Ask the doctor: If I am feeli... Health Article

Ask the doctor

Q. I am a 73-year-old male. I’ve been diabetic for 50 years, and had a quintuple bypass eight years ago. I try to get an hour of exercise on a treadmill each day. While working out a couple of days ago, I developed a sudden sharp pain on my left side at about chest level, toward my back. Naturally I stopped, but I wondered when a person like me should call 911.

A. Pain in the chest always deserves special attention, especially in someone like you who has coronary artery disease (atherosclerosis of the heart’s arteries). Pain from coronary artery disease is felt as heaviness, or a squeezing, pressing or burning sensation, in the middle of your chest, under the breastbone. In many cases, the sensation spreads to either or both shoulders, arms, neck, back, or jaw. You may also feel it high in the abdomen, just below the chest.

Angina is a particular type of pain caused by coronary artery disease. It usually lasts 2–10 minutes and is brought on by exercise, exposure to the cold, or psychological stress — particularly anger. Unstable angina is angina that may not have such a clear trigger. It’s more serious, usually lasts longer — about 10–20 minutes — and may keep on coming back. Unstable angina can be an indication that the atherosclerosis in the arteries is worsening — waxing and waning in severity and intermittently getting in the way of smooth blood flow to the heart. It can be the prelude to a heart attack.

When coronary artery disease causes a heart attack — full blockage in one or more coronary arteries that results in damage to the heart muscle — the pain often begins when a person is at rest, lasts 30 minutes or more, and often goes into the neck, jaw, shoulders, and arms.

Other heart conditions that sometimes cause angina-like chest pain include aortic stenosis, the thickening and stiffness of the aortic valve. Pericarditis, a condition that involves inflammation of the membranous sac that surrounds the heart, can cause chest pain that feels like angina but persists for days and is relieved by sitting up and leaning forward. Aortic dissection, a sudden weakening of the wall of the main artery coming from the heart, can cause a severe and prolonged ripping sensation in the chest and back.

However, chest pain can be a symptom of problems unrelated to the heart or its blood supply. Lung conditions that may cause chest pain include pulmonary embolism (a blood clot lodged in a pulmonary artery) and pleurisy (an infection of the lung’s outer lining). Usually the pain emanates from one spot, not the middle of the chest as it does with heart disease, and it gets worse when you take a deep breath or cough. Injury to a rib or to muscles that hold the ribs together, or inflammation where the ribs connect to the breastbone, also can cause pain in one spot that worsens when you take a deep breath or cough.

Esophageal spasm, gallbladder disease, gastroesophageal reflux disease (GERD), stomach and intestinal ulcers — they all cause pain in the lower midchest that is sometimes mistaken for a cardiac problem. They can be hard to tell apart, but if the pain is accompanied by a bloated feeling and triggered by a meal, that’s a clue that it’s your gut, not your heart, that is giving you trouble.

Here is what I recommend about chest pain and calling 911: If the discomfort (pain, pressure, squeezing) is severe, felt in the midchest area, occurs when you’re at rest, lasts at least five minutes, or is accompanied by lightheadedness, a sudden sweat, or unusual shortness of breath, make the call. If you have known coronary artery disease, and it feels like your typical angina, and it’s not relieved by three nitroglycerin pills, make the call.

When none of these is true, but the chest pain keeps recurring with exertion, exposure to cold, or psychological stress, or if you have been diagnosed with angina and the pain has gotten more severe or lasts longer, you don’t need to call 911, but you do need to call your doctor — pronto.

— Anthony L. Komaroff, M.D., Editor in Chief, Harvard Health Letter