“I was asleep and my symptoms woke me up. I had several simultaneous symptoms, but the first one seemed to be central chest pain. It wasn’t sharp or crushing or burning, more like a dull pressure. The pain radiated down my left arm and up into my neck and jaw. I had cold sweats, and I felt nauseated.”
Laura Haywood-Cory, age 41, heart attack, six stents
Researchers tell us that over 90% of us already know that chest pain like Laura’s could be a symptom of what doctors call Acute Myocardial Infarction (AMI – or heart attack) or Acute Coronary Syndrome (any condition brought on by sudden reduced blood flow to the heart muscle). So it may not surprise you to learn that chest pain is the main reason that over 6 million people rush to the Emergency Departments of North American hospitals each year. These visits also represent a whopping 25% of all hospital admissions – yet 85% of these admissions do NOT turn out to be heart-related at all.
Admitting people to hospital who don’t need to be admitted not only takes up valuable staffing and hospital resources that could be assigned to real heart patients in need, but also costs the health care system billions of dollars each year.
As you can imagine, this is a real dilemma for the medical profession.
So what do you do if you’re working in Emergency medicine? Do you admit every patient complaining of chest pain despite knowing that 85% of the time, the symptom is actually unrelated to the heart? Or do you come up with an alternative diagnosis and send the patient home – at the risk of failing to diagnose a real heart attack? See also: What is causing my chest pain?
That latter choice of alternative diagnosis may be behind the alarming tendency of many Emergency physicians to dismiss women’s cardiac symptoms – even in those like me who present with textbook AMI signs but “normal” cardiac diagnostic test results.
Research on cardiac misdiagnoses reported in the New England Journal of Medicine, for example, found that women 55 and younger were seven times more likely to be misdiagnosed and sent home from the Emergency Department in mid-heart attack compared to our male counterparts. (1)
The consequences of this were enormous, according to researchers: being misdiagnosed and sent away from the hospital doubled the chances of dying.
Trouble is, we know that at least 10% of women experience no chest pain at all during a heart attack.(2)
And even standard cardiac diagnostic tests may not be as accurate as we’d like them to be in women.
For example, as reported in the Emergency Medicine Journal, a patient’s initial electrocardiogram (ECG or EKG) in the Emergency Department has a sensitivity of just 20% to 60% in accurately identifying an acute myocardial infarction – so cannot be relied upon to rule out heart attack.(3)
And the sensitivity of a single set of blood tests for cardiac enzyme markers at the time of a patient’s presentation to hospital is considered “poor”, according to the American College of Emergency Physicians.(4)
If we’re counting on our health care providers to figure out these tests, we might do well to remember a study published in the Journal of Internal Medicine that asked residents in internal medicine to read the ECGs of suspected heart attack patients. There was disagreement among these doctors about over 70% of the test results.(5)
I sometimes wonder how many people with chest pain had already shown up in my Emergency Department before I arrived on that fateful morning – each of them presenting with frightening symptoms like mine, but who were actually among the majority of people with chest pain that ends up being caused by something other than heart disease.
I must have seemed to that clearly burned-out, exhausted, disinterested Emerg doc as just another middle-aged woman with indigestion. That was the misdiagnosis he then awarded me before I was sent back home, feeling supremely embarrassed for having made such a fuss over nothing.
Remember that many women experience no chest symptoms during a heart attack.(6)
This means no pain, no pressure, no heaviness, no fullness, no tightness, no aching, no burning or any other symptoms of any kind in any part of the chest area.
But for those who DO have chest pain, how can patients (and Emergency physicians) tell if that inherently scary symptom might be caused by a brewing heart attack or not?
Dr. Salim Rezaie asked this very question recently, writing for fellow Emergency Medicine colleagues who wonder:
“Are there specific aspects of the patient’s history that can increase or decrease the likelihood that a patient has acute coronary syndrome and/or acute myocardial infarction?“
Dr. Rezaie teaches Emergency Medicine at the University of Texas Health Science Center at San Antonio, and is also the founder of REBEL EM, where he published this review to help Emergency physicians figure out if any given person with chest pain needs to be admitted with a possible cardiac event.
The review is based on five studies that looked at how a patient’s chest pain symptoms correlate with an actual cardiac event (studies recommended by Dr. Amal Mattu on his EMCast podcast of July 2012).*
Here’s Dr. Rezaie’s summary of what the five studies found.
- Chest pain radiating bilaterally to both the right and left arms/shoulders
- Diaphoresis (sweating) associated with chest pain
- Nausea and vomiting associated with chest pain
- Pain during exertion
Clinical factors that DECREASE this likelihood include chest pain that is:
- Pleuritic (associated with taking deep breaths or coughing)
- Positional (made worse by moving the neck or arms)
- Sharp, stabbing chest pain
- Reproducible with palpation (pressing on it)
But Dr. Rezaie also adds this important warning to colleagues working in the Emergency Departments of the world:
“These were all fantastic articles looking at aspects of the patient’s history in helping aid us in clinical decision-making, but none of these elements alone or in combination can reliably help us rule in or rule out ACS or AMI.”
I’m including the key findings below of these five studies mentioned by Dr. Rezaie, but with one important disclaimer:
These studies (particularly older studies) were not specifically focused on women’s experience with cardiovascular disease. Female patients may or may not have been included in statistically significant numbers in these studies. In the first study mentioned, Edwards’ sample included a hefty 57% female population. But in the Goodacre study, only 38% were women. (Where available, I’ve included gender demographics below).
“Women are not just small men.”
When University of Toronto cardiologist Dr. Wendy Tsang reviewed cardiac research published in three prestigious medical journals (The Journal of the American Medical Association, The Lancet, and the New England Journal of Medicine), here’s what she found.
Athough women comprise 53% of all patients with cardiovascular disease, in published cardiac research they represented on average only:
- 29% of subjects with coronary artery disease
- 25% with congestive heart disease
- 34% with cardiac arrhythmia
In fact, despite sweeping National Institutes of Health policy changes in research protocol to correct this under-representation of women in cardiac research, Dr. Tsang says that “under-representation has not drastically changed over the past decade” – a reality she describes as “shocking”.
So with that specific grain of salt, and for your general information, here are the five studies on cardiac symptoms that Dr. Rezaie evaluated:
1. Edwards et al, 2011
The objective of this study on over 3,300 people (57% women) presenting to Emergency with chest pain was to see if severe chest pain is linked with a greater likelihood of heart attack. Severe chest pain here was defined as 9–10 on a pain scale of 0 to 10.
Bottom Line: Severity of pain is NOT related to likelihood of AMI either at initial presentation to Emergency, or composite end points (death, revascularization, or AMI) within 30 days.(7)
2. Body et al, 2009
- Nausea and vomiting with chest pain
- Chest pain radiating to both shoulders, right shoulder, or left shoulder
- Central chest pain
Symptoms that did not strongly predict AMI were:
- Pain located in the left anterior chest
- Chest pain described as pain being “the same as previous heart attack”
- Presence of chest pain while at rest
Bottom Line: Many “atypical” symptoms are more likely to render a cardiac diagnosis than traditional “typical” symptoms.(8)
3. Swap and Nagurney, 2005
These researchers wanted to identify the specific elements of chest pain that might be most helpful to physicians in identifying Acute Coronary Syndrome (ACS) by searching medical literature published from 1970 to 2005 (number of women: unknown). They reported that the chest pain most likely to mean heart attack was:
- pain radiating to both shoulders and arms
- pain radiating to the right shoulder
- pain that comes on with exertion
- pain accompanied by sweating
Chest pain less likely to mean heart attack was:
- pain that’s described as “sharp” or “stabbing”
- pleuritic pain (pain that’s worse with deep breaths or coughing)
- positional pain (for example, pain that’s worse if you move your neck or arms)
- pain that can be reproduced by palpation (pressing on it)
Bottom Line: No characteristics of chest pain alone, or in combination, identify a group of patients that can be safely discharged home without further diagnostic testing. Also beware the chest pain which radiates to the RIGHT shoulder.(9)
4. Goodacre et al, 2002
This study of 893 patients (38% women) looked specifically at patients who were clinically stable and had a non-diagnostic EKG (an electrocardiogram that did not clearly show any cardiac event had occurred). Researchers found that even among these patients, symptoms that were most predictive of cardiac cause were chest pain on exertion and pain radiating to both arms and/or right arm. Symptoms that were less predictive were presence of chest wall tenderness, nausea, vomiting or sweating (diaphoresis).
Bottom Line: Clinical features have a limited role in triage decision-making.(10)
5. Panju et al, 1998
“The single greatest contributor to financial losses in malpractice claims against emergency physicians comes from failure to accurately diagnose acute myocardial infarction.”
*© 2014 Salim Rezaie R.E.B.E.L. EM
(1) Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000; 342:1163-1170.
(2) S. Dey et al, “GRACE: Acute coronary syndromes: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events”, Heart 2009;95:1 20–26.
(3) Speake D, Terry P. Best evidence topic report: first ECG in chest pain. Emerg Med J. 2001; 18:61–2
(4) American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina. Ann Emerg Med. 2000; 35:521–44.
(5) Gjorup T et al. Interpretation of the electrocardiogram in suspected myocardial infarction: a randomized controlled study of the effect of a training programme to reduce interobserver variation. J Intern Med. 1992; 231:407-412
(6) Canto JG, Rogers WJ, Goldberg RJ, et al. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA. 2012;307(8):813-822.
(7) Edwards et al. 2011. Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes. Annals of emergency medicine, no. 6 (July 29). doi:10.1016/j.annemergmed.2011.05.036.
(8) Body, Richard, Simon Carley, Christopher Wibberley, Garry McDowell, Jamie Ferguson, and Kevin Mackway-Jones. 2009. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation, no. 3 (December 29). doi:10.1016/j.resuscitation.2009.11.014.
(9) Swap, Clifford J, and John T Nagurney. 2005. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA, no. 20 (23).
(10) Goodacre, Steve, Tom Locker, Francis Morris, and Stephen Campbell. 2002. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Academic Emergency Medicine : official journal of the Society for Academic Emergency Medicine, no. 3.
(11) Panju, A A, B R Hemmelgarn, G H Guyatt, and D L Simel. 1998. The rational clinical examination. Is this patient having a myocardial infarction? JAMA, no. 14 ( 14).
Q: Have you sought emergency care for chest pain that turned out NOT to be heart-related?
NOTE FROM CAROLYN: I wrote much more about chest pain (and other cardiac symptoms) in Chapter 1 of my new book (A Woman’s Guide to Living With Heart Disease, Johns Hopkins University Press, November 2017).
- What is causing my chest pain?
- The freakish nature of cardiac pain
- Misdiagnosed: women’s coronary microvascular and spasm pain
- Words matter when we describe our heart attack symptoms
- The chest pain of angina comes in four flavours
- “You’ve done the right thing by coming here today”
- Check out my patient-friendly, non-jargon glossary of over 200 words, phrases and terminology you’ll hear about cardiology
- Read more on how specialized Women’s Heart Clinics cover a broad range of gender-specific cardiac conditions experienced by women, as described in this report, Focused Cardiovascular Care for Women