On Tuesday, March 14, the Navigating the Medical System Lecture Series featured Nathan Tehrani, MD FACC, attending cardiologist at NewYork-Presbyterian Hospital Queens, on the cardiologist’s approach to evaluating chest pain. The Zoom lecture, as always, was hosted by Congregation Etz Chaim.

Dr. Mel Breite, Founder and Director of the Navigating the Medical System Lecture Series, greeted everyone and shared that chest pain is common. He related that he saw two people in the office today with chest pain in the front left side. In both cases it was rib pain.

Dr. Tehrani related that approximately 7.6 visits to the emergency room in the United States are for chest pains. Many organs can cause chest discomfort, such as the lungs, the esophagus, or the stomach. Our goal is to differentiate what the pain is from.

Noncardiac causes include peptic ulcer, inflamed esophagus from GURD, collapsed lung, or some other causes.

The lining and valve of the heart can cause chest pain. Blockage of the arteries to the heart is coronary heart disease. The blockage causes narrowing of the arteries, and this limits blood flow to the heart. The blockage is called angina and it involves fatty deposits in the arteries.

The heart pumps blood out of the aortic valve. There are two main arteries to the heart; these arteries are on the surface of the heart and they provide oxygen and blood to vessels in the heart. The clogging of arteries disrupts the blood flow to the heart muscle, and that is angina. Angina is pain in the chest in some part of the heart muscle that doesn’t receive blood flow.

A heart attack is when there is enough blockage of the heart muscle that blood and oxygen don’t reach the heart. In a heart attack, the heart muscle dies. In the United States, 20 million adults, age 20 and above, have coronary heart disease. Every year, 805,000 people in the United States have a heart attack.

Dr. Tehrani then listed risk factors for coronary heart disease. These include ones you can’t control, such as being a male, a family or personal history, and then those risk factors you can control, such as smoking, high cholesterol, diabetes, hypertension, physical inactivity, being overweight or obese, and eating a diet high in carbohydrates and fat.

He then shared detailed information about the anatomy of the heart and how it functions. He pointed out that the heart is an organ, and it needs oxygen, which it gets from coronary arteries so it can pump blood to the other organs.

Following this part of the lecture, he explained what happens when you arrive at the emergency room. You check in and receive a wrist band. The nursing triage takes your history and vitals and an EKG. Then you go to the waiting room either to an ER bed or a trauma bed. The ER nurses and physicians will do a series of tests to determine the cause of your chest pain. The initial evaluation includes the following: first impression, history, history of present illness, past medical history, family history, social history (drugs, alcohol, smoking), vital signs, physical exam, EKG, chest x-ray, and blood work. A focused history helps determine the type of chest pain that the patient is experiencing. The doctor will ask when the pain started and if it was sudden or slow-developing. What were you doing when it started and what is the duration of the pain? Are you still having it? What is the severity on a scale of one-to-ten? Is it coming and going? Do you have a sensation of pressure or is it a feeling of squeezing? Is it burning or knife-like, and where is the location of the pain and does it move? Also, does it get worse when you walk or experience stress? Does it improve when you rest? Are there associated symptoms of nausea, or difficulty breathing? The doctor will also inquire about previous testing. He shared, “I press on the chest to see where they are complaining and to determine if it’s muscle or bone pain.” He also views the cheeks, lungs, neck veins, and legs to make sure there is no swelling and that they are normal temperature. He noted that you can have normal troponin level [Troponin is a type of protein found in the muscles of your heart. Troponin isn’t normally found in the blood. When heart muscles become damaged, troponin is sent into the bloodstream. As heart damage increases, greater amounts of troponin are released in the blood.] in a blood test in the beginning of a heart attack. The echocardiogram can show how well the heart squeezes and if some walls are not moving well. It also gives the doctor a view of the heart walls. When there is lack of blood flow to the heart muscle, then the heart won’t squeeze well.

He added that, throughout the testing, the physician ensures that the patient’s symptoms are not life-threatening.

He then shared life-threatening symptoms, which include:

acute coronary syndrome due to rupture of cholesterol plaque in the coronary artery

A tear in the wall of the aorta, which causes a knife-like sensation

Pulmonary embolism, which is a blood clot in the arteries

A collapsed lung or esophageal perforation. The EKG test and the Troponin blood test play a role to determine which it is.

He explained the types of diagnostic tests. There is the treadmill stress test, an EKG, a nuclear stress test, an echo stress test, and a cardiac CT. He explained that “looking at the EKG while you exercise gives a lot of information.”

Dr. Tehrani shared ways to prevent cardiovascular disease. Diet recommended is the Mediterranean Diet or the Dash Diet, no smoking, exercise, healthy weight, reduce alcohol, and keep other health problems under control. For exercise, it is recommended greater than 150 minutes of moderate exercise per week, like swimming, biking, or brisk walking. He also recommended greater than 75 minutes of vigorous exercise per week, like jogging, running, tennis, swimming, or basketball.

The community thanks Dr. Breite and Congregation Etz Chaim for these informative, life-changing lectures.

By Susie Garber