This is an important question. And I have to try to answer it every day. Sometimes several times a day. Patients come to the emergency department with pain in the chest, or some other symptoms that make them worried about a heart problem. Maybe walking up steps and getting winded, with some aching in an arm at the same time. People worry about their hearts, and for good reason. The body doesn’t work very well if the heart doesn’t.

The answer can be straightforward. It may be quite obvious that it’s really not a heart attack but indigestion. Some acid produced by the stomach has escaped upward into the esophagus. The lining of the esophagus doesn’t have the stomach’s natural protection against that acid, and inflammation, with a burning pain, ensues. Reflux esophagitis. No, it’s not your heart. Pain from a diseased gall bladder can also mimic a heart problem. And we can often tell the difference fairly easily. Sometimes pain in the ribcage can be worrisome to the patient yet readily distinguished by the astute clinician.

It would make my job so much easier if the answer were always obvious. When it really is the heart, it can be quite clear.

Anyone who has been a paramedic, or a nurse or doctor who takes care of emergency patients for years, can often tell when first laying eyes on such a patient. Uh-oh. Some heart attack patients just have that look. And then the story, and the findings on physical examination, and the appearance of the electrocardiogram just confirm the initial impression.

Sometimes the story and the examination are not clear-cut, but the test results give us a definite answer.

‘Patients with symptoms suspected of being of cardiac origin are a constant challenge because the initial evaluation in the ED – history, examination, ECG, lab tests – still leaves us uncertain.’

Yet patients with symptoms suspected of being of cardiac origin are a constant challenge because the initial evaluation in the ED – history, examination, ECG, lab tests – still leaves us uncertain about whether this is really a heart problem. And the patient will require further evaluation.

Uncertainty is not a good thing when what we’re uncertain about could be life-threatening. People expect – and it seems to me a very reasonable expectation – a high level of diagnostic certainty when there is concern about something that could kill them.