My husband, 62, has recently experienced “tightness” in his chest. He has been diagnosed with panic disorder. The doctor did an EKG and said his heart is healthy. Are the EKG results sufficient to rule out everything else? He has had recent blood work done and everything is fairly normal. He does work very long, intense hours (he is a pastor of a large congregation), anywhere from 10 to 14 hours a day for two to three weeks at a time with little or no downtime.
Chest pain, tightness or discomfort can come from many conditions, but the one we are always concerned about ruling out is the pain of angina. It almost always indicates that there is significant coronary artery disease, caused by athersclerosis, and may be a warning sign that a heart attack is about to occur, or has already occurred.
I say that the art of medicine is crucial here because eliciting a good history of the pain, and evaluating it in conjunction with what the doctor knows of the person’s risk factors for coronary artery disease, is the most important part of arriving at a presumptive diagnosis. It’s essential to being able to say, “This is probably angina, and indicates heart disease,” or “This is probably not angina, and is not coming from the heart, and is therefore not so serious.” The EKG (electrocardiogram), contrary to the popular myths about it, is usually not very helpful in coming to a conclusion.
Angina occurs when the heart muscle does not receive sufficient blood to support the work that it is doing. It usually, but not always, occurs with exercise, when exertion causes the heart to beat more rapidly and more forcefully. In a classic case, a person will say to the doctor, “Whenever I climb the one flight to my apartment, I get this squeezing pain in the chest, and it takes about five minutes to go away when I rest.”
But other things than exercise can provoke angina: fear, anger, a panic attack, a nightmare or perhaps even a heavy meal. Anything that pushes up the work of the heart, or occasionally, that causes a spasm of the coronary arteries, can cause the pain.
Knowing a person’s risk factors may make one more or less likely to diagnose angina. Does the person smoke, never exercise, and have high cholesterol, diabetes or obesity? That person is a sitting duck for a fatal heart attack. On the other hand, if the person is young, can jog five miles without chest pain, had parents who lived to age 85 and died of “old age,” is slim, doesn’t smoke and has normal cholesterol, we would be more likely to look for another cause. Before all of you sports experts write me citing the case of Jim Fixx, the world-class marathoner who died apparently of a heart attack while out for a run, let me admit that there are always exceptions. In his case, it appears that he did have a family history of heart attacks and had in fact been having some chest pains in the days prior to his death, which he ignored.
Does the physical exam help us here? Examining the heart in someone who may have angina is seldom helpful. Coronary artery disease does not produce distinctive physical findings.
Is the EKG that your husband had helpful? It may be, if it shows signs of an old heart attack or of heart enlargement, but more often than not, it is not helpful in predicting heart disease, particularly if done at a time that the person is not feeling pain or discomfort. The EKG measures the electrical currents in the heart muscle. If a person is having or just had a heart attack, the EKG will often show the distinctive alterations in electrical patterns that indicate the death or severe stress of some heart muscle. But in angina, the muscle isn’t killed, it’s only complaining a bit, and when the pain stops the EKG may be totally normal. At this point, the doctor should ask: Do this person’s history and risk factors make it likely that he is experiencing angina? If the answer is yes, he should be referred for more testing. Or, is the likelihood of angina low enough that he can simply be reassured and not tested further?
In the case of your husband, we have too little information to make a judgment about his chest tightness. He does have two risk factors for coronary artery disease: He is male and 62 years old. I would not judge the amount that he works to be a risk factor. If he smokes, has high cholesterol, is diabetic or hypertensive, or had several close male relatives die of heart attacks, then he is at higher risk, and perhaps deserves to have the next step of testing, which would usually be a stress test, perhaps with radioisotope imaging of the heart.