Chest pains and heart attacks

Gino Bottino, MD


Maybe one of the most frightening things that can happen on your boat is for someone to develop chest pains. If this happens, do you know what to do?

The most common causes of chest pain in the primary care population aren’t usually life-threatening, but it’s often difficult for someone without medical training to know the difference. For that reason, anyone with undiagnosed chest pain, especially if severe, should seek immediate medical attention.

Acute coronary syndrome

Patients with acute coronary syndrome have chest pain that feels like squeezing, pressure, heaviness or tightness when at rest. The pain could be new, unpredictable, or worsening (more frequent, longer in duration, or occurring with less exertion than previously). Women, diabetics and young adult patients may not have classic chest pains; instead, they may have difficult or labored breathing, weakness, nausea and vomiting, palpitations, or fainting. All patients with symptoms of acute coronary syndrome require an electrocardiogram and should be given aspirin (162 to 325 mg) and sublingual nitroglycerin tablets, if available, before being transferred to an emergency facility.

Aortic dissection

Patients with acute aortic dissection typically present with acute chest and back pain that is severe and sharp and may have a ripping or tearing quality. Pain can radiate anywhere in the chest or into the abdomen. Although rare, aortic dissection is often fatal and requires emergency surgery.

Pulmonary embolism

The most common symptoms of pulmonary embolism include difficult or labored breathing followed by sharp chest pain that worsens when breathing, cough, and symptoms of deep vein thrombosis. DVT symptoms include throbbing or cramping pain in one leg, swelling, warm skin around the painful area, red or darkened skin around the painful area, and swollen veins that are hard or sore to the touch.


Patients with spontaneous pneumothorax, or collapsed lung, present with sudden onset of difficult or labored breathing and sharp chest pain that worsens when breathing.

Esophageal rupture, perforation

Spontaneous perforation of the esophagus (Boerhaave syndrome) is caused by straining or vomiting and presents as excruciating chest pain behind the breastbone.

Cardiac tamponade

In patients with pericarditis, the development of cardiac tamponade can be life-threatening. Symptoms are sudden in onset and include chest pain, abnormally rapid breathing, and difficult or labored breathing. Jugular vein pressure is markedly elevated and may be associated with distended veins in the scalp and forehead. Heart sounds are often muted.

Sarcoidosis-related arrhythmias

Cardiac sarcoidosis can cause arrhythmias (including heart block and ventricular tachycardia) and sudden death, which may be heralded by chest pain, palpitations, fainting or dizziness.

Heart attack

Patients with severe and acute myocardial infarction (ST-elevation myocardial infarction) require rapid diagnosis and treatment to reduce the risk of death and permanent myocardial injury.

Thrombolytic therapy (the use of drugs to break up or dissolve blood clots) is greatest when administered within two hours of symptom onset. Immediate treatment helps reduce the risk of death and the extent of permanent cardiac injury associated with a heart attack. The effectiveness and survival benefit of thrombolytic treatment fall progressively the longer treatment is delayed.

Rapid diagnosis only requires the presence of symptoms suspicious for an acute cardiac syndrome, such as chest discomfort, difficult or labored breathing, and a confirmatory electrocardiogram.

Characteristic symptoms and signs include chest pain or chest discomfort, difficult or labored breathing, ventricular arrhythmias, cardiac arrest, or fainting. Atypical symptoms could include malaise, weakness, and back pain.

The time from first medical contact, whether it be in an ambulance capable of delivering the appropriate fibrinolytic therapy or a hospital emergency department, to drug administration should be less than 30 minutes.

For this reason, take swift action if anyone on board shows signs of a heart attack. Do not second-guess the situation. Call mayday and contact the U.S. Coast Guard and local police. If you are offshore, be prepared to have the victim airlifted off the boat. Offshore boaters should take a Safety at Sea class or at least watch some YouTube videos on the procedure.

If near shore, be prepared to have the authorities come alongside to transfer the victim, which can be tricky. Preparation and practice are the keys to success.

And remember, chest pain that turns out to be indigestion is nothing to be ashamed of or embarrassed about. If it isn’t indigestion, you may have just saved a life.

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