraternity would term it.
Says Dr.S.S.Yakoob, General Practitioner and Paediatrician, Dune Medical Centre, Dubai, “Chest pain is a symptom which can occur in a number of instances, unrelated to the heart. The chest contains so many structures, from the skin to the bones, the walls, nerves, lungs, heart and their respective coverings, that any inflammation in any of these structures can bring on a chest pain! Chest pain can occur from simple superficial skin inflammation over the chest region to acidity, angina, infection from pneumonia or tuberculosis, pulmonary embolism, esophageal rupture, esophagitis to heart attack. While it is important to seek help to evaluate a first time chest discomfort or pain, the associated symptoms are often indicative of the nature of the root problem. The age and family history of the patient, type and time of pain, exact location and radiation of pain, together with symptoms as nausea, vomiting, dizziness, fever et al are important to determining the patient’s true condition.”
Though the present trend does indicate heart attacks in younger age groups of people, still chest pain caused by a heart condition is quite rare in previously healthy men below the age of 30 and women below 40, opines the doctor.
How would a layperson be able to distinguish the pain of the one from that of the other? In certain instances, explains Dr.Yakoob, the indications may be pretty stark. “The heart pain is a sudden unwarranted pain, felt more like pressure or squeezing pain in the chest. The heart pain suggestive of an impending attack, will usually be in the middle of the chest region and sometimes on the left side. It can radiate to the left arm and jaw. Besides the pain, the patient will experience shortness of breath, palpitation, sweating and weakness to an extent he may not even be able to talk. However, not all these symptoms need exist in a patient at a time. Of course in some cases, the pain from gastric trouble could mimic the heart pain.”
What then would be the differentiating point between a heart pain and pain emerging from a gastric disturbance? “Esophagitis”, as the condition may be called, occurs due to an irritation of the mucous lining of the esophagus or when there is spasm in the esophagal muscles, explains Dr.Yakoob. “The pain of esophageal spasm usually follows a mean, is poorly localized, and may mimic angina in nature and intensity. The pain associated with gastric disturbances will not come all of a sudden and the patient will exhibit a history of the condition, with heartburn, reflux or dysphagia, pain in the lower abdomen and belching. This pain usually lasts for quite some time and on rare occasions may radiate to the neck and very seldom the arms. The pain of the heart is not related to food, in the sense it does not get aggravated or alleviated by taking food.”
What about an Anginal pain? How does one know its symptoms and to what extent can it threaten a heart attack? Angina may be stable or unstable explains the doctor. “In stable angina, you typically feel a pressure behind the sternum or the breastbone which lasts for about a maximum of 15 minutes,” explains Dr.Yakoob. In most cases, it may be accompanied by pain radiation to the jaw, neck, shoulders, or arms. It may not have symptoms associated with heart attacks like sweating, breathlessness and nausea. Angina occurs when the innermost layer of the heart, the myocardium becomes ischemic, that it suffers from insufficient oxygen and blood. This in turn can happen when a person is exercising, is stressed or strained, is having anaemia or suffering from hypotension. Rest relieves the symptoms and also keeping nitroglycerin pill under the tongue relieves.”
Unstable angina occurs at rest or is an increase in the frequency, severity, or duration of previously stable angina, clarifies the doctor. However, whichever form it may assume, respiration or posture of the patient does not influence the pain in any way.
Unstable angina is often a precursor to a heart attack and if left untreated, progresses to myocardial infarction within three months in a substantial number of cases. Where the chest pain is indicative of an impending heart attack, it is likely to last longer than 15 minutes and is not relieved by rest or nitroglycerin.
The pain of a heart attack, explains Dr.Yakoob, is felt typically behind the breastbone in the center of the chest or to the left and is a squeezing pain, as from pressure or constriction in the region. The pain may well radiate to the neck, jaw, shoulders and left arm. Most often, the pain is accompanied by additional symptoms, such as breathlessness, dizziness, nausea or vomiting and these last longer than 15 minutes. In fact, some people may not even experience the pain but have some of the other symptoms; diabetics in particular have what is known as “silent” attack without any of the typical symptoms.”
What of the chest pain, which is shooting and often associated with deep breathing? “This is the typical pain which occur when the covering of the lungs, the pleura gets inflamed, a condition called pleuritis,” explains Dr.Yakoob. “There will often be tenderness in the region where the pain is getting generated. Similarly any inflammation or infection in the respiratory passages, as in the case of bronchitis, tuberculosis and pneumonia may have chest pain as a symptom. The pain of pneumonia often begins as a general sense of pressure and aching, generally felt on one side of the chest and may be accompanied by chills and fever. Cough may yet be another symptom which again brings on the pain.”
Chest-wall pain originating in the tissues of the chest-wall rather than the heart, is superficial, assures Dr.Yakoob. “There will be pain when you apply pressure to the area – it is very much localized and on the surface. If there is any problem with the bone or skin lesion in the chest cavity, you can locate it by pressing on the region, as there is aggravation of pain on pressure. This pain can be in any side of the chest. Not so the heart pain which will be in the center or to the left and will not be impacted by the application of pressure.”
The outermost layer of the heart, the pericardium may be inflamed, causing chest pain. The pain of pericarditis, says Dr.Yakoob, is usually felt behind the breastbone and often travels to the back or neck. It may be worsened by adopting certain postures as when lying down and a sharp pain is experienced on certain movements or deep breathing.
A sharp pain in the chest which produces a sensation of a catch at the end of a deep breath may even indicate some problem in the lungs like a clot, cautions the doctor.
Risk factors for chest pain indicative of heart attack include:
• Individuals above the age of 35
• Those with a sedentary lifestyle and individuals lacking physical exercise
• Individuals with faulty eating habits with high fat, low fibre diet
• Individuals having hypertension, diabetes.
• Obese and overweight individuals
• Individuals with a family history of heart attacks
• It is not uncommon to find respiratory and lung problems finding their way to the heart and contributing to heart attacks. In this sense environmental factors like pollution play a contributory role.
• Cigarette smoking and excessive alcohol
Dr.Yakoob emphasizes, “With chest pains, one has to rule out a heart pain since this is the most serious condition requiring emergency measures. All the other problems which show up chest pain as a symptom can be treated well if rightly diagnosed and without too much loss of time, not bordering on urgency.