Chest Pain Needs Immediate Attention, Experts Warn

New guidelines from the American Heart Association urge people experiencing chest pain to call 911 right away.

Medically reviewed in November 2021

Chest pain isn’t always related to the heart but when it is, it’s serious. Chest pain is the most common symptom of a cardiac event, such as a heart attack. This possible warning sign of trouble should be considered a medical emergency and be checked out right away, advises the American Heart Association (AHA) and the American College of Cardiology (ACC).

The AHA and ACC updated their guidance, recommending a new approach to the evaluation and diagnosis of chest pain that could save lives along with valuable resources.

Under the revised guideline, which was published in Circulation and the Journal of the American College of Cardiology, those who experience chest pain or discomfort should call 911 right away­—and not wait to seek care. 

“Everyone should know the symptoms that can indicate a heart attack and that calling 911 is the most important thing to do to save their life or that of their loved one experiencing chest pain,” says Chair of the guideline writing group Martha Gulati, M.D., M.S., FACC, FAHA, a professor of cardiology and former academic division chief of the division of cardiology at the University of Arizona in Phoenix in an October 28 news release.

Chest pain: a heart attack or something else?
Chest pain is the number-two reason for adults to go to emergency departments in the United States, accounting for more than 6.5 million visits every year. Of these visits, 5.1 percent involve a blockage or sudden drop in blood flow to the heart. More than half of all chest pain-related emergency room visits, however, are due to non-heart related issues.

Chest pain, pressure, tightness, or discomfort can extend to the shoulders, arms, jaw, neck, back, and upper part of the belly. Some people, particularly women, may also develop additional symptoms, such as nausea, shortness of breath, or fatigue. When these symptoms occur, they should be considered “anginal equivalents,” or types of heart pain, until a heart event is ruled out, according to the updated guideline.

Experts caution that women with chest pain are at risk for underdiagnosis or a missed heart attack. During serious heart events, men and women both have chest pain but women are more likely to also experience other symptoms, such as nausea or trouble breathing. Health care providers should ask women with chest pain to describe any other symptoms they may have, the guideline notes.

Like women, older people may develop some less obvious warning signs of a heart attack. The experts advise that additional symptoms, such as trouble breathing, fainting, unexplained falls, or confusion, should also be considered among those ages 75 and older.

Overall, the revised guideline warns that the heart should always be considered as a possible cause of chest pain and these accompanying symptoms.

The right tests—no more, no less
Emergency department providers should first consider serious causes of chest pain, such as heart attack due to coronary artery disease, aortic dissection (a spontaneous tear in the lining of the body’s main artery), pulmonary embolism (a blood clot in the lung), or a ruptured esophagus (a tear in the tube between the throat and the stomach).

Chest pain can be a challenge for healthcare providers to sort through. Recognizing this, the guideline provides standardized ways to assess patients’ individual risk, step-by-step care pathways, and tools to diagnose and communicate with people who are having symptoms.

The idea is to catch and treat serious causes of chest pain while avoiding unnecessary tests that can be stressful or risky for patients as well as costly.

“This standard approach provides clinicians with the guidance to better evaluate patients with chest pain, identify patients who may be having a cardiac emergency and then select the right test or treatment for the right patient,” Dr. Gulati adds.

Evaluating patients’ risk for a heart-related event, like a heart attack, allows them to make an informed decision with an emergency medical provider on the next steps—additional heart tests or follow up care with their own healthcare provider (HCP).

“While there is no one ‘best test’ for every patient, the guideline emphasizes the tests that may be most appropriate, depending on the individual situation, and which ones won’t provide additional information; therefore, these tests should not be done just for the sake of doing them,” Gulati explains. “Often, patients have additional concerns because they fear a heart attack or other severe cardiac event, which is understandable. However, we have advanced tools that help us determine whether a cardiac emergency or severe heart event is likely or not.”

American Heart Association. “Chest pain may extend outside the chest, often needs to be checked by a professional.” Oct. 28, 2021.
Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published online ahead of print, 2021 Oct 28]. Circulation. 2021;CIR0000000000001030.

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