Chest pain severity not a heart attack indicator

NEW YORK - A high degree of pain does not make it any more likely that someone coming into the emergency room with chest pains is having a heart attack, researchers found in a study of more than 3,000 patients.

The most severe chest pain was not a good predictor of which patients were actually having a myocardial infarction, or heart attack, nor of which patients were most prone to having one within the next month.

Conversely, "If chest pain isn't severe, that doesn't mean it's not a heart attack," said Dr. Anna Marie Chang, an author of the study and an emergency physician at the Hospital of the University of Pennsylvania.

Using a scale of zero to 10, with zero representing no pain and 10 being the worst imaginable, researchers gauged the pain levels of about 3,300 patients who arrived at the UPenn hospital emergency department complaining of chest pain. They then followed the patients for 30 days to see who had further heart-related events.

Patients with the most severe chest pain were no more likely to be having a heart attack, or to have one within the next month, than patients with lesser pain. Pain that lasted more than an hour was also not a useful sign of a heart attack versus other conditions.

Chest pain of any severity should be cause for concern, experts caution. Pain is a red flag for other serious health problems, too, such as stomach ulcers or a tear in the aorta, the heart's main artery, like the one that killed actor John Ritter in 2003.

"The cause of chest pain may or may not be a heart attack, but it could definitely be something serious," said Dr. James Feldman, an emergency physician at Boston Medical Center who was not involved in the study.

Classic heart attack symptoms do include chest pain or pressure, but other hallmarks are shortness of breath, nausea, vomiting and faintness.

Moreover, the pain of a heart attack doesn't always settle in the chest area.

"Pain may occur in the chest, arm, jaw, back or abdomen and may be described differently by different people," said Dr. Rajiv Gulati, a cardiologist at the Mayo Clinic in Rochester, Minnesota, who was not involved in the study.

Although in the study pain severity wasn't a good indicator of who was having a heart attack at the hospital, having arrived at the emergency department in an ambulance was.

That may be because people tend to dismiss chest pain until they are having symptoms they deem serious enough to warrant calling emergency services, Feldman explained.

"If you are only waiting for crushing chest pain, you may wait to delay care, and that would be a problem," he said. "Any chest pain is a serious complaint and means you need to seek medical care right away."

"Unexplained chest discomfort should be taken seriously, regardless of the intensity of pain," Gulati agreed. "Early evaluation can save lives."

The current findings, published in the Annals of Emergency Medicine, could also help save doctors money by helping them judge who is and is not having a heart attack.

Failures to diagnose acute myocardial infarction account for 20 per cent of malpractice claims paid out, the authors note, and some two to five percent of patients who are having heart attacks are inappropriately discharged from emergency departments.

SOURCE: Annals of Emergency Medicine, online August 1, 2011.