Chest Pain - is it a Myocardial Infarct?

Chest Pain - over age 40,and our immediate concern is myocardial ischemia. However, GERD(Gastroesophageal Reflux Disease) Costochondritis, Pleuritis, Myofascial Strain(pulled muscle), and Anxiety(with Panic) can mimic cardiac-based pain very closely.

So, short of running to the ER with every chest-based pain, how is one to know if the pain is of cardiac origin?

This blog's concept is to maintain a level of wellness adequate to maintain clean coronary arteries and prevent the possibility of heart attacks. However, if you find yourself experiencing chest pain, you need to have the basic information available with which to base your decision whether or not to proceed to the emergency room.

So here I am (hypothetical case) working in the ER with an elderly man that presented at two am with chest pain, with history of CAD (oronary artery disease), severe GERD, anxiety, and CHF(congestive heart disease).

Patient - 80+ yowm, c/ awakening with severe lower, mid-sternal chest pain with pressure, non-radiating, +SOB, +nausea, no light-headedness, no diaphoresis.

Paramedics - 3 SL NTG tabs with relief of most pain, pressure remains, now arrived at ED

So this is what we do:
Patient placed on cardiac monitor, vital signs taken T35.6 HR 99, RR 20 BP 136/60, ) O2 sat 99% on 2L NC oxygen. EKG taken - shows LBBB (left bundle branch block) This pattern makes it difficult to use an EKG to evaluate cardiac ischemia, but if it is new - this could be a good indicator. Old medical records show no change (not new).

Obtain history from patient to begin risk-stratification
Symptoms - epigastric pain-mild -sharp, non-radiating, no SOB, no nausea, no diaphoresis

Cardiac risk factors - +htn, +diabetes, type 2, insulin dependent, +hyperlipidemia, +h/o CAD, +remote h/o cigs (smoking). +age(male over age forty). He has all the risk factors for having a heart attack.
But also - history of severe GERD, anxiety with panic. H/o CHF. No recent history of muscle strain.

Exam alert, c/o epigastric to mid-sternal pressure only, lungs - rales 1/3 up, dry, Cardiac - RRR, III/VI sem at LSB(an appreciable, but not severe aortic valve murmur)
No abdominal pain, Foley catheter in place - urine clear, no LE edema (ankles not swollen with fluid).

ER action - 324 mg aspirin, oxygen via nasal canula at 2 liters/minute, iv access, cardiac monitor labs drawn, chest x-ray ordered.

CXR performed - COPD changes, minimal infiltrate bilaterally. normal mediastinum So CHF is ruled out, aortic aneurysm not present.

Remember - he was lying flat while asleep and awakened with epigastric pain, sharp.
So - GI cocktail (Maalox and viscous lidocaine) po (givien orally). with immediate relief of all symptoms. Patient now looks relaxed, HR now 76, BP 125/66.

Now labs begin to return. CBC - normal WBC, mild anemia, BMP (electrolytes and kidney function) - normal, BNP(marker for CHF) - normal, Troponin(measure of cardiac cell death) - normal, U/A + for UTI(urinary track infection)

Patient's wife arrives. She feels he is now symptom-free (now complaining about the quality of our blankets).

Old records show recent admission for chest pain - determined to not be a candidate for cardiac intervention (due to several factors I can not go into here). Medical regimen optimized, and discharged back to nursing home.

Assessment - GERD exacerbation. Due to recent prior full inpatient cardiac evaluation, and complete resolution of symptoms, and ability of the nursing home nurses to monitor his condition, he is transported back to NH with change in medical regimen to use a stronger PPI (proton pump inhibitor, to be administered in the evening).

Patient and wife comfortable with ED course of action and plan to return to his living environment. A Reasonable, happy ending.

Take home points
Acid reflux - can closely mimic cardiac pain. Worst after lying flat, due to gravity. Also, nitrates can alleviate esophageal pain!
Muscle strain - if you can alter the pain by moving your arm or twisting your back, or breathing deeply - this is muscle and or pleuritic pain, not cardiac pain.
Costochondritis - the ribs connect to the sternum via small joints - these can become inflamed after coughing from a respiratory illness. This causes pain often perceived to be of cardiac origin. Simply press on these joints with your fingers - if this action elicits sharp pain = you have your answer.
Anxiety with panic - by its nature, one cannot properly self-evaluate this!

However, it is quite possible to have both cardiac pain and one of the above symptoms simultaneously - if any doubt exists, especially if one has appreciable risk factors, then calling 911 is the proper course of action.


Of all the patients presenting to the ED with chest pain, a good percentage of these are admitted for observation while serial lab studies are performed. Most of these patients rule out for having experienced a myocardial infarction. It is common to undergo a cardiac stress test prior to hospital discharge.

It is important to use adequately wide enough admission criteria to find the actual myocardial infarctions. To do this, we expect that most patients will rule out and return home.
Note: acute severe MI patients proceed rapidly down a more medically agressive pathway, receiving thrombolytic therapy and/or cardiac catheterization.