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What am I talking about?Image

I am talking about Chest Pain. 

What can cause chest pain? 

1. Stable angina: a symptom. The heart is working harder than usual. Not really a myocardial infarction. 

2. Unstable Angina: Doesn’t follow a pattern. Can occur at rest on exertion. It can be new, change in frequency, intensity, duration. It can happen at rest and is a medical emergency. 

Your EKG may initially be normal and cardiac markers can be normal. 

3. Variant angina:  is rare. A spasm in a coronary artery causes this type of angina. 

4. Non-ST Elevation MI: 

Non-ST Segment Elevation Myocardial Infarction (NSTEMI) is one of the three types of Acute Coronary Syndrome (ACS)  and like all ACS, NSTEMI should be considered a medical emergency.

NSTEMI is identical to unstable Angina except for one thing. In NSTEMI, in contrast to unstable angina, cardiac enzymes (namely Troponin 1) blood tests are abnormal, indicating that at least some actual cell damage is occurring to heart muscle cells. However, NSTEMI and unstable angina are identical. They both indicate that a plaque has ruptured in a coronary artery that the ruptured plaque and the associated blood clot are producing partial blockage of the artery, and that the heart muscle supplied by that artery is in grave danger of sustaining irreversible damage.5. ST-Elevation MI: Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia. Usually results from imbalance between blood supply and demand. The ST elevation refers to part of the ECG in which there has been irreversible damage. ECG reflect active and ongoing transmural myocardial injury. Without immediate reperfusion therapy, most persons with STEMI develop Q waves, reflecting a dead zone of myocardium that has undergone irreversible damage and death.

 

Other causes of chest  can include the following:

 

  • Pulmonary Embolism
  • Lung Infection
  • Pericarditis
  • Musclular-Skeletal pain
  • Panic Attack
  • GERD (Gastroesophageal Reflux Disease
  • Gastritis 

 

Patients with neuropathy including that as a result of Diabetes Mellitus or female may often not present with chest pain and be having cardiac chest pain. Therefore, careful evaluation of risk factors including family history, lipids, smoking, age, independent risk factors for heart disease including diabetes mellitus.  etc is important in evaluation of the patient with chest pain. 

 

It is very important that patients are honest with their physician and that physicians take excellent history. This is important in risk stratification. 

 

All patients presenting with chest pain should be treated with oxygen and aspirin, unless there are absolute contraindications. An EKG and cardiac markers must be drawn on all patients. An EKG is an objective means of determining the patients current status and can tell us about ischemia, complete occlusion, or MI of indeterminate age. Moreover, betablockers are used to reduce the work of the heart. In patients with Chest pain and a rapid heart rate, physiologically speaking there is reduced filling times in the coronary arteries during diastole. A beta blocker will slow the heart rate, allow for coronary artery filling and provide more blood flow. Beta blockers in general decrease the oxygen demand of the heart by reducing the heart rate. 

 

Moreover, chest pain should be treated with sublingual nitroglycerin. SL Nitroglycerin is administered under the tounge ever 5 minutes for a total of 3 doses. Patient should be monitored on telemetry looking for any changes in ST segments suggestive of reperfusion or further ischemia.  There are certain GI diseases which can cause chest pain and respond to SL NTG, however the treating physician should not focus primarily on the response to NTG in a GI pathology. If the patients pain continues then the event is serious.  Initially an EKG and cardiac markers can be normal in both cardiac pathology and esophageal and pulmonary pathology. Continuous monitoring is thus required and ruling out the most dangerous of conditions is warranted. 

 

Chest pain that is relentless and not responding to treatments is serious despite normal ekg and cardiac markers initially. Cardiac markers are drawn initially and then every 8 hrs typically for a total of 3 sets

 

 

Physicians often try to rule out other causes of chest pain simultaneously while treating for cardiac causes. You may have heard of the “GI Cocktail” which includes Maalox/Mylanta 30ml +viscous lidocaine 10ml +Donnatal 10ml administered orally in a single dose. This medication tends to “numb” your mouth down to the stomach and if in fact you have a GI cause of your chest pain, you may have relief. If you don’t have relief then always consider cardiac and pulmonary. 

 

What if you do not get relief  of your chest pain with all the above treatments, despite an unchanged EKG and first set of normal cardiac enzymes? 

 

Internists and cardiologists focus on risk factor stratification. There are some risk factors which are controllable, and others which we can’t control. Risk factors for cardiac disease include:

 

Risk Factors we cannot change

 

  • Male Patients
  • Age
  • Older age
  • Family History of heart disease
  • Post-menopausal
  • Race (African Americans, American Indians, and Mexican Americans are more likely to have heart disease than Caucasians)

 

Risk Factors which are controllable

 

  • Smoking
  • High LDL, or “bad” cholesterol and low HDL, or “good” cholesterol
  • Uncontrolled hypertension (high blood pressure)
  • Physical inactivity
  • Obesity (more than 20% over one’s ideal body weight)
  • Uncontrolled diabetes
  • High C-reactive protein
  • Uncontrolled stress and anger

 

You must treat this situation as an emergency and  as unstable angina. This necessitates treatment with heparin, aspirin, beta blocker, aspirin etc

 

Cardiac markers should be followed for at least 3 sets, each 8 hrs apart for a total of 24 hours and if there are EKG changes or positive troponins, these patients will require cardiac cath, echo and nuclear stress testing. 

 

As people with high levels of stress and busy schedules, we don’t like going to the emergency room, sitting and waiting. We often are in denial and tell ourself, “it is my anxiety or my GERD.” Unfortunately, I have seen just this. Patients don’t want to be hospitalized because of a planned event in the next 24-36 hours, they downplay there symptoms and are often discharged or not treated appropriately. Unfortunately, there are patients with drug dependence who present with chest pain and are written off as drug seekers. This is unfortunate as believe it or not, they too can have myocardial infarctions. 

 

It is better to be safe than sorry, no matter whether you believe it can happen to you or not you should be evaluated. Unfortunately there are patients who don’t want to be inconvenienced or inconvenience others and wish to be discharged or leave against advice. Some of these patients will go home and die of a massive myocardial infarction. Don’t let this be you. Pay attention to your health just as you would be attention to anything in life. This is your life and your loved ones want to see you!