Chest Pain: Wolf or Lamb

I was discussing chest pain at a pre-race clinic when a runner stood up and said he had frequent bouts of chest pain. “My body is always crying ‘wolf,’” he said, What should I do?”

My answer was what you would expect from a physician: “Take the wolf to your doctor and see if it really is a wolf.”

Most frequently it is not. The wolf of coronary artery disease is only one of many causes for chest pain. Usually pain arises from what I call the “barrel.“ This is the complex of ribs, muscles, tendons, joints, ligaments and nerves that comprise the chest wall. Much less frequently, it is due to the contents of the barrel-the heart, lungs and esophagus.

The doctor’s first task is to decide whether the pain comes from the barrel or the contents; ultimately the major decision is whether or not the pain is due to the heart. In the numerous instances of chest pain, the worry is not about its severity-it is frequently mild and often little more than a discomfort-but what it means.

If it’s chest wall pain, it means virtually nothing. And being reassured of that, runners quickly go back to their sport. They find ways to get rid of the pain, or simply put up with it.

Some, however, are not satisfied. Chest wall pain is too vague a diagnosis. Some physicians are not satisfied either. They would like tests to prove diagnosis. But the diagnosis of chest wall pain is not made by tests. It is made by a history and a physical exam. In fact, in diagnosing the cause, the most accurate method is the history.

The history is 97 percent accurate in the diagnosis of chest pain due to coronary heart disease. This surpasses any one of the high-tech ways of establishing the presence of coronary narrowing or obstruction short of angiography. For instance, the history is superior to stress tests, which frequently are positive when there is no disease and negative when there is.

Furthermore, the physician who relies on tests is also misled by them. If an echocardiogram reveals a mitral-valve prolapse, that prolapse is immediately accepted as the cause of the chest pain. Yet we know that the association of mitral-valve prolapse and cardiac symptoms is questionable. In the highly regarded Framingham, Mass., study, a survey found no difference in the incidence of chest pain in comparable groups with and without mitral-valve prolpase.

Physicians also pursue the equally questionable hiatus hernia. I have a hiatus hernia myself and know it can cause symptoms, but the pain is not brought on by effort and is readily distinguishable from that caused by heart and chest wall. So finding a hiatus hernia need not be the explanation of a patient’s chest pain.

There are two elements to a good history. The physician must ask the right questions. When this is done, the answer to whether the pain is coming from a barrel or from its contents can be established in short order. If worry shifts to the contents of the barrel, a few basic questions will distinguish between cardiac, lung or esophagal pain. When the full story is obtained these pains are as different-and as easily distinguished-as the rash of measles differs from that of chicken pox.

This certainly, however, depends also on the patient being a good historian. Vague answers are of little help.

Does it awaken you from sleep? If it does, must you sit up to get relief? Does it occur at rest? Or must you exert yourself to bring it on? What relieves it? What makes it worse? Does aspirin help? Parenthetically, it is remarkable how few patients have tried an over-the-counter medication for a pain that brings them to a doctor.

The more pertinent information the patient brings to the physician, the better off both of them are. When dealing with chest wall pain, a family or personal background of rheumatic disorders, neuralgia or allergies becomes important. When you get sick, how do you usually get sick? Muscles and joints? Respiratory tract? Intestinal disorders?

There are probably 50 or more causes for chest pain. The specific diagnosis requires some very specific questions.

Be assured, however, that the pain of serious coronary artery disease can readily identified by an experienced physician. I have received numerous calls from runners with chest pain. In a space of a few minutes conversation I know those who clearly have coronary disease, even though most have had stress tests which said they didn’t.

It is remarkably easy close up to tell a wolf from a lamb. But let your physician be the judge, don't try to do it yourself. (1990)