How Your Cardiologist Evaluates Chest Pain (Shortness of Breath)
Emergency or Non-Emergency
If you experience any symptom that is new and concerning, go to the nearest ER. I advise my patients to not delay care paging doctors, going to urgent care centers. Many people also make the mistake of delaying urgent care hoping that 'Dr. Google' can help them. That could be a fatal mistake. Presenting to an emergency room also expedites your evaluation as cardiac testing can be performed as an inpatient without pre-authorization delays, etc.
In this article, I am referring to non-emergent or outpatient evaluation of chest pain/discomfort. So don't confuse the two.
Be aware that any symptom can be substituted for 'chest pain' such as jaw discomfort, shortness of breath, fatigue, dizziness, etc.
Life Threatening Causes
If you experience chest discomfort, a symptom that is often incorrectly characterized as 'chest pain' (see below), your cardiologist must exclude life threatening causes which include, among others:
Of course, there are other dangerous causes of chest pain as well as non-cardiac complaints, but the work up will focus upon heart disease.
There are 6 basic tests that are used to evaluate for coronary artery disease, listed in order of accuracy.
Non-imaging stress test: This type of test is very limited in utility and should not be used in the modern era of medicine. However, cardiologists are forced to perform this downgraded testing for our patients in Hawaii.
Stress/echo. A stress/echo is considered to be a ‘low level’ stress test intended for patients with a low suspicion of heart disease. If you have CABG, stents, previous heart attacks, this is not the best test for you. However, in Hawaii, more advanced, appropriate testing is typically downgraded for our patients.
Stress/Nuclear scan. This is a decades old test intended for patients with a higher suspicion of underlying heart disease or those who have previous coronary stents or bypass surgery.
Stress/MRI. A newer study, highly accurate that does not require radiation exposure.
CCTA: Coronary CT Angiography: the most accurate non-invasive test. I have promoted this test since 2006 in Hawaii with tremendous resistance from private insurance carriers, to this day, from local insurance. This test is the national standard for Europe, irontically.
Catheterization. The gold standard for testing. Invasive assessment of the coronary arteries.
Although there are superior studies available, in the U.S. these more accurate studies are not allowed by private insurance and CMS (Medicare).
Additional testing that is routinely a part of the evaluation of chest pain:
Special Section: Can I Need a Stent or a Bypass Surgery and Not Even Have Chest Pain?
Yes. In fact, a more accurate title of this article would be: 'How Cardiologists Exclude Flow-Limiting Coronary Artery Disease'. Most people wrongly assume that if they have a blocked heart artery (CAD), they will experience chest pain. This is often not the case. Advanced imaging techniques such as cardiac MRI confirm what cardiologists have know for a long time: many people suffer silent heart attacks and don't even know it.
Important Points to Remember:
1. A coronary artery blockage (stenosis) must be approximately 70-80% or greater in severity before it will decrease blood flow to your heart resulting in angina/symptoms. In other words, you could win the gold medal in the next Olymic marathon, setting a world record, with a 50-60% coronary artery stenosis in your left anterior descending artery. Now you understand the reason we perform stress tests in the first place--to identify patients who require a stent or bypass surgery. 'Passing a stress test' indicates that you do not need a stent or a bypass surgery, but you may still have CAD. This is where preventive tests such as calcium scoring or CCTA play a role.
2. Anginal Equivalent Complaints. As discussed above, doctors, PAs, APRNs, nurses, NA, MAs loosely use the term 'angina' to describe chest discomfort associated with severe CAD. More accurately, any symptoms that occurs with exertion could signify significant a severe stenosis. Women may experience atypical symptoms: shortness of breath, insomnia, fatigue. Diabetic patients: shortness of breath, fatigue or nausea. (16-40% of diabetics may suffer a silent heart attack. Click here). In other words, any exertional symptom(s): fatigue, shortness of breath, chest heaviness, chest pressure, chest pain/discomfort, squeezing in the chest, jaw discomfort/pain, neck discomfort/pain, indigestion, dizziness, palpitations--could be an 'anginal equivalent' complaint.
3. What if I don't have an exercise program? People who don't exercise, won't have exertional symptoms. Although this seems obvious, think about our principles in Prevention. If you can walk an hour 5 days a week, it's highly unlikely that you have significant heart disease. It is possible, but far less likely than someone with multiple risk factors who has no exercise program.
Note: Understanding your heart condition is not difficult. Patients become frustrated and confused when doctors don’t explain things clearly. If you don’t understand what your doctor is talking about, then you won’t be able to ask meaningful questions. I hope that my posts provide you with a framework that you can build upon to become an active participant in your healthcare.
Gregg Yamada MD FACC
Disclaimer: I hope you find my medical blogs to be pertinent, interesting, and thought provoking. The information provided is educational and should not be taken as medical advice. I am a doctor, but I am not your doctor. Please schedule an appointment with your doctor to discuss these issues and to determine what is right for you.
© 2019. Gregg M. Yamada, MD FACC. All rights reserved.