What causes chest pain if ecg is normal

Brady WJ, Harrigan RA, Chan TC. Basic electrocardiographic techniques. In: Roberts JR, Custalow CB, Thomsen TW, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia, PA: Elsevier; 2019:chap 14.

Ganz L, Link MS. Electrocardiography. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 48.

Mirvis DM, Goldberger AL. Electrocardiography. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 14.

Last reviewed on: 5/8/2022

Reviewed by: Michael A. Chen, MD, PhD, Associate Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

I wasn't worried about my heart on the day of my annual physical. At 63, I was a non-smoker with a BMI of 20 who got (mostly) regular exercise and took no daily medication.

A blood test the week prior had shown my total cholesterol was 187, with a good HDL/LDL cholesterol ratio and low triglycerides. According to the National Library of Medicine, a healthy total cholesterol level for women over 20 years is 125 to 200mg/dL, so I was within a healthy range. 

The report included a reassuring notation: "Lower relative cardiovascular risk, according to American Heart Association/Centers for Disease Control and Prevention guidelines."

At my check-up, my blood pressure registered at 110/70, under the 120/80 measurement that the American Heart Association (AHA) recommends as normal to decrease the risk of stroke, heart attack, and other cardiovascular issues. And per the Centers for Disease Control and Prevention (CDC), LDL cholesterol levels are particular essential in determining heart attack risk. Additionally, I had an electrocardiogram (EKG), which showed no abnormalities. 

I left my doctor's office with a clean bill of health.

That was on July 7th. On July 8th, I had a heart attack in an unlikely scenario, even for fiction.

Strange Chest Tightness

I awoke that morning with vague jaw pain. Was it sinus-related? I also had an odd, persistent ache in my left arm. Could that be from the booster shot I had the day before?

While I mulled over the possibilities, I noticed a tightness in my chest—not exactly painful, but uncomfortable and strange. My first impulse was to give it time, have my usual cup of coffee, and wait for the symptoms to subside.

My daughter had a better idea. She told me to get dressed and took me to the emergency room.

The chest discomfort seemed to worsen on a short drive to the hospital. I also had a dry, throat-clearing cough, and I had begun to feel queasy.

According to the AHA, warning signs of a heart attack include:

• Chest discomfort or pain
• Breaking out in a cold sweat
• Nausea and vomiting
• Lightheadedness
• Jaw, neck, or back pain
• Discomfort in one or both arms or shoulder
• Shortness of breath

I was experiencing some of those warning signs. But as I checked in to the ER, I half-apologized for presenting with symptoms that, as I explained, were "probably due to a vaccine I got yesterday." Nonetheless, they quickly whisked me away to a treatment room. And within minutes, a healthcare provider sternly rejected my Google-inspired diagnosis: "This is not related to any shot," they told me.

A Deadly Blockage

That was the first hint things might be severe. My second clue was seeing the energy in the room change; there was a sudden sense of urgency. But ironically, it wasn't until a healthcare provider put an aspirin under my tongue and said, "You're going to be fine," that I began to panic. Do you mean "being fine" is even a question?

Within minutes, I was wheeled into the hospital's cath lab, where a cardiac team got ready to perform an emergency angioplasty. 

According to the AHA, angioplasty is when a healthcare provider threads up special tubing with an attached deflated to the coronary arteries. The balloon inflates to widen blocked areas where blood flow to the heart muscle has been reduced or cut off. 

I would later learn that a bit of plaque had erupted in my left anterior descending artery (LAD), causing a blockage. A stent opened the blood vessel and restored blood flow.

In other words, I had a heart attack in the LAD. 

A blockage high up in the LAD is the kind of heart attack they call the "widow maker." No surprise why. The LAD is the biggest of the three arteries that supply blood to the heart. So, a blockage in the LAD can be particularly deadly.

Onto Recovery

My recovery protocol was pretty standard: A few days in the hospital, regular visits to a cardiologist, and a regimen of medications designed to prevent another attack.

Of course, the looming question: Why did a "low cardiac risk" person like me have such a major cardiac event? 

Could stress be to blame? A troubling family issue had reached a crescendo earlier that week. Was family history a factor? Relatives on my father's side succumbed to heart-related ailments, though not until they were in their 80s.

My doctors said my heart attack was unusual, and there was no way to pinpoint the cause with 100% certainty. 

But I learned a crucial lesson: low risk doesn't mean no risk. 

So, here's what my experience taught me that I wish I'd known sooner.

Minutes Count

If you have heart attack warning signs, every moment wasted can mean more heart cells are dying. The AHA advises calling 911 immediately since an ambulance often gets you to the hospital fast. Plus, emergency medical services professionals can start treating you as soon as they arrive. 

As described in an article published in 2018 in the Journal of the American Heart Association, hospitals are rated on their "door-to-balloon time." That's a performance measure that refers to the time from a patient's arrival at the hospital to when they undergo percutaneous coronary intervention (PCI). A PCI is a mechanical means of treating a heart attack by restoring blood flow to the heart via the balloon and stent.

An EKG Has Limits

It measures heart rate and rhythm—but it doesn't necessarily show blockages in the arteries unless they are causing acute loss of blood flow to the heart muscle. 

My EKG the day before didn't detect anything. Now that EKGs are available with some smartphone apps and fitness trackers, it's essential to know what this test can and can't do.

Heart Attacks Aren't Always Obvious

Not everyone experiences the "chest-grabbing" drama shown on television. Symptoms can be subtle and not overly painful. And symptoms can differ between women and men.

All cardiac symptoms—including chest tightness, shortness of breath, and pain in the jaw, arm, or back—must be taken seriously. That's even if you think you couldn't possibly be having a heart attack. 

Sure, taking action and discovering it was just indigestion or stress might be embarrassing. But despite the cliché, nobody has ever died of embarrassment.

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