For a great many people, one of the biggest obstacles to getting critical, life-saving medical attention for chest pain is a four letter word: F-E-A-R. What are they so afraid of that they risk serious damage to their heart or even death? One of the reasons people experiencing chest pain delay getting help is that they just don’t believe it could actually be a heart attack. “I’m too young to have a heart attack,” they reassure themselves, or think, “…the pain will go away if I just ignore it.”
Unfortunately, neither of these reasons hold water. The leading cause of death in people age 30-50 is heart attack. Surprised? So were their loved ones. The pain might go away, but that doesn’t mean you aren’t having — or didn’t have — a heart attack. When it comes to chest pain, lost time means the death of critical heart cells. The longer you wait, the more irreversible damage your heart could sustain.
In today’s world, chest pain is not all that uncommon, and it can have a variety of sources. It can be caused by stress, by indigestion (gastroesophageal reflux disease), by over-exertion, or by upper-respiratory problems.
The pain can be intermittent, mild or acute; it can be sharp or dull; or it can come up suddenly or gradually. Chest pain can radiate to the arms, neck or back, and it can cover both the right and left sides. And, no matter how easy it looks to diagnose on TV, chest pain is a difficult symptom to assess, and it is always a symptom that should be evaluated as soon as possible.
According to Juan R. Amell, M.D., “Chest pain can signal any number of medical conditions, and certainly not all of them are serious or life-threatening. We know people with chest pain worry that if they go to the hospital, their fears will be confirmed and they will have to be admitted. Others are afraid they will be embarrassed if nothing is wrong with them. When it comes to having a professional evaluation of chest pain, sometimes just knowing the cause of the pain will help make it go away, especially when stress, anxiety or other emotional factors are at the heart of the problem,” the doctor said. “We know a lot more about how the heart works these days, and just about everyone knows we can actually stop a heart attack in progress. Even with all this knowledge, however, we still have trouble getting people to do what’s necessary to save their own lives. There are still far too many people dying of embarrassment.”
Each year, more than 300,000 Americans die before they can reach medical assistance because they denied they could possibly be having a heart attack. Or perhaps they just didn’t recognize the symptoms or ignored the pain.
“The main reason we established the Chest Pain Center here at Red Oak Cardiovascular Center,” said Gustavo Grieco, M.D., “is to provide some important services for people experiencing chest pain of unknown origin. Since time is the enemy in any potential heart problem, we provide quick, simple access with immediate medical attention. Second, we do a thorough professional assessment of the chest pain sufferer’s condition through the appropriate diagnostic lab work and testing. Then, as soon as the results are available, we update our assessment and determine if the chest pain is the result of a cardiac event — in which case the patient is immediately transported to the hospital — or if the patient may safely go home without incurring unnecessary expenses resulting from a hospital stay.”
The cardiologists at Red Oak point out that the Center has the cardiovascular diagnostic capabilities, sophisticated equipment, and qualified personnel of an emergency center, including a CLIA certified laboratory, on site outpatient cardiac catheterization, and nuclear imaging equipment. Test results and the patient’s information will be provided to his or her primary care physician without delay.
“The important thing is that we are able to do what is necessary in the way of medical diagnostic testing and intervention in a patient-friendly environment,” Metram J. Rao, M.D. explained, “where their concerns are addressed promptly and the chest pain sufferer along with his or her family members are involved in the process and kept informed along the way. When we have the results, the decision is made about appropriate treatment and hospitalization, if that is warranted.”
Studying The Numbers…
Under managed care, the growing pressure to keep a lid on healthcare costs, without compromising the quality of patient care has prompted research into the best methods for accomplishing this objective. Studies have confirmed that the systematic and organized approach of Chest Pain Centers improves the quality of care — as measured by time to treatment and physician diagnostic accuracy — and reduces the cost of care and length of stay.
“Getting people home if they don’t need to be in the hospital is the primary goal of chest pain centers,” said another of the Center’s cardiologists, Amilcar Avendaño, M.D. “This result satisfies the patient and the insurer since avoiding unnecessary hospitalization can save thousands of dollars, and the critical care facilities can be reserved for people who really need them.”
Traditionally, the cost of evaluating chest pain in emergency environments has been high — in terms of dollars and human lives. Consider, for example that next year the total number of emergency room visits in the U.S. is expected to top 100 million. About 5 million of these trips to the ER will be made by people with acute chest pain. An estimated 6 to 10 thousand Americans die each year after inadvertently being sent home from the emergency room when they are actually having a heart attack, so there has been very real concern about the safety of short term observation. About 50 percent of the people who go to the ER with chest pain are in the “gray zone” — according to the Association for Health Care Policy and Research (AHCPR) guidelines for assessing risk for fatal heart disease.
To address this concern, Mayo Foundation and Aetna Health Plans collaborated on a study at the Mayo Clinic to evaluate people with unstable angina, a form of chest pain due to coronary artery disease. The participants were considered at intermediate risk for a heart attack, congestive heart failure or other cardiac event based on their age, medical history and risk factors. The research team found that nearly half of the intermediate risk group could safely be sent home after 9 hours of observation in the Chest Pain Unit.
The study, reported in the New England Journal of Medicine, found that no significant heart problems occurred in the patients discharged early from the Chest Pain Unit. This confirms what most physicians now believe: that cardiologists can now reliably identify which patients can be sent home safely after prompt, appropriate diagnostic testing and evaluation, and which can not. The results of the study were so compelling that a Chest Pain Unit was established at the Mayo Clinic within a month of the study’s completion.
The First Hour Can Be a Killer…
So, if there have been so many dramatic advances in saving lives and stopping heart attacks in action, why is it necessary to get medical attention in such a hurry? Statistics tell a grim tale: about half the people who have heart attacks wait about two hours or longer before seeking medical treatment.
Of those that survive the delay, most have already experienced permanent damage to their heart muscle caused when the supply of oxygen rich blood is reduced. A heart attack can evolve over a four to six hour process and, with every passing minute, the potential for irreversible damage increases.
Another very real threat after the first initial minutes of a heart attack is ventricular fibrillation — an unstable and ineffective heart rhythm that sends an inadequate flow of blood to vital organs and can lead to sudden death.
Two potentially life-saving treatments are most effective during the initial stage of a heart attack: the “clot busters” (tissue plasminogen activator or tPA and streptokinase) which dissolve the clot to restore blood flow, and emergency angioplasty — an invasive procedure that widens blocked arteries.
According to the American Heart Association, during any given year about 1.5 million people in this country suffer heart attacks, and there are an additional 2.5 million Americans who have angina. Angina may be one of the most common causes of chest pain, but other contributors — in addition to emotional factors — can be hot drinks and spicy foods, ulcers, and even just over-doing it. One of the most “telling” things about chest pain can be an accurate description of how it feels.
The chest pain of angina, caused by decreased oxygen flow to the heart muscle, is usually described as a tightness in the chest, arms, neck, jaw or back. It usually strikes suddenly or as the result of physical exertion, emotional upset or other factors that cause the heart to work harder. An anginal attack usually lasts less than five minutes and the discomfort can frequently be relieved by rest and medication.
Cardiac arrhythmias, while generally not painful, can cause some mild discomfort, as well. Unlike the tightness or crushing pain experienced in a heart attack, abnormalities in heart rhythm can create an uneasy feeling when the heart seems to “skip a beat.”
People with premature ventricular contractions might experience a “thump” in the chest that can cause alarm. Others feel lightheaded as their heart races and seems to pound in their chest. Arrhythmias can be triggered by stress, caffeine, alcohol, nicotine, and very low calorie diets. Whatever the cause, with or without accompanying chest pain, these disturbances should also be checked out without delay.
“What a difference it would make if everyone knew the early warning symptoms of heart attack and sought professional help at the first sign of a problem,” Dr. Amell commented. “Since this is not a realistic scenario, we believe it is important to offer people a prompt, accessible, affordable, convenient, and patient-friendly way to find out the cause of their chest discomfort, to learn at once if the problem is heart-related, and where we can make sure they get the very best emergency care without delay.”
On the other hand, the cardiologists agreed, if the problem is NOT a heart attack, the rest of the evaluation can be completed in a reasonably short period of time, they can be given an accurate diagnosis, treatment can be recommended, and they can be on their way — without incurring unnecessary expense or endangering their health.
“The important thing, “ Dr. Amell stressed, “is that our Chest Pain Center will be here to help those people who might not otherwise get professional assistance.”