Why is minimalism such a big word? What was the best thing before sliced bread? If the number 2 pencil is the most popular, why is it still number 2? Is chest pain from anxiety or is it from heart damage? These are age old questions that have plagued so many for so long, and the answers are eternally elusive.

From a patient’s perspective, chest pain from cardiac ischemia (or decreased blood flow through vessels that supply the heart) can feel exactly the same as chest pain from anxiety. This is what makes this pain so fearsome, both for patients and their physicians. Luckily, there are some hints that can help us differentiate between cardiac chest pain and chest pain from anxiety. Please remember that medicine is not black or white but rather shades of grey. Your symptoms may or may not describe either anxiety or cardiac chest pain, or they may describe both. If you are concerned please visit your nearest emergency department.

Onset and Timing

Think back to when you first had chest pain, was it today, yesterday, a week ago? What were you doing just before it started? Cardiac chest pain often starts with movement or exertion. Typical cardiac chest pain will disappear with rest after ten to fifteen minutes. Chest pain from anxiety often has a precipitating event where something triggers an attack and is unrelated to exercise. This pain does not typically subside based on timing and rest alone and depends largely on the level of anxiety.

Pain Characterization

The description of pain is very important as it can provide further data to help us arrive to a conclusion. Cardiac chest pain can present as sharp or dull and pressure like. People often describe this as a feeling of something or someone sitting on their chest. This pain can often radiate to the jaw, back, or down the left arm. Pain from anxiety can also present as chest pressure and/or sharp or dull pain and this is often where lines blur.

Associated Signs

When having chest pain, be sure to pay attention to not only the pain but also your body’s response. In cardiac chest pain, other signs that are concerning can be sweating, gasping for breath, and feeling winded from the slightest bit of exercise. You can also have sweats and shortness of breath with anxiety; however the ability to exercise should not be affected. Some may have isolated neck pain and this could represent heart damage.

History

This is another key part of differentiating cardiac chest pain and pain from anxiety. If a 65 year old patient had a history of a bypass surgery, diabetes, and high cholesterol, that patients risk of cardiac disease is already very high and having chest pain would be very suspicious of cardiac chest pain. On the other hand if a patient was 24 years old with no other medical history, suspicion for cardiac chest pain would be lower. Patients with diabetes may present atypically and present with nausea and vomiting due to heart damage. Patients taking beta blockers may have a blunted physiologic response and may not have sweating or as much pain as someone else. People present at different ages with different histories and this is why obtaining a thorough medical history is so important.

What to expect at the hospital

If you currently have chest pain, I strongly recommend evaluation at your local emergency department. Since the difference between cardiac chest pain and chest pain from anxiety often overlap, it is important to come in for us to assist with making a diagnosis. Electrodes will be placed on the chest so we can take an electrocardiogram. This gives us an electrical picture of the heart and if there is damage, the electrical picture may be subtlety distorted and physicians are trained to pick up on these findings. A blood draw will be done to check a troponin level, which is a protein found in the heart, and if detected in the blood is a marker of damage. Depending on your history, you may be admitted to the hospital to be observed and ensure that the troponin level does not rise over a period of 24 hours.

Chest pain is always concerning because of the potential of a fatal event. The goal of all of this is to collect enough data to help everyone, from the patient care technician to the nurse to the physician, paint the right picture with the end goal of helping you in a safe, efficient, and timely manner.

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