Scott Webb (Host): Sometimes chest pain is a sign of a heart attack or other cardiac emergency. Sometimes it's just acid reflux. My guest today is Dr. Ahmad Hadid. He's the medical Director of the Kaplan Family Center for Cardiovascular Medicine and Interventional Radiology, and he's here to explain chest pain and give us a sense of when it's time to go to the emergency department.

This is Doc Talk, presented by Montefiore St. Luke's Cornwall. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk about chest pain. You know, folks have chest pain and maybe sometimes that means something and sometimes it doesn't. Sometimes it's more, you know, severe than other times. But that's why we have experts to kind of sort all this out for us. So, let's start there. What are maybe the most common causes of chest pain in adults, and how can people maybe tell the difference or tell which types are, you know, more likely to be dangerous?

Dr. Ahmad A. Hadid: Yes. So, the most common chest pain presenting to the emergency room, up to 35% to 50% resolve without definite diagnosis. But obviously, after safely ruling out acute emergency like acute heart attack, pulmonary embolus, dissection, et cetera. Those are the serious findings that we should rule out anytime a patient comes to the emergency room.

The other common cause really, musculoskeletal, costochondritis, chest wall muscle strain, rib injury, up to 15% to 25% Gastrointestinal symptoms also could be up to t10% to 15% like GERD, acid reflux, esophageal spasm, peptic ulcer disease, et cetera. Cardiovascular or life-threatening is really not common, like up to 8% to 10%, 15%, which acute coronary syndrome, acute myocardial infarction, which, you know, known for heart attack, unstable angina, et cetera.

Other causes could be psychiatric, psychological, panic attack, up to 8% to 10%, severe. Severe generalized anxiety are usually associated with hyperventilation. And other causes, also respiratory, pulmonary, pneumonia, pleurisy, pulmonary embolism, blood clot on the lung, up to 5% to 10%. The way the patient describes their pain is a very, very important feature.

The cases that we should never miss are the most serious cause of chest pain, like acute coronary syndrome, heart attack, unstable angina. And the way the patient describes it, it's like a pressure, tightness, heaviness, discomfort, dullness. You know, a lot of time patient tell me, "Oh, I don't have pain. It's just a tightness. It's just a pressure. It's like heaviness." I got one time an older patient, he described it as a bear hug. Another patient, like magma in his chest. And, you know, women describe it also differently, and sometimes they describe as a bra is too tight. It's usually heaviness, crushing pain, ischemic type. Usually, also, the patient looks sick. They could be like, you know, pale, diaphoretic. Sometimes patient tells me the feeling of doom, like they're going to die. They know they are sick.

Host: Yeah, I see what you mean. So, lots of things might cause chest pain, some maybe more serious than others. It makes me wonder, Doctor, are there some maybe red flag symptoms that, together with chest pain that might suggest that it's a heart attack or, you know, some other cardiac emergency?

Dr. Ahmad A. Hadid: Yes, absolutely. A red flag, you know, like a shock or hypotension if the blood pressure is low. If there's altered mental status, the patient become like fainting, could be almost passing out, syncope, could be fainting, severe weaknesses. Sometimes, cyanosis, blue, you know, and a pulmonary embolus feature of the chest pain, crushing, heavy, pressure-like, lasts 10 to 15 minutes associated with shortness of breath, associated with sweating and nausea and vomiting. Sometimes inferior wall myocardial infarction or heart attack, that's the inferior wall, it comes with, you know, abdominal pain. They don't really complain of chest pain, they complain of abdominal pain, nausea, vomiting. Patients think it could be an ulcer or peptic ulcer disease, but it could be heart attack too. Radiating to the jaw, to the arm, shoulder, or back;occurs with exertion. Sudden severe tearing pain radiating to the back, we have to always think of possible aortic dissection. It's a very serious condition. So, those are red flags and it's recommended to call 911 if somebody experiences that.

Host: Right. Get to the ED as quickly as possible. And then, you know, along those lines, Doctor, how do docs in the ED rapidly—you know, obviously, time is of the essence—rapidly evaluate chest pain, whether blood tests, ECG, imaging, like, you know, and how reliable are those tests at ruling out a heart attack?

Dr. Ahmad A. Hadid: Yes. So obviously, after the emergency room staff sees the patient, evaluates the patient, take vital signs, if it's suspected acute coronary syndrome, EKG is essential in doing that, and it should be done within 10 minutes and interpreted. Our protocol in the emergency room that the EKG technician right away takes the EKG to the provider, let him look at it and interpret it to evaluate for acute myocardial infarction. It is very good. It's very sensitive, not a hundred percent. You know, we have to look at the whole picture, obviously.

And nowadays, we're lucky with the blood test, the troponin. We have high sensitivity troponin, very sensitive to myocardial necrosis, heart attack, and it comes quick and it helps. Also, we usually do blood count for anemia, infection, electrolyte, renal function. We do chest X-ray for pneumonia, for pneumothorax, for pleural effusion, cardiomegaly. These look kind of like a basic workup. We do that on almost all patients to orient us and give us more, you know, more information about the chest pain.

Host: Yeah. Right. So, you're listening to patients, provided they can tell you what's going on and what they're experiencing. Got some tests trying to rule in or rule out, you know, it being a heart attack. So, let's sort of rewind a little bit, Doctor. Like, how do we avoid ending up in the ED with a potential cardiac issue or heart attack? Like, are there some lifestyle changes, diet, exercise, that kind of thing? Maybe even, you know, just getting better sleep, for example. In other words, like, how can we reduce the chances of having heart-related chest pain and the risk of cardiac events? Like, what can we do to help ourselves?

Dr. Ahmad A. Hadid: Yes. Certain modifiable risk factors, we do, you know, good diet, good exercise, those things. You know, for adults especially with family histories, it's recommended to check the cholesterol level to see and make sure it's as low as possible. Anything modifiable we can do: exercise usually up to like 75 minutes a week. And healthy lifestyle. You know, certain things also are not easy to measure. Stress, you know, exercise decreases stress also. So, all those helps, you know, minimize the risk of heart attack and modify risk factors.

Host: Yeah. Right. So, knowing our family history, doing something about it, modifying the risk factors, eat better, exercise more, quit smoking, all of that. Good stuff today just to understand, like when we should be concerned, when we're not. Of course, if we're concerned, you know, call 911, get to the ED.

I just want to finish up and kind of go back in. You talked earlier about sometimes folks, maybe especially women might experience atypical symptoms. So, maybe you can just give us a better sense. Like, you know, we don't want to dismiss these symptoms and say, "Oh, it's probably GERD. It's probably this," because we, you know, we know time is of the essence here to save folks. So, what are some of the atypical symptoms?

Dr. Ahmad A. Hadid: Yes. So, a high-yield presentation, note that high-risk patient should have a low threshold for EKG and troponin testing. This is where it's very important not to miss atypical presentation as woman, an older patient, a patient with diabetes, they may have different presentation. Some patients, they may present without chest pain altogether. So, those people we have to be aware. I do STEMI on call, and I serve here in St. Luke's. Like a month ago, we got a patient with just abdominal pain, as I said, abdominal pain, and she's Spanish-speaking, ended up having a heart attack, and we have to take her to the cath lab to open the blockage., Those atypical presentation very important not to miss.

Also, you know, I should point out, sometimes patient can have pain out of the chest, they can have jaw pain, as I said earlier, shoulder pain, neck pain, abdominal pain. You know, they may have that and, you know, can still be, you know, a heart attack obviously. Yes. So, we should have a high suspicion of that.

You know, in the last 20 years, we saw a trend in patient admission to the hospital. Really, we are lucky to have high sensitivity troponin that is very, very sensitive to detecting myocardial injury or necrosis in a patient of heart attack. And nowadays, we're utilizing that like an expedite protocol, you know, in the emergency room. We can do like two blood tests. And if they are stable, negative, or downtrending, we feel good about sending them home to have outpatient follow-up.

The other trend also, we found that demographic difference in the evaluation of patient. Looking at the data, women and Black adults frequently experienced longer wait time to be evaluated by a clinician when presented to the ER than white males. So, you know, we should be aware of that differences, and we should try to narrow the gap.

Host: Yeah, no doubt. Narrow the gap. And for all of us, if we have the risk factors, if we have either the sort of expected traditional, you know, chest pain or something else and something doesn't feel right, you know, get to the ED. Better to be safe than sorry, I think, is the expression. So, I appreciate your time today. Thanks so much.

Dr. Ahmad A. Hadid: Thank you. Thank you. Have a good day.

Host: And to learn more about our cardiac services, visit montefioreslc.org. And if you found this podcast to be helpful, please be sure to share it on your social channels and be sure to check out all the other Doc Talk episodes. This has been Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. I'm Scott Webb. Stay well.