Learn All About Chest Pain

Matthew DeVane, DO, FACC: [00:00:08] Hi, I'm Dr. Matt Devane.

Carolyn Lacey, MD, FACC: [00:00:09] And I'm Dr. Carolyn Lacey. We are cardiologists at John Muir Health, and this is our podcast, Living Heart Smart.

Matthew DeVane, DO, FACC: [00:00:16] Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.

Carolyn Lacey, MD, FACC: [00:00:24] Thank you for listening and we hope you enjoy our show.

Matthew DeVane, DO, FACC: [00:00:33] Everybody [00:00:30] gets chest pain once in a while. It can be scary, right? Is this a heart attack or is this just some reflux and acid? I thought it would be great to get three cardiologists together to just talk about how we think about chest pain. Today. Dr. Lacey and I are happy to welcome to the program Dr. John Vu. Dr. Vu has been my partner for at least ten years. He's a great guy and his patients love him, and we're thrilled to have him with us today. Dr. Vu is a local guy. [00:01:00] Went to high school in San Francisco. He got his undergraduate degree at UC Davis. He went on to Penn State College of Medicine to get his medical degree. He then did his internal medicine training and his cardiology fellowship at UC Irvine. He even went on to get an advanced cardiovascular imaging training at Scripps Clinic in La Jolla. We've asked Dr. Vu to join us today to talk about chest pain and the way he approaches patients with chest pain. I really hope this episode will be helpful [00:01:30] for the patients out there that have symptoms. Well, Dr. Lacey and I are lucky enough to have with us this morning Dr. John Vu. Dr. John Vu, thank you so much for being here.

John Vu, MD: [00:01:44] I appreciate the invitation.

Matthew DeVane, DO, FACC: [00:01:47] Yeah, look forward to just we're going to chat a little bit today. I think we wanted to bring you in just as a general cardiologist and a guy that's interested in a lot of noninvasive testing and an expert in a lot of these [00:02:00] areas is to talk about why patients are coming to see us a lot. I wanted to talk with you specifically about some of the symptoms that cardiologists see patients for and then get into some of the testing around which we commonly do for our patients. So with that, let's let's get rolling here. So cardiologists when people think of seeing a cardiologist, there's a couple of reasons why they may come see us, but symptoms are a big one. And so we often get patients referred [00:02:30] from their primary care physician or they just call us directly. So a couple of the biggest symptoms I think about when I see patients in my list of patients for the week is kind of two things come to mind. Number one is chest pain. Chest pain is a worrisome symptom. A lot of people have. And the second one is palpitations. So I think maybe we can kind of go through those two things either together or separately today to talk about how we view those and then how we treat those and how we can reassure our patients that they're going to do really well. So let's start with chest [00:03:00] pain first. I think that's a big topic. So back in medical school, I still remember the day we had a lecture and the teacher titled The Lecture The 100 Causes of Chest Pain. And I thought to myself, Man, that's about 94 more than I want to hear about, But I'm okay to kind of see where this takes me because, you know, there's a lot going on inside the chest. So let's just talk about the big picture. So chest pain, can we talk about and what we think of what are some of the causes? [00:03:30] What are people tell you they're feeling? So chest pain?

John Vu, MD: [00:03:34] Sure. I think that's like number one, two, and three in terms of seeing patients for most cardiologists. And, you know, we're biased. Obviously, we're going to be worried about coronary artery disease and plaques in your heart and potentially those plaques being obstructive and potentially, you know, breaking apart or causing an acute heart attack. I think that's probably what patients come to [00:04:00] the outpatient clinic worried about, having a heart attack from their chest pain.

Matthew DeVane, DO, FACC: [00:04:04] Right, Yeah, I think so. Patients think of chest pain and they just say, that's got my heart. I mean, chest pain to most people is a heart pain. Whereas in our, I think thought process and is chest pain is chest pain. And then we start separating it out. And I kind of think of, you know, I'm trying to think of what I tell patients is, you know, let's make sure it's nothing dangerous. And then the rest we can sort of figure out later. So from a heart standpoint, coronary artery disease and [00:04:30] heart attacks is sort of the most dangerous type of chest pain that we think about. So when you see somebody with chest pain, what are the kind of the keywords or the sparks that you hear to say, oh, this sounds like something real here. What is the chest pain that you think of? Or when you hear the word, you say, okay, we might have a heart problem here. Let's dig in.

John Vu, MD: [00:04:51] Well, I'd like to talk to them about the nature of their pain. You know, when the onset was and what they were doing. Is it exertional [00:05:00] has it have some associated symptoms like shortness of breath? Were they nauseated, Were they diaphoretic breaking out in a cold sweat? And, you know, does the pain go down their arm or go to the back or, you know, where is the location of pain? You know, those are all important characteristics.

Matthew DeVane, DO, FACC: [00:05:20] I think when I hear pain, the kind of words that catch my attention are when the patient is describing the pain is like a crushing [00:05:30] heaviness, a sensation on my chest, like a pressure or heaviness. And a lot of patients will say, there's an elephant sitting on my chest. Is that is that the kind of thing that catches your attention?

John Vu, MD: [00:05:41] Yeah, absolutely. Now, just back up a little bit, because sometimes patients don't actually complain of pain. They complain of a symptom in their chest, typically like a pressure like you noted there, or a tightness or a squeezing sensation. So those are all important things because everybody's chest pain can be quite different. And technically [00:06:00] we call it angina. And then we break it down from typical to atypical angina and everybody's characteristic, quote-unquote, chest pain might be different.

Carolyn Lacey, MD, FACC: [00:06:09] I think that's important to really I think language is important. We lump everything, every sensation into the chest as a pain. And I always I'm oftentimes told, Doc, it's not a pain, it's a pressure. And to me, while that is, those are all synonyms to me they're not necessarily all [00:06:30] synonyms to the to the patients. And when you. Really talk to them, especially the ones that don't get chest symptoms. They might get jaw pain, they might get arm pain, but they often will have some exertional component sort of driving up into when they finally come into the emergency department, anyway, in the office it might be a little bit different, but.

Matthew DeVane, DO, FACC: [00:06:53] Yeah, I think it is funny how some people because, you know, we do get called to the E.R. and we get down there and say, oh, I heard you had you know, when we meet the patient, [00:07:00] we tell you, I heard you had chest pain. And some of them are very specific, like, no.

Carolyn Lacey, MD, FACC: [00:07:03] That is not a pain.

Matthew DeVane, DO, FACC: [00:07:04] I've told everybody that I didn't have any pain. It was a heaviness in my chest. It was a pressure. It was a tightness. So some people are very, very specific about that. So when I hear the word heaviness, I mean, that is a trigger in my mind, heaviness, tightness, pressure. Those are then then it certainly becomes high on my list. This is coming from the heart, which is kind of interesting. So, okay, so chest pressure, tightness, heaviness. Women may be a little bit different. Oftentimes [00:07:30] when I hear women tell me about their symptoms, it's more of little fatigue and maybe arm or ear pain or jaw pain or just tiredness in general with very minimal chest symptoms. I don't know why women are different. Dr. Lacey, any comments there?

Carolyn Lacey, MD, FACC: [00:07:50] Am I just supposed to know that because I have the right chromosomes? No, I think, you know, honestly, when I don't, I think [00:08:00] that sort of the. How am I trying to say it? So it's not just that the symptoms are a little bit different because actually in a lot of the women that I see and I see a lot of women in the office and when you really do get down to it, they have exertional symptoms. And that's when I say that the language is important because then they might not say, oh, you know, it's not just fatigue all the time. It's I'm exercising and I'm really [00:08:30] tired out at a time that I should expect to be able to go. I used to be able to run a mile and now I can only go a half a mile before I have to stop. And they and I think that there's just not a lot of understanding of what their symptoms are because they're just hard to put into words Something's wrong. And I have an objective finding that I can't do what I used to be able to do. And so, plus, I think there's a lot of a lot more shortness of breath that women [00:09:00] are associated with because I think that when you get down to it in the findings, when you find women who are having cardiac issues, cardiac events, it's not always the traditional big blockage in big artery that we can put a stent in. It's more of the smaller, tiny arteries, which are very, very difficult to conceptualize and to explain to patients. And so it's more sort of global. Sort of symptoms.

John Vu, MD: [00:09:28] Yeah. I think it's important to, you [00:09:30] know, definitely listen to the patient, let them tell their story because sometimes they get their own insight into why this is happening and maybe they, you know, sort of make their own diagnosis and you can see what their stress levels are that can possibly contribute to this. And some of the things I remember in med school, like Dr. DeVane was saying, was that we had this classic picture of a man, you know, middle age or late 50s shoveling snow, having that classic heart [00:10:00] attack in the cold air. You know, he's overweight. He's a smoker. But that's not the classic picture we see anymore. A lot of the patients come in with more, like you said, shortness of breath, exercise, fatigue and just not quite feeling like the way they used to. And it's good to listen to sort of hear their story because that's going to really help us pinpoint, you know, which testing we're going to do. What are we going to do next in terms of  [00:10:30]evaluating?

Matthew DeVane, DO, FACC: [00:10:32] Yes, well said. So, yeah, so I think what we're saying is the kind of words that we hear when someone's describing their symptoms, they catch our attention as being possibly cardiac. So it's pressure, tightness, heaviness. It's, you know, those symptoms associated with shortness of breath. Typically, symptoms are worse with exertion. They go away when you rest. So those, radiation from the chest to the [00:11:00] arm or to the jaw is sort of a constellation of those things that kind of grab our attention doesn't mean the other types of pains aren't coming from the heart. But that would be sort of the typical description of chest pain that we think is heart-related. But we also hear it all day in our office about symptoms that we know right away aren't cardiac. You know, chest pain can come from muscles and tendons and bones and ribs and reflux and acid and all sorts of other things.

Carolyn Lacey, MD, FACC: [00:11:25] Sometimes all at the same time.

Matthew DeVane, DO, FACC: [00:11:26] Yeah, that can be a challenge. It's a challenge for us to kind of sort those things out. So, [00:11:30] Doctor Vu, if someone was coming to you with some musculoskeletal type symptoms, how do they usually or phrasing what their symptoms are that you can say and it's probably coming from something other than your heart?

John Vu, MD: [00:11:42] Yeah. So sometimes they would say, well, the pain is constant and that's it's less concerning. If it's constant, it's lasting for hours or whole days. And I had it after I, you know, did some heavy lifting or maybe, you know, somebody threw a basketball at my chest and it hurts now. And, you know, it's typically [00:12:00] things they don't think of that could cause this musculoskeletal kind of strain or inflammation. So I'm not as concerned. I'm still concerned. But it's just when they say it's hours or it's days, I've had this, and especially when they can reproduce it by palpation like push on it or it sounds that makes me sound think more of a musculoskeletal cause, right?

Matthew DeVane, DO, FACC: [00:12:24] So for me, to some, they can point if they take their finger and point to it exactly. You know, [00:12:30] toward their shoulder or somewhere in their chest. Usually if they can point to it and say it's a sharp pain that they can point to, and then if they can move their arm or get in certain positions. So if it's positional, we tend to point away from the heart as well. And again, symptoms that last for hours or days is not coming from anything bad from the heart standpoint.

Carolyn Lacey, MD, FACC: [00:12:49] I think the same with bleeding things, too. So long symptoms as well as super short. That's a good point. It's a stab and it's gone.

Matthew DeVane, DO, FACC: [00:12:57] So someone's sitting there, they're at the desk and they get a [00:13:00] stabbing pain in their chest for a second. You know, that's. A or happens happened three weeks ago and it came again a day. But they're doing absolutely nothing. And it comes and goes. That's not coming from the heart. So usually those types of phrases, those are the things we're looking for from patients to help us figure out how aggressive we're going to need to be to work up their symptoms. So I think that big term of musculoskeletal pain sometimes we call costochondritis, which is inflammation of the chest wall or pain in the chest and those sort of things. So it's [00:13:30] usually helpful for patients if they can kind of think about their symptoms, what we ask them, what brings it on, what makes it better, what makes it go away, is it reproducible, Those kind of questions that they can expect, I think, from their doctor when sorting that out. Okay. So what about so another big class of causes of chest pain would be pain coming from the gastrointestinal tract. People say reflux and GERD and all those sort of things. So Dr. Vu, can you maybe describe what someone would say if they [00:14:00] were having more of a GI type of chest pain?

John Vu, MD: [00:14:02] Yeah. So, you know, you mentioned reflux and GERD, and then also there's esophagitis and gastritis and even an esophageal spasm can feel like a tightness that's, you know, constant and not even exertion related. You really have to kind of clue into is it related to when they age or what time of the day it is. Those are all important things. And I think when you talk about exertion and [00:14:30] non-exertion, that sort of separates it already. Possibly it's non-cardiac possibly GI. If they say it's associated with a heavier meal or they have a prior history of some heartburn or reflux already.

Matthew DeVane, DO, FACC: [00:14:44] Yeah, I think timing is key there. Like every time I, you know, after I eat a meal, I'm getting some discomfort in the chest or it's relieved with belching and you know, our timing of meals as well or even laying in bed. If people eat late meals and they're laying in bed, they get acid going back up in there and their esophagus is [00:15:00] not a fun feeling and sometimes very scary.

John Vu, MD: [00:15:03] You know, one thing is that the gallbladder disease can cause referred pain and it can feel on the left side, even though the gallbladder is on the right side.

Matthew DeVane, DO, FACC: [00:15:11] So it's yes, the body does like to trick us and patients with referred pain. That's why people with heart attacks get pain to their arm and to their jaw and to their ear. The same way certain gastrointestinal things like gallbladder issues can cause pain on the left side that feels all in the world like a heart attack. [00:15:30] So it can be very scary. I think GI Musculoskeletal are two big classes of chest pain that aren't heart-related. So we talked about some of the ways we can help sort that out. The tough one for us is just some people feel anxiety and stress in their chest, right? I mean, so, you know, I don't think there's a typical description for that, but it gets into working with the patient closely and listening to what they have to say about what's going on in their lives and other things kind of help bring [00:16:00] out, oh, you know, I'm going through a divorce or my kids are causing me some stress or I just lost my job. And then, you know, there's no test to rule it out. But it's certainly an important piece of information for a cardiologist.

John Vu, MD: [00:16:12] Absolutely. Yeah. You see that some of them have come to the emergency room. They've had anxiety issues. There's turmoil in their life. And so, you know, you want to hear they tell their story about those things because I think it gives them some insight. When you eventually [00:16:30] diagnose, it's non-cardiac pain. It's really hard to tell them, look, it's not your heart, it's something else. And hopefully, they can find some resolution.

Carolyn Lacey, MD, FACC: [00:16:39] I mean, I think it's important for as I listen to you talk about the different types of pain, it's very detailed. The questions that you're asking, trying to get patients to tell their story and having patients sort of be aware when they come into the office. We're not just there are 100 types of pain. [00:17:00] And the more you can know about your pain and be descriptive about your pain is very important. And I always think it's also important. I always try to find from my own patients to try to get a sense of what are they really most worried about? Because once we make that decision, once we sort of sort that out, then we can say, okay, we've got that. How are we going to figure that out? But then but being very descriptive is extremely important, maybe more so than what Dr. Google found. [00:17:30]

Matthew DeVane, DO, FACC: [00:17:30] Well, this is where doctors become little detectives, right? I mean, so just saying chest pain doesn't mean much. We really are going to have to work with them closely to figure out if we because we you know, we'd like to save them from a bunch of tests if we don't need them, if we can sort of pinpoint. I tell people a lot of times I'm better sometimes because the body, the body is so complex. I say sometimes I'm better telling you what is not than what it is. And so we'll say, Hey, listen. And my job is to tell you that it's not anything dangerous and nothing bad. I don't always have an answer [00:18:00] as to why you're having that bleeding chest pain. Once a day. But I can tell you for sure that it's not coming from the heart, which is oftentimes reassuring, which is a lot of people, you know, that helps a lot of people in many ways. So.

John Vu, MD: [00:18:11] Yeah, absolutely. It's good to tell them what's not. But unfortunately, it's frustrating not to tell them what it is.

Matthew DeVane, DO, FACC: [00:18:18] But you know what? I've come to live with that. I'm okay with that now because my job is to make sure they're going to be safe and, you know, and comfortable. And then I think that [00:18:30] just helps a lot of it doesn't help everybody, but it does help a lot of people get through it. And then and then we can kind of go from there. Okay. I've got to say, I really enjoyed this conversation about chest pain today. I think this topic really speaks to our patients. Chest pain can be concerning and not everybody's story is the same. Dr. Lacey pointed something out, that really stood out today. She said language is important because it's so key for physicians to listen to their patients, hear their story about chest pain, and then put together the puzzle pieces [00:19:00] that frame that patient's symptoms. It's through listening to our patients that we're going to be able to make the biggest impacts in their lives. Well, I hope this discussion about chest pain was helpful. And I especially want to thank Dr. Vu for joining us today. We really appreciate your input and thank you so much for listening.

Matthew DeVane, DO, FACC: [00:19:20] This is Dr. Matt Devane, and on behalf of my co-host, Dr. Carolyn Lacey, and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living [00:19:30] heart smart.

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