There are many conditions which can produce chest discomfort, but the most dreaded is that of coronary artery disease, a condition in which blocked heart arteries cause oxygen deprivation to the heart muscle, resulting in chest pain. That discomfort, called angina pectoris, was so named by Dr. William Heberden, an 18th century English physician who, at the suggestion of Ben Franklin, once wrote a pamphlet on smallpox inoculation for the American colonies.

In 1772 Heberden published his classic description of angina pectoris as “a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it and the sense of strangling and anxiety with which it is attended”. His dramatic description included the classic observations that angina occurs during exercise, feels as if one might die, and then subsides dramatically with rest. These observations made Heberden famous (along with his original work on chicken pox and nodular arthritis of the fingers) and have stood the test of time.

When angina pectoris occurs in its classic form, as described by Heberden, any competent doctor can make the diagnosis just by talking to the patient—without performing a single test. The history alone may also provide the opportunity to identify classic symptoms of common non-cardiac chest pain including esophageal reflux, musculoskeletal inflammation, or pleurisy.

But heart disease can sometimes cause atypical chest pains that do not fit into the usual pattern. This is especially true in women. The angina may masquerade as something else, and the true cause of the pain may lurk under the surface, while the patient is busy taking Pepcid or Motrin. On the other hand, non-cardiac conditions can produce chest pain which can mimic that of heart disease, such as the substernal burning of esophageal reflux. Medical students are taught to “listen to the patient; he is telling you the diagnosis,” but sometimes the diagnosis is elusive because the patient is unable to give a coherent history, or sometimes the doctor is unskilled at eliciting a good history or perhaps he just doesn’t take the time. So, talking to the patient is a really good diagnostic technique, but the doctor usually must go further in order to define the depth and breadth of the situation. This need to go further is why it is hazardous for a doctor to come to a conclusion over the telephone and why he should see anyone complaining of chest pain.

The physical examination, ECG and chest X-ray seldom add much to the history in determining the cause of chest pain, but they should be done anyhow. On occasion, they may offer additional information, such an ECG which reveals evidence of a prior “silent” heart attack, or a physical exam which discloses a heart murmur, or a chest x-ray which shows fluid around the lung or an enlarged heart.

At this point, if the doctor is still unable to make a definite diagnosis, he might order more tests in order to find the correct answer or he might conclude that the situation is harmless and does not require further assessment. The decision to proceed with costly and potentially risky tests depends on the physician’s perception of the likelihood of a serious problem. Medicine is an inexact science, and the doctor must do a probability assessment and use his best judgment in deciding what to do next. I f the patient is an obese middle aged man who smokes and has high cholesterol, then the doctor is more likely to go further with testing than if the patient is a slender 20 year old who doesn’t smoke and runs three miles per day.

If another test is ordered to assess for coronary disease, it usually is an exercise stress test. Many doctors go right to a high tech stress test using nuclear or ultrasound methods, although an inexpensive regular stress test might be a reasonable first choice. A negative stress test does not completely rule out heart disease, but it may be last test required, if the doctor thinks the patient has a low likelihood of heart trouble. The doctor must continue with his probability assessment each step of the way, so a negative result may still be followed by more testing.

A positive stress test result may strongly suggest coronary heart disease, but a positive result seldom provides all the answers, even if the physician is now sure of the diagnosis. The stress test doesn’t show the blocked arteries or give enough prognostic information.
In addition, positive stress test results can occur in people with healthy hearts (i.e. a “false positive” result), but it’s risky for a doctor to end the workup in the face of a positive stress test.

At that point, a consultation with a cardiologist is desirable to see if coronary angiography (i.e. cardiac catheterization) is required. This invasive procedure will show if blockages are present and, if so, will provide important anatomic and prognostic information to help guide therapy.

So doing an angiogram may be warranted whether the stress test is positive or negative. The reason that angiography isn’t done at the outset of the evaluation is because it has risks and might be avoided with a noninvasive workup.

Even if the diagnosis of coronary artery disease is conclusively made, there is one more test which should be done, and that is the echocardiogram (cardiac ultrasound). This noninvasive procedure helps fill in the blanks by checking the heart valves, the strength of cardiac contraction, and the condition of the walls of the heart.