Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners re-imagine and better understand an extraordinary health and care experience.

Scott Webb (Host): Sometimes chest pain is nothing to worry about, and sometimes we should call 911 immediately. But how do we know when to call 911 and when we can wait a bit to see our doctors? Here to answer that question and more about chest pain is Dr. Sujith Kalathiveetil. He's a cardiologist with Duly Health Care.

Doctor, it's so nice to have you here today. We're going to talk about chest pain. And as we get rolling here, you know, I know me and maybe many patients and listeners get concerned when we have chest pains. So, I just want to hear from you, like what are the most common types of chest pains that are not medical emergencies and how do we distinguish between them?

Dr. Sujith Kalathiveetil: A great question, Scott. I think you kind of hit the nail on the head. There are many causes of chest pain, some of which are dangerous and life-threatening. And we put cardiovascular disease at the top of the list there. There are causes that are generally benign and there are some things in the middle. And when we think of, you know, non-necessarily life-threatening causes of chest pain, other things to consider are gastrointestinal causes, musculoskeletal causes, pulmonary causes, which is related to the lungs, even some neurologic and neuromuscular causes involving the spine as well.

Host: Yeah. And that's why we have experts, right? That's why we have doctors and nurses and hospitals and diagnostics and all of that, because we're sitting here going, "Well, this is different. Did I hurt myself while I was lifting weights or am I having a heart attack? Like, what's going on here?" Are there some non-cardiac causes of chest pain? It sounds like there are.

Dr. Sujith Kalathiveetil: Sure when we think of like the "most benign" non-cardiac causes of chest pain, we think of musculoskeletal causes, typically involving the bones or muscles.

Host: So, give us a sense then, how can a patient determine when the chest pain is a sign of a serious condition versus something less urgent, because most of us didn't go to medical school, right?

Dr. Sujith Kalathiveetil: Cardiovascular disease, we put at the top of the list. There's a medical term that we use for heart-related chest pain. We call it angina or an-JY-nuh. Angina is a unique experience for each of us, because each of us is wired a little bit differently. So, we all perceive heart-related pain differently.

For most patients, but not everyone-- for most patients, angina typically is described as a substernal, so right in the middle of the chest or a little bit off to the left, either a pressure or squeezing sensation. It has a tendency in many patients to radiate into the left arm or into the jaw and the neck. It is often associated with shortness of breath, nausea and sweatiness. Those are the classic features. But again, not all of us are wired classically. Some of us can have different types of sensations. But any of those types of sensations are generally red flags.

Host: Yeah, that's when we would want to call 911, and get to the hospital probably as quickly as we can. And I want to talk to you about, you say we're not all wired the same. And I know that in television and movies, and I don't want to date myself, but there was a show when I was a kid called Sanford and Son, and Fred Sanford, you know, he always said he was having the big one, and he would clutch his chest and make a big thing out of it. And I know for some, it is that, right? It is much the way it's been portrayed in television and movies. And others, it's kind of more subtle, especially for women I've heard. So, give us the signs and symptoms of, you know, an actual heart attack. Like, what do most of us experience?

Dr. Sujith Kalathiveetil: Kind of a general rule of thumb for any type of chest pain, be it heart-related or non-heart-related, so the American College of Cardiology actually has specific definitions of what is severe chest pain. So in medicine, we love 1 to 10 scales. So, anything that's eight or greater out of 10 is considered severe. Anything that's described as crushing, if a patient were described verbally, that's considered severe. And I know this sounds a little bit ominous, but if a patient has a sense of impending doom, that again is considered severe. Any of those things should prompt someone to actually activate EMS, call 911, and get taken to the emergency room. When you have symptoms that don't meet those criteria, that are not severe, that's when we talk about, you know, urgent care or outpatient evaluation.

Host: Right. And we're sort self diagnosing ourselves in the moment. And I'm guessing you're a proponent of when in doubt, you know, err on the side of caution, but you gave us a sense there. If it's eight or greater, if it's crushing, if you have this feeling and this sense of doom, yeah, probably call 911, get to the hospital as quickly as you can, because we know time is heart, time is brain in the case of stroke. Do I have that right, though, that the symptoms are a little bit different, generally speaking, between men and women?

Dr. Sujith Kalathiveetil: Yeah, they are. So, there is a misconception that women don't get chest pain. Women do get chest pain. But it is noted that the type of chest pain women get is often different than men do. It's often less severe. It's often not substernal. It often tends to radiate more. So, it has more what we call, you know, atypical features associated with it. So, I do have a lower threshold when I see a female patient with chest pain and to be particularly careful not to discount her symptoms because they don't carry the classical features. Women do get chest pain, but they don't get these classical features that we normally associate with heart-related chest pain.

Host: Yeah, that's what I've heard from other experts. So, it's always good when experts agree. That makes me feel better. It gives me a sense of relief, right? So when we think about patients and them sort of us assessing our own risk for cardiovascular conditions, how do we do that? And what preventative measures can we take? I'm assuming, you know, quit smoking if we're smokers, get more exercise, eat right, but I'll leave it to the expert.

Dr. Sujith Kalathiveetil: Sure. You know, the number one thing all of us can do is to see a primary care physician at least once a year.

Host: Okay.

Dr. Sujith Kalathiveetil: All primary care physicians are going to do some basic things, which is to check your blood pressure and check your cholesterol. Your blood pressure and cholesterol are probably our two biggest modifiable risk factors for cardiovascular disease.

In addition to that, yes, regular exercise. So, there is a sweet spot in terms of how much cardiovascular benefit we get from exercise. But the goal that we generally recommend is 150 minutes of moderate intensity exercise per week. And finally, from a dietary standpoint, you know, there's a lot of emerging data showing that a plant-based diet and a diet low in processed foods also seems to, you know, work in our favor in terms of preventing future cardiovascular disease as well as cancer for that matter.

Host: Yeah. See our doctors, have respective tests done, get those medications if we need them, take those medications, of course. Doctor, I know in 2022, Duly opened the Cardiac Evaluation Center, the CEC. So, what does the CEC do for patients who visit?

Dr. Sujith Kalathiveetil: It's one of unique aspects of our practice. So, the Cardiac Evaluation Center is essentially an urgent care center for heart disease. We can deal with a variety of acute, but not necessarily life-threatening heart conditions there that would normally would go to an emergency room and often end up in a hospital admission. We can actually treat those patients there.

Chest pain, for example, is one of the main focus points that we treat at our cardiac evaluation center. So for example, you know, we're talking about, you know, who should go to the emergency room, who shouldn't. So, let's say you have a patient, you know, with 8 out of 10 or greater chest pain, then, yes, they should activate EMS. If they don't have that pain, let's say it's more mild or moderate, they would actually be excellent candidates to come to our cardiac evaluation center. When they show up at our center, they'll get a variety of tests done in a rapid fashion, blood tests to look for signs of a heart attack and EKG.

In 2024 and soon to be 2025, in a patient without any prior history of stents or bypass surgery, our preferred first line test for evaluating chest pain is a test called a coronary CT angiogram. It's a special type of CT scan where we inject dye through an IV and we can see all the arteries of the heart non-invasively. We actually have that kind of scanner, a high quality scanner at our CEC that's capable of doing that. So, patients can walk in and literally get a scan of their heart. And we can find out if they have any severe blockages that could put them at risk for a heart attack.

Host: That's great. Yeah, it's one of the things I love about hosting these podcasts is just learning new things from experts and learning sort of the latest and greatest. And the CEC sounds fabulous. As you say, urgent care for the heart, basically. Good stuff today, let's finish up here. When patients are trying to determine whether or not they should visit the doctor, the emergency room, or the CEC, I know you said in medicine you love the 1 to 10, so take us through that. When we're trying to decide based on what we're experiencing, what our risk factors are, all of that stuff, how do we decide where to go?

Dr. Sujith Kalathiveetil: Great question. So, the 1 to 10 scale, 10 being the worst pain that one could possibly think of, I would consider an eight or so to be severe enough for the point that you're having difficulty speaking where it's truly uncomfortable, for you to have a conversation with someone, you really feel a need to seek medical attention. You know, you have this intuition that something, you know, is wrong. Any type of crushing pain, again, you should go to the emergency room. And again, I always tell all patients, trust your instinct. You know, if you have a sense that something very bad is about to happen, trust those instincts, go to the emergency room.

In patients who have a prior history of heart disease, let's say you're a patient who had a prior stent or bypass surgery, these are all patients who previously had severe blockages. If you're having the same symptoms that you had prior to those events, yeah, go to the emergency room. If you're having chest pain that's very subjectively different than what you had before, those are patients that are very appropriate to come to our CEC. So, the typical ways a patient can come to our CEC, one, they can actually call, and then we try our best to accommodate patients on the same day.

 Duly has a variety of urgent care centers as well, too, that we'll also see patients for chest pain. A lot of times, those patients will go to one of our many urgent care centers. They'll get basic testing done to rule out a heart attack, and they'll usually see us in the CEC the following day where we can do more definitive heart testing there.

Host: That's great. And all of us at home, when we have these things and we experience these things, and then we're trying to figure out, you know, where are we on the 1 to 10? Okay, we might be at 8, it definitely might be described as crushing, you know, then yeah, go to the hospital, right? If you can wait a day or so, you know, there are other options and good to know what those options are. So, I really appreciate your time and your expertise today. Thanks so much.

Dr. Sujith Kalathiveetil: My pleasure, Scott. Thank you for having me.

Host: And for more information, go to dulyhealthandcare.com. And if you found this podcast helpful, please share it on your social channels and check out our full podcast library for additional topics of interest. This is Duly Noted, a health and care podcast from Duly Health and Care.