Myth: You Must Have Chest Pain To Be Having A Heart Attack

by Steve Sainsbury, MD

Heart attacks are definitely one of our biggest fears. We have become a nation of joggers, dieters, and pill takers, much of this behavior directed towards avoiding "the big one." Yet many myths surround heart attacks, not the least of which is that in order to be having a heart attack, you have to feel crushing chest pain -- "Doctor, I feel like there is an elephant sitting on my chest."

Not so. And because of this fact, this myth can actually kill unsuspecting heart attack victims if they fail to seek care in a timely fashion.

Yes, it is true that many patients have the classic signs and symptoms of a heart attack. I can visualize them now, walking into my emergency room— breathless, pale, hand clutched over their chest, a look of pain and terror on their face. Most of those patients are indeed having a heart attack—a true medical emergency.

If only the diagnosis was this easy But when it comes to heart attacks, chest pain is NOT the rule. While about half of patient will have chest pain, half will not. And that half without chest pain will oftentimes sit at home, ignoring some of the other signs of "the big one," as their myocardium (heart tissue) becomes irreversibly damaged.

These Other Signs

I have seen patients with heart attacks have only right-sided chest pain, only neck or jaw pain, only back pain, and only arm pain. I have treated many victims who only felt short of breath, or nauseated, or weak, without a hint of pain. I have diagnosed heart attacks in people who had simple "heartburn" (where do you think the name comes from?), sweats, or dizziness.

Interestingly, the older you get (and the more female you are), the more likely you are to not have left-sided chest pain when experiencing a heart attack. A prominent study in 2004 looked at two thousand heart attack patients. Those under age 65 had chest pain about 80% of the time, but those over 65 had chest pain only 50% of the time. For women, this statistic was even more pronounced. Another study showed that women of all ages suffering a heart attack had chest pain only 20% of the time—astonishing.

How can this be so? How can the heart, basically a powerful muscle, not feel pain when it is deprived of oxygen and starts to die? The answer lies in how our body perceives pain. The nerves from the heart converge with those nerve impulses returning from the jaw, neck, arm, and back. The brain basically gets confused, and can't distinguish where the actual pain impulse is coming from. And as we age, this convergence becomes even more pronounced and confusing.

Diabetics are particularly at risk for confusing symptoms. As a result of their disease, they often have nerve damage, in which pain fibers fail to function properly. As you may predict, diabetics often have NO pain when suffering even major heart attacks.

And women? Why don't they feel chest pain as often as men? That, along with many other aspects of the feminine mystique, remains a mystery.

Adding to our challenge as physicians, heart attacks are obviously not the only cause for chest pain, as well as the other symptoms such as shortness of breath, back pain, dizziness, or nausea. In fact, most patients with any of these symptoms are not having a heart attack at all. Doctors have identified hundreds of conditions that mimic the signs of a heart attack. Some of the more common ones include esophagitis (also known as the infamous "heartburn"), pneumonia, a blood clot to the lung, or chest wall spasm. Even shingles can look like a heart attack. Hopefully, you can appreciate the challenge that the potential heart attack patient presents to the emergency room when they walk through the door. Neither doctor nor patient wants a misdiagnosis.

So how do we diagnosis whether or not you are indeed having a heart attack? Through a careful history and exam, followed by an EKG (a tracing of your heart's electrical signals), a chest X-ray, and blood work, looking for specific markers of heart muscle injury. It isn't easy, but a thorough (and sometimes boringly long) evaluation can usually make the correct diagnosis.

So what should you do if concerned about some pains or symptoms? What is the take home message? Do what we do as emergency physicians. Be very suspicious of chest pain of any sort. Worry about pain in the heart-related areas that have been discussed like the jaw, neck, and shoulder. And also be very aware of the more subtle signs of a heart attack, such as breathlessness, sudden fatigue, dizziness, and nausea. When in doubt at all, and particularly if you are older than 60-65, a diabetic, or female—get the problem checked out right away - not in two months when your HMO can squeeze you in. Not in two days when your family doctor has his next available appointment. Get it checked out immediately by visiting your nearby friendly emergency room. The visit just may save your life.

Mountain Gorilla image on banner by Steve Sainsbury. It may interest you to know that this particular one is Steve's favorite gorilla, a friend from one of his stays in Rwanda.
This article was originally run in May 2010. Our Dr. Sainsbury is off to Africa to lend a hand again. He'll be back with a new column in June.