Chest Pain

Call 911 now if you have chest pain with shortness of breath, sweating, nausea or vomiting. Call 911 if pain spreads to your arm, back, neck or jaw. Call 911 for chest pressure that lasts more than a few minutes, or that goes away and comes back. Do not drive yourself. Do not wait to see if it passes. These are heart attack warning signs, and treatment works best in the first minutes. Women, older adults and people with diabetes often have milder or unusual symptoms. Call anyway if something feels wrong.

What is chest pain?

Chest pain is any discomfort felt between the neck and the upper abdomen. It is a symptom, not a diagnosis, and it has many possible causes. The one that must be ruled out first is reduced blood flow to the heart muscle. A narrowed coronary artery starves the heart of oxygen during exertion. The result is angina: pressure, squeezing, tightness or burning that comes on with activity and eases with rest. A heart attack happens when that flow stops completely. The discomfort is then usually more intense, and it does not ease. Not all chest pain is cardiac. Acid reflux, muscle strain, rib inflammation, anxiety and pneumonia all cause it. So does inflammation of the sac around the heart. The difficulty is that these can feel alike. That is why the American Heart Association advises treating unexplained chest pain as an emergency until a clinician says otherwise.

Symptoms to watch for

Cardiac chest pain is more often described as pressure or heaviness than as sharp pain. Pay attention to the pattern.

Call 911 immediately for:

• Chest pressure, squeezing or fullness lasting more than a few minutes.
• Pain radiating to the arm, shoulder, back, neck or jaw.
• Chest discomfort with cold sweat, nausea, or shortness of breath.
• Sudden severe pain with fainting or a feeling that something is badly wrong.

Call the office to be seen soon for:

• Chest tightness that reliably appears with walking or stairs and stops with rest.
• Discomfort that has been happening for weeks without getting worse.
• Chest pain that comes with palpitations or unusual fatigue.
• Pain that is clearly reproduced by pressing on the chest wall or by certain foods.

Angina that is new, more frequent or now occurring at rest is called unstable. The National Heart, Lung, and Blood Institute treats that as an emergency.

How Dr. Nanavati diagnoses it

The goal is to answer one question first. Is your heart muscle getting enough blood? Testing is chosen for your symptoms and risk profile.

• Electrocardiogram (ECG or EKG) is performed in the office at the first visit. It shows evidence of strain or prior injury.
• Treadmill stress testing records the heart while you walk. It reproduces the conditions that bring on your symptoms.
• Nuclear stress testing adds imaging that shows which region of muscle is short of blood.
• Advanced stress testing is used when you cannot walk a treadmill. It also helps when a standard study is inconclusive.
• Echocardiogram and transthoracic echocardiography assess pumping strength, valves and the sac around the heart.
• Coronary CT angiography images the coronary arteries themselves without a catheter.
• Ischemic heart disease evaluation brings these findings together into one assessment.
• Advanced lipid testing measures the cholesterol particles driving plaque.

The non invasive results may point to a significant blockage. A transradial angiogram through the wrist then follows, or a transfemoral angiogram. Both are performed at an affiliated hospital.

Treatment options

Treatment follows the cause. Care moves through three levels when the cause is coronary artery disease.

Lifestyle and risk factors. Stop smoking. Control your blood pressure and blood sugar, move daily and eat for heart health. These steps lower the frequency of angina. The heart healthy living guidance from NHLBI is the practical starting point. Every patient also reviews the seven risk factors for heart attack.

Medication. Nitrates relieve angina. Beta blockers and calcium channel blockers reduce the heart's oxygen demand. Statins stabilize plaque. Aspirin or other antiplatelet drugs reduce clotting risk.

Procedures. A severe narrowing is opened with a balloon. That is angioplasty, also called PTCA. A coronary stenting procedure then holds the artery open. Some patients are better served by bypass surgery. These are hospital based procedures. The office arranges them and follows up. Cardiac rehabilitation afterward improves stamina and lowers the chance of another event.

What to expect at your visit

Bring a medication list. Also bring any records from an emergency room or urgent care visit for the same pain. Be ready to describe what brings the pain on and how long it lasts. Say what relieves it and whether it has changed. Your visit includes an exam, blood pressure and an ECG. Stress testing and echocardiography are done in the office. Staff explain how to prepare, including whether to hold caffeine or a particular medication. You leave with an explanation of the likely cause and the tests being ordered. You also get clear instructions on when to call 911 in the meantime. More preparation details are on the FAQs page.

When to see a cardiologist

Schedule an evaluation for chest discomfort with activity. Do the same for pain that has been dismissed but keeps returning. An emergency room visit that did not find an answer is another reason. Anyone with a family history of early heart disease, diabetes, high cholesterol or aortic aneurysm should be assessed. Request an appointment online or call the Bonita office at (619) 585-0476.

Dr. Vimal Nanavati, MD, FACC is board certified in cardiology and interventional cardiology. He has 32 years of experience. He founded Advanced Heart Care, Inc. in 1997. He sees patients at three locations. The Bonita office is in South San Diego. It serves Chula Vista, Eastlake, Otay Ranch, National City, Spring Valley, Imperial Beach, San Ysidro and Coronado. The North San Diego office at 5190 Governor Dr serves University City, La Jolla, Clairemont and Mira Mesa. The Redding office serves Shasta County, Anderson, Red Bluff, Palo Cedro and Cottonwood.

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