Search for tag: "heart attack"

In medicine, we were taught that women were protected against heart attacks until they went through menopause, and then our risks caught up with men's risks. But what if we weren't really protected that well?

For many years, our research into the heart attacks has been focused on men. Even on TV and the movies, something awful happens, and a man clutches his chest and keels over. And we find if it's a police or a medical show, that he died of a heart attack. Most of us could have figured that out before the forensic pathologist told us on the TV show because we know what men's heart attacks look like.

In fact, we understood men's heart attacks and the causes, high blood pressure, smoking, eating red meat and fatty foods, and high cholesterol. Doctors really got on men's cases, and since 1960, men have decreased their smoking. And if their cholesterol or blood pressure is high, and their wives drag them into the doctor, the men were on blood pressure medications and cholesterol-lowering drugs. And meat and fatty foods, they're still Super Bowl yummies and fast food, and they're doing better.

Men's rates of heart attacks dropped dramatically. And then we noticed that postmenopausal women caught up with men in the rates of heart attacks at about 60. So we sort of got on it and started a national campaign, like the red dress for heart health, to help women understand their risks and the signs of heart attacks. But we were still thinking about women over 50, at least OB/GYNs were. And now comes a troubling study that shows that the rate of heart attacks in young people, people under 50 are increasing and are increasing more for women. This is worrisome. And it's important to look at the communities where this work was done and see what we can learn.

From 1995 to 2014, the ARIC, A-R-I-C, Community Surveillance Study gathered information on almost 29,000 heart attacks. ARIC stands for Atherosclerosis Risk in Communities. And atherosclerosis is the clogging up of the arteries in the heart that can lead to heart attacks.

The communities that were involved in this study were in four geographic areas in the U.S. -- counties in North Carolina, Maryland, Mississippi, and suburbs of Minneapolis. Some of these counties have Americans at risk for heart attacks based on increased rates of diabetes, smoking, hypertension, obesity, and poverty in African American race. Of those 29,000 heart attacks, over the 20 years, one-third in what they called young people, people 35 to 54. Over those 20 years, the annual rate of young men's heart attacks went down some. But women's rates went up to the point that young women, pre-menopausal women had the same rate of heart attacks as young men. These data are alarming, and they mirror similar data from Canada, suggesting that the incidence of heart attacks in young women is rising.

Well, what are some of the risk factors for these young women? Smoking, high blood pressure, and diabetes very substantially increase the risk in women. And black women had very significantly more heart attacks than white women. Seventy-five percent of the young women with heart attacks had high blood pressure, 36 percent had diabetes. And women who had heart attacks were more likely to have multiple risk factors than men.

Young women who had heart attacks were less likely than young men who had heart attacks to have their cholesterol treated or their blood pressure treated. Young men and young women who had heart attacks had a 10% chance of dying the following year. Young women have some extra risk factors for heart attacks compared to men. They're more likely to have demonstrated risk for diabetes by being diabetic in pregnancy. They're more likely to demonstrate risk of hypertension and vascular disease by having preeclampsia when they were pregnant. And they are more likely to suffer the psychosocial stressors of poverty than men.

This information hurts my heart. These young women were mothers of young children and teens. They were at the most productive times of their lives, and they were also at the most stressful times of their lives. So what do we do with this information as women and as physicians? The risk factors in this study are ones that we all know about, risk for heart health, such as smoking, diabetes, and hypertension. But diabetes and hypertension often don't have physical symptoms.

Unless women are getting regular checkups, getting their blood pressure measured, their cholesterol measured, and their blood sugar checked, they may not know. Women used to go to their OB/GYN or their family doctor, get a Pap smear every year, but now they don't. Many women who used to go regularly for their checkups when they were having babies, don't go anymore. All clinic visits, for one reason or another, will have a blood pressure check, but cholesterol or diabetes checks aren't done so often in young women.

Of course, the big risk of smoking cigarettes in an unbelievable 48 percent of the young women who had heart attacks were cigarette smokers, would be addressed by the clinician, if women admitted to it. See our podcast on lying to your doctor.

So all women and men need access to health care. All the women and men need regular checkups at this very busy time of their lives, 35 to 54. All women and men need to have their blood pressure, high sugar, and high cholesterol managed according to national guidelines. And women need to take their medication.

How we manage the stressors of poverty, the stresses of being a minority are issues that we all need to address as a community and as a state and as a national level. So, ladies, please take care of your heart. And thanks for joining us on "The Seven Domains of Women's Health" on The Scope.

updated: September 5, 2019

originally published: February 7, 2014

Interviewer: You have chest pain, but you don't think it's probably a heart issue, what could that be? Well, we're going to examine that next on The Scope.

Announcer: This is "From the Frontlines with Emergency Room Physician Dr. Troy Madsen" on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health, and Dr. Madsen, sometimes I get this thing on my left side of my chest. I don't think it ever happens on the right, but it feels like there's a lot of pressure in there. It feels like a bubble, like an air bubble maybe. It's difficult for me to take a deep breath. And it'll either just go away, or if I can take a deep enough breath, it feels like it pops. What could that possibly be? I hope I haven't been having heart attacks this whole time.

Dr. Madsen: I hope you haven't. This is a very common question I get in the ER, and I may see over the course of the shift maybe even a couple of people, like yourself, who have this exact same question. So in my mind, of course, I'm thinking, "Okay. I've got to make sure it's nothing serious." So I would ask you about, do you have any risk factors for heart disease, any risk factors for blood clots in your lungs? So those are number one and two I'm thinking about. Have you had any recent surgery or anytime you just haven't been moving a lot where you could have formed a clot that went to your lungs?

But what you're describing doesn't sound much like either of those things. I might do some basic tests to make sure things are okay there. But once we rule out the more serious things, and I start to think about other things that often cause chest pain. And probably one of the most common things is acid reflux. People get acid reflux, acid that's working it's way up from the stomach through the esophagus into that food tube that runs down your chest, and that can oftentimes cause a feeling like maybe a bubble in your chest. Most people describe it as a burning sensation there, maybe a bitter taste in the back of their mouth.

Another thing we see often is something called costochondritis. And that's an inflammation in the cartilage where the ribs come and they meet the sternum. So the breast bone there, where they come together there, that that can get inflamed either from sometimes a viral infection, or just from maybe overuse, or maybe even you've been twisting wrong, and that causes some inflammation that can cause some pain.

Sometimes, you can get what we call pleuritis, where you get inflammation along the lining of the lungs. And that can cause, again, some chest pain in there that sometimes worse when you take a deep breath. But with your symptoms, if I had to say it's anything, I would lean more toward maybe some reflux, that feeling like a bubble in there.

Interviewer: I was thinking that's about as close, but it's not in the center. It's always off to the side, like up in this area. And it tends to be pretty consistent to where it will develop when it develops.

Dr. Madsen: Yeah interesting.

Interviewer: And it freaks my wife out a little bit when I'm like, "Oh, oh." And I try to take that deep breath and I can't, because there's that catch or something there.

Dr. Madsen: And sometimes you can, in your back, you can have some muscle spasm. You've got muscles between your ribs. Sometimes you could get maybe some muscles spasm or some inflammation between the ribs. That could cause, possibly, something that comes and goes like that, especially where it's worse when you take a deep breath. The reality with chest pain is, I tell patients, "Hey, once we've ruled out the bad stuff, it could be any of a number of things. It could be reflux. It could be the costochondritis. It could be some muscle thing, some inflammation there.

There's not a lot I'm going to do differently for these things. Maybe try some acid medications, some stomach medication for the reflux. Try some ibuprofen for some of these other things. And so I wouldn't worry about it. I don't want to tell you that now, I know you are going to have a heart attack just [Inaudible 00:03:36]

Interviewer: Well, I was going to say, this could point probably at this point two things. One, I'm going to pay attention next time and see maybe if I feel that it is acid reflux. Because sometimes just realizing what it could be makes you visualize it differently.

Dr. Madsen: Exactly.

Interviewer: Maybe that is indeed what it is. And then the second thing that I want to do right now is the importance of if you do feel like you are having a heart attack that you should go to the ER. And are there some very specific symptoms of that?

Dr. Madsen: Absolutely, yeah, and that becomes the challenging thing because the reality is if I were to see you in the ER, I'd probably at least do a couple tests. I'd probably do a chest X-ray just to look at your lungs, look at your heart size, make sure everything is normal there. I would do an EKG, just a basic test on your heart, to make sure the electrical activity looks normal, make sure I'm not seeing anything unusual there.

But the biggest things with heart attacks are people describe it as a crushing chest pain, like someone sitting on their chest. They say when they go upstairs or they try to walk, the chest pain is much worse, or they get short of breath. And they feel pain up their neck or down their arm. They feel sweaty, nausea, but it's challenging, because certain groups of patients like women, people with diabetes, sometimes older patients have really unusual symptoms. Some of them may just have some abdominal pain or just shortness of breath.

So it is a little bit of a challenge. If you have risk factors for heart disease, like high blood pressure, or high cholesterol, smoking, family history, these are all things where even just some kind of unusual chest pain like you're describing might be a reason to, if nothing else, at least see your doctor and get things checked out there.

Interviewer: Especially if it doesn't go away right away?

Dr. Madsen: Absolutely, yeah.

Interviewer: What about the pulse? Does the pulse increase if you are having a heart attack, or could the pulse stay at a resting heart rate?

Dr. Madsen: I've seen both. I've seen people come in with heart attacks who do have a high heart rate. I've certainly seen other people who come in and say, "Yeah, I'm having this crushing chest pain." But you look at their heart rate and it's normal.

Interviewer: So just it doesn't really manifest itself in any one way for any certain person, it sounds like? It's very unique. At least it could be.

Dr. Madsen: Yeah, and some people with heart attacks are on medication that slows their heart down so that affects it too when I see those patients.

Interviewer: So when in doubt, go see somebody.

Dr. Madsen: Yeah, chest pain is one of those things . . . it's tough. You want to take it seriously. Ninety-five percent of the time, people we see with chest pain, all the testing is normal, at least 90 percent of the time it is. But that 10 percent or 5 percent, you don't want to mess around with those things.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: June 12, 2018
originally published: May 27, 2016

Interviewer: Heart attack patients are not all the same and that's important to know. We'll talk about that next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking to Dr. Rashmee Shah, Assistant Professor of Cardiovascular Medicine at the University of Utah. What did you find?

Dr. Shah: We looked at heart attack patients who had a specific complication called cardiogenic shock. Cardiogenic shock occurs in patients who have very big heart attacks, and the heart muscle becomes so weak that it can't pump blood to the rest of the body. These are the sickest of the heart attack patients. In the last decade, we've gotten a lot better at treating heart attacks using stents, interventions and stents, to open the blocked arteries.

A lot of these patients are now surviving the hospitalization. That means they get hospitalized, get treated for their heart attack and then make it out of the hospital. Since that's happening more frequently, we need to know what happens to these patients after they leave the hospital. Are they going home and resuming their usual life? Or are they disabled and still sick like they were when they were in the hospital?

Interviewer: What did you find amongst these patients? How are they doing when they leave the hospital?

Dr. Shah: In a publication that preceded this one, we found that two-thirds of patients like this will survive the hospitalization and get discharged. We took it up from there. So among these patients who survived the hospitalization, we found that, surprisingly, within a year over half . . . almost 60% of these patients will either die or be rehospitalized.

Interviewer: Oh gosh.

Dr. Shah: Yeah, so not great. The interesting finding was that this risk is really clustered in the immediate, post-hospital period. So within the first 60 days after discharge, this is when these cardiogenic shock patients are the most vulnerable to have an adverse outcome, meaning death or hospitalization.

One interesting finding was that actually all heart attack patients, over 50% die or were rehospitalized within a year. That's all heart attack patients. That was a bit surprising and I think we'll have to delve a little deeper to see what could be driving that and what we can do about it.

Interviewer: That's not common knowledge yet, right, until this paper?

Dr. Shah: Correct.

Interviewer: Do you have any ideas of what's happening within this 60-day period that might put these patients at risk for dying?

Dr. Shah: Yeah. So there are some theories out there about the post-hospital, discharge period. One interesting idea is there's so-called post-hospital syndrome, especially among critically ill patients. Patients with cardiogenic shock are often in intensive care units, they're very sick. What happens is they become debilitated because they don't have adequate nutrition during that period, they're lying in bed, their days and nights gets reversed.

Everything about their daily life has changed and they become really weak. Critically ill patients, not just limited to cardiogenic shock patients, when they get home or when they get discharged to wherever they go, they're still very debilitated. This post-hospital syndrome is one possibility and efforts related to rehabilitation, physical therapy, occupational therapy could address that issue.

The other issue is that cardiogenic shock is a condition in which there's not enough blood getting to other organs of the body so they might have renal failure. They might have had less blood going to their brain, some kind of neurological effect. All those things coming together make patients very debilitated so it could also be a multi-organ issue.

Interviewer: Among patients who have heart attacks, what percentage is represented by this population?

Dr. Shah: The dataset we used is called the Action Registry and it's from the American College of Cardiology. This is the largest registry of heart attack patients in the US. In this population, 5% of heart attack patients will have cardiogenic shock.

Interviewer: You would think that if they have those serious problems, that they would be under a close watch once they're discharged. Do we know if that's happening?

Dr. Shah: Yeah. There are guidelines that encourage one-week follow-up for patients after a heart attack. That happens fairly consistently and it's something we work on aggressively here at the University of Utah. Often, the patients . . . there are standard therapies following heart attacks and these patients might not be able to get some of those therapies because, for example, their kidneys aren't working as well so they can't have the drug that can sort of protect the heart. They could have a follow-up, but that doesn't necessarily mean they eligible or able to get those evidence-based therapies to help the heart heal.

Interviewer: What are the next steps? What do you think this information is telling you about what can be done or what should be done?

Dr. Shah: I think there are many things we can do from here. A couple of things I'm interested in are focusing on the so-called patient recorded outcomes. We measure these very quantitative metrics, "Did the patient die? Did they get hospitalized?" But there's much more to patient wellbeing than just that. We want to know, "Are they able to function? Do they feel like they're short of breath every day?" those sorts of symptoms.

We can only get that by asking the patients and asking every patient, every time. Especially in this population, it'll be interesting to know what their daily life is like because it could be very different than what these somewhat simple metrics imply. I think that's a really important part there for subsequent research.

The other issue I think is important is, "Can we find a way that, while these patients are in the hospital, that we could proactively identify them before they leave the hospital?" That's really useful information for planning subsequent treatments or helping the patients and families understand what to expect when they leave the hospital.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: The Super Bowl and heart attacks: is there really a risk? We are going to find out from cardiologist Dr. John Ryan, next on The Scope.

Dr. Ryan, I've seen news stories, I'm sure our listeners have seen news stories, I even did a Google search because the thought of somebody having a heart attack during the Super Bowl seems kind of crazy to me. Really, does this happen? Is it a common thing or a rare thing? But there's some research out there that says that it really is possible. Is that true?

Dr. Ryan: Yeah, so it is a recognized risk, namely that's the Super Bowl and this has been shown in several studies the time of the Super Bowl is a high-risk time for heart attacks or a higher risk time for heart attacks. It's also been shown in the World Cup, in the soccer World Cup, there has also been shown that there is a higher risk of heart attacks around this time. It seems, in particular, in cities hosting the Super Bowl and in the cities whose teams are playing in the Super Bowl it seems to be higher. So when there's an investment in the game, it does seem to be higher as opposed to other cities that either aren't hosting or don't actually actively have a team in the Super Bowl. And this is, again, the same with the World Cup.

However, when you look at the people who have heart attacks during the Super Bowl, they're already at higher risk of having heart attacks. So they are typically folks who have high blood pressure, maybe a history of heart disease, a history of smoking, a history of high cholesterol, and then the stress and circumstances surrounding the Super Bowl event can be a trigger towards that cardiac event.

Interviewer: So if you've been told by your doctor that you are at a high risk of a heart attack and your lifestyle kind of reflects that, would it be the equivalent of going out and trying to run a marathon?

Dr. Ryan: Yeah. That's a good analogy, yeah, that's a good analogy.

Interviewer: Because I don't think that people watching the Super Bowl and having some wings and beer would be like running a long-distance race.

Dr. Ryan: Yeah, that's a good analogy. Again, it's all about you're introducing more stress onto your cardiovascular system and into your life and what are the consequences of that stress. One of those consequences of that stress is an increased risk of having a heart attack. So, a lot of times, it's just about stress management and how you deal with stress as well as you've rightly pointed out, it's risk factor modification.

When you look at heart disease in general, it's all about risk factor modification, eating better, not smoking, not drinking as much alcohol, and not getting dehydrated. And these are all things that happen in or around the time of Super Bowl or college game day or workups. When folks bring this up, I talk about my father, during Ireland rugby games, will sit outside in the garden and then when the game is over, he will come in and ask what the result of the game was. And that's his way of modifying his risk. So it's a matter of modifying your risk. Thanks, Dad.

Interviewer: And, as a result, he's been there for you all these years.

Dr. Ryan: Exactly. Exactly.

Interviewer: So if you're worried that you're going to have a heart attack leading into the Super Bowl, you probably need to take a bigger look at . . .

Dr. Ryan: Figure out your coping mechanisms, figure out your stress, what you do for stress and what you're doing for your risk factor modification with your heart disease.

updated: February 9, 2022
originally published: February 3, 2016

Interviewer: How e-cigarettes affect your heart and it's not in a good way, and it might not be better than smoking after all. We're going to find out more about that next with cardiologist, Dr. John Ryan on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Before we get into the conversation about e-cigarettes and how they affect your heart health, I think it's important that we say that cigarettes and e-cigarettes are linked to many different health problems. But today, we're just focusing on one particular and that's issues related to the heart. So, Dr. Ryan, how do e-cigarettes affect a person's heart health and are the threats real?

Dr. Ryan: I think the threats are real. I think the concerns are legitimate. One particular concern with e-cigarettes is that it's really re-normalizing cigarette smoking, nicotine consumption, and tobacco use within North America. Some of it, the science is uncertain. We are not sure of the long-term effects of e-cigarettes, either on heart or lung disease. And then legitimate concerns get raised because of this chronic exposure to nicotine, chronic and also varying exposure to nicotine. One of the particular issues there seems to be marked variation in how much nicotine is being consumed with each vape.

Interviewer: Because when you get the little vapor things, it tells you how many milligrams per whatever, but that's not regulated so we don't know if that's accurate or not.

Dr. Ryan: Exactly. And the anticipated is .05 is what's often quoted. It can really range up to 15 whereas where your cigarettes would be about two to three. So in that regard, there's variation there that's concerning. Also, some of the physiologic effects that e-cigarettes and nicotine consumption, in general, are concerning, in particular, high blood pressure, fast heart rate, endothelial dysfunction, which is the lining of the blood vessels of the heart, in particular, which can be a trigger for atherosclerosis and coronary artery disease.

And all of these things are affected by the nicotine consumption and, in particular, by the e-cigarette nicotine consumption as well as other chemicals that are in the e-cigarettes. And as you rightly pointed out, the regulation of this is difficult and not as robust as many physicians and scientists would like. And that just raises further concerns.

Interviewer: So you mentioned a lot of different bad things that can happen from e-cigarettes, and it's related to nicotine primarily, the raising your heart rate, the blood pressure, your blood vessels narrowing, high risk of hardening of the arteries. What does that do, then, that causes heart failure or heart attack or stroke?

Dr. Ryan: So a lot of it we don't know, first of all. That specifically raises concerns, but the issues, in particular, that are raised with high blood pressure, with fast heart rates, with narrowing of the blood vessels of the heart, the coronary arteries, as you mentioned, this puts extra strain on the heart. The heart obviously depends on blood flow in order to get oxygen, and in the setting of high blood pressure, fast heart rate, decreased vessel size, you do raise the risk of having a heart attack.

So the essential concern, in particular, is for heart attacks, that the use of nicotine, e-cigarettes, and cigarettes raises your risk of having a heart attack. And also, it's not necessary, and that's where I got back to the normalization of tobacco consumption and nicotine consumption within North America. This is not a necessary thing that we need to do. This distinguishes it from . . . and there's controversy of this as well, but diet consumption, fat consumption, etc. However, we do need to eat. We don't need to smoke and we don't need to vape.

Interviewer: So for sure, we know nicotine causes these negative effects to the heart.

Dr. Ryan: Exactly.

Interviewer: What about the other chemicals, like . . . I've heard the flavoring chemicals. Even if you're getting the dose without the nicotine, they've found that it can cause other diseases.

Dr. Ryan: Yeah, so the flavoring has recently been associated with what's called popcorn lung or bronchiolitis obliterans, which is a form of inflammatory and fibrotic lung disease. The reason this raises concerns is, first of all, lung disease, therefore, puts a strain on your heart. And secondly, if there's chronic inflammation, which we see in the setting of poor air quality and stress, it can result in triggering heart attacks or heart disease. So I think there are two main concerns with the chemicals that you bring up in terms of e-cigarettes.

Interviewer: If you've got a patient that's right in front of you now that smoked e-cigarettes, how would you convince them that they shouldn't? Because a lot of people get enjoyment out of it, or it's an addictive habit that they can't stop. It takes a lot of willpower to quit.

Dr. Ryan: Being sensitive enough in terms of convincing people to do things. Ultimately, I think you have to introduce the risks associated with the disease, the risks associated with the risk factors, and hope that they make an informed, educated decision about their habits. And so I try and present to them the uncertainty about e-cigarettes. I try to present them with some of the concerns that I have about e-cigarettes and nicotine consumption in general. And then, hopefully, when they leave the clinic and when they go home, they're able to access resources themselves and make good decisions themselves and be comfortable with the decisions they're making.

Interviewer: And I think, essentially, it comes down to this is something that you don't have to do to your heart.

Dr. Ryan: Exactly, yeah. You don't have to do it to your heart. You don't have to do it to your lungs.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: January 8, 2019
originally published: January 26, 2016

Interviewer: Is it bad enough to go to the Emergency room, or isn't it? Find out now. This is E.R. or Not on The Scope. Time for another edition of E.R. or Not with Dr. Troy Madsen. This is an interesting one: I'm having pains in my chest. E.R. or not?

Dr. Madsen: And that is always a tough question because chest pain is one of the most common things we see in the E.R., and 95% of the time or more, all the testing we do is negative. But it's very concerning because there's that 5% of the time where it's a heart attack, where it's something really serious and it's something you need to come to the E.R. for.
Risk Factors for Heart Disease

Dr. Madsen: So the big thing I base this on is what are your risk factors for heart disease? Because when we think chest pain we think of the heart. If you're someone who is older, let's say over the age of 55, if you're a smoker, you've got high blood pressure, high cholesterol, diabetes, all these things that increase your risk, absolutely you need to come to the E.R. If you're someone who is 25 years old, who was maybe out running, maybe got a little bit tight, maybe coughing a little bit, there, I'm not so concerned. Maybe it was a little bit of asthma, something like that that just caused some tightness in the chest.

So the big thing in my mind is, what kind of risk factors do you have for heart disease, is it a crushing pain that goes up to your neck? Is it causing you to sweat? Does it go down your arm, you feel nauseated, and all these other things that are signs of a heart attack? All good reasons to come to the E.R.

Interviewer: I've had instances where I feel like there's a gas bubble in my chest and it's hard to breathe in deeply.

Dr. Madsen: Yes.

Interviewer: And eventually if you do breathe in deep enough it kind of pops and goes away.

Dr. Madsen: Yeah.

Interviewer: What's that?

Dr. Madsen: It's probably something that's worked it's way up into your esophagus, maybe a little gas bubble up in there that you're feeling over in your chest. Sometimes a lot of causes of chest pain are maybe not causing symptoms exactly like you had, but maybe some kind of a viral illness that can cause some inflammation along the ribs, or along the lining of the lungs. All those can cause these sort of things that cause chest pain. And they're not really that serious.

Interviewer: Is chest pain for a heart attack on the left side, or can it be on the right side?

Dr. Madsen: It's tough. Sometimes, even in older women, it can be abdominal pain. They can have signs of a heart attack where they're actually having pain down in their abdomen and you're thinking, "Oh, maybe they've just got a little bit of food poisoning or a virus." So it's really tough. So that's why it's usually the left side and it's usually going to cause pain to go up and down your neck and your arm and make you sweat. That's a classic heart attack, but I've seen lots of cases of heart attacks that aren't classic, so that's why in my mind, I think a lot in terms of what are their risks for heart disease, and if they have a lot of risks, I'm going to do more testing on those patients.

Interviewer: And come into the E.R.

Dr. Madsen: Yeah, absolutely.

Announcer: We're your daily dose of science, conversation and medicine. This is The Scope, University of Utah health sciences radio.