What are the tests for chest pain?

General responses to selected questions from Joel Braunstein, MD, of Johns Hopkins University and Joseph Toscano, MD.

Question:

Nearly a year ago I complained to my primary care physician of chest pain. My EKG apparently looks fine, but the pain remains. I don't exactly know how to describe it - it is on my left side and beneath my breast. It kind of feels like a bruise being pressed and released, but sometimes it is feels more like a weight. The pain usually occurs while I am still or laying in bed. I am a smoker and heart disease runs in my family. What kind of heart test is recommended for symptoms like these, if any?

Answer:

As far as your smoking, this is an important risk factor for heart disease, as well as cancer (lung, breast, and others) and other health problems, and you should try to do everything you can to quit. If you haven't already, ask your doctor for help or check with the American Lung Association or American Cancer Society about smoking cessation classes and assistance in your area. If you've already tried to quit and weren't successful, try again! Your family history of heart disease also puts you at increased risk, but there's not much you can do about that, except to work hard to control and treat any other risk factors you might have, including diabetes, high blood pressure, high blood cholesterol levels, being overweight, and not exercising regularly (as well as the smoking).

Regarding your chest discomfort, it's difficult to say exactly what's causing it based on your description. Some features (a pressure-like sensation) make it seem like it may be your heart, but overall it sounds more like it may be in the chest muscles or esophagus (which is a common cause of chest discomfort when lying down). However, just the fact that someone over 35 is having recurring chest symptoms deserves further evaluation to be sure it's not heart disease. An exercise treadmill test (link to stress test patient guide) is frequently used in this situation (after a chest x-ray and a resting ECG), though false positive results frequently occur in women. If you have a negative test, it would be reassuring. If you have a positive result, it will require additional testing to be more certain. A better option would be to start with a stress echocardiogram, which is the same thing as a treadmill test, with the addition of an echocardiogram. The "echo" uses some gel on the chest, an ultrasound probe (similar to that used to look at pregnant women's babies), and a computer monitor to directly observe the heart's function before and immediately after exercise. A comparison of these "before" and "after" images greatly enhances the accuracy of the test.

If the stress echo is positive, you'll need additional testing, but if it's negative (hopefully, and most likely it will be given the overall scenario) the likelihood of heart disease would be extremely low. You can then begin to consider the other potential causes of your symptoms. I'd recommend talking to your doctor about trying a treatment for gastro-esophageal reflux disease to see if it helps. There are confirmatory tests for this, if necessary, but a trial of treatment is usually the first step.

Lastly, a lack of direct breast tenderness or other breast symptoms makes it less likely that it's related to the breast itself. If there is any question whether it might involve your left breast, then a mammogram or more in-depth breast evaluation would be helpful to be more certain regarding this possibility, after the cardiac testing.