Chest Pain

If you arrive in the emergency department with chest pain, the first thing that will be suspected is a heart attack. A heart attack is not always easy to detect because there are many causes of chest pain such as respiratory disease, gastrointestinal disease, myocardial disease and vascular disease. Evaluating people with chest pain usually includes four steps:

1. medical history, including symptoms and risk factors
2. physical exam
3. a test called an electrocardiogram (ECG)
4. blood tests called cardiac markers.

The pain of a heart attack is usually described as "crushing" chest pain and it usually lasts longer than angina. Often, the symptoms are less severe. Other warning signals of heart attack are:

1. Uncomfortable pressure, fullness, squeezing or pain in the center of the chest that lasts more than a few minutes or goes away and comes back
2. Pain that spreads to the shoulders, neck or arms
3. Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath.

The current emphasis is not so much in ruling out acute myocardial infarction, but in ruling in unstable angina currently discussed as patients with acute coronary syndromes. To do so it becomes important to perfect the category of patients with low probability of having ischemic heart disease so as not to admit such patients to the CCU inappropriately while at the same time not sending patients with potential MIs home from the hospital.

Why is this step so important ? Because it gives to the hospital the machinery necessary to sort out patients with low probability of ischemic disease with safety in sending such patients home from the hospital thereby opening the door to the community to patients with chest discomfort not perceived as painful enough to come into the Emergency Department. The paradigm shift taking place allows patients with mild chest discomfort (pressure, ache, fullness, etc.) occurring in a stuttering manner to be summoned to the hospital to rule in patients with acute coronary syndromes. The prodromal recognition of a heart attack needs to be seen as a form of prevention which is the earliest form of secondary prevention and provides more benefits than can be given to patients being treated with infarcting myocardium. The prodromal link is enhanced even more so when one realizes that this occurs in 50% of patients with heart attacks and does so over days allowing for a much wider window of opportunity to prevent the cascading process which can lead to heart damage and death to the individual.

Chest Pain Centers become very important and allow community hospitals to get to the "very heart of the heart attack problem in the community where heart attacks begin fester, erupt, occlude and fibrillate". It Is here where we truly belong in giving our best care and the chest pain strategy allows us to accomplish this.

So, what are some of the signs and symptoms of a heart attack? When should you seek help? If you experience:

• A discomfort or pain, pressure, or tightness that may be heavy, crushing, or burning in the chest area
• Discomfort in the chest that may stay in one location or extend into the jaw, shoulder, back, left arm, right arm, or both arms
• Severe, intense indigestion that does not go away after antacid or burping
• Nausea
• Cold sweat
• Shortness of breath
• Dizziness, faintness, lightheadedness
• Weakness
• Anxious feeling

For women the symptoms may be different and often vague :

• Shortness of breath
• Vague abdominal pain
• Pain between the shoulder blades
• Pain down the right arm
• Wrist pain
• Feeling of impending doom
• Discomfort at rest

SEEK HELP IMMEDIATELY! The first hour is the most critical time to prevent or interrupt a heart attack.

If you experience these warning signs of a heart attack, do not delay in getting medical attention immediately. Heart attacks can cause permanent damage or death.

What are the risk factors for heart disease ?

• Smoking/Tobacco use
• High blood pressure
• High cholesterol
• Age - over 45
• Male gender
• Family history of heart disease
• Diabetes
• Obesity
• Lack of exercise
• High stress lifestyle
• Substance abuse

Women may have additional risk factors :

• Protein in the urine
• Elevated hematocrit levels
• Enlarged heart
• Use of birth control pills, especially when combined with smoking and hypertension
• Post-menopausal