Chest pain that feels like pressure or tightness can be an indicator of serious and life threatening heart disease and should be evaluated promptly ideally in an emergency department.
It is critical to visit a hospital that has a system in place for management of chest pain of suspected cardiac sources. This is a set of steps, based on the current scientific evidence, which guide the patient, family, health care professionals and other hospital staff involved in the patients’ care on efficient management of patients with chest pain.
Utilisation of these care pathways consisting of timely provision of life saving therapies has seen deaths from acute heart attacks drop from as high as 30% in the 1990s to as low as 6% in the modern era.
What should I do if I develop chest pain/discomfort?
Chest pain, especially if it develops suddenly and is associated with a cold sweat is highly suspicious of a heart attack and needs urgent evaluation. The recommended course of action is to present to a hospital which is capable of diagnosing and treating acute heart condition emergencies.
You should go to the emergency department (casualty) and inform the medical staff immediately that you are experiencing chest pain /discomfort. Ideally patients should come to the hospital in an ambulance.
What should I expect when I present to the hospital emergency department with chest pain?
The nurse and doctor who will attend to you will measure your blood pressure, pulse, oxygen saturation and temperature, you will be asked a few questions about your chest pain, perform a physical examination and an electrocardiogram (ECG) – a recording of the electrical activity of the heart. All this should be done within 10 minutes of your arrival.
The ECG forms the basis of early decision making and helps the doctor decide whether you are having an acute heart attack (ST elevation myocardial infarction, STEMI) – which is a type of heart attack resulting from sudden blockage of the artery that supplies heart muscles.
An acute heart attack (STEMI) requires prompt treatment to re-establish blood flow in the blocked artery. Other tests you can expect to be done while in the emergency department include blood tests that check for heart enzymes, blood counts, electrolytes, a chest X Ray or CT scan of the chest and an echocardiogram (ultrasound of the heart). If the ECG is normal, then a blood test called troponin will be performed and the report should be available within an hour or two.
What is a heart attack?
A heart attack occurs when cholesterol deposits in the arteries cause a blood clot to form, causing either partial or complete blockage in the artery. This blockage slows or blocks blood flow to the area of heart muscle supplied by that artery. If prolonged, the muscle can become damaged or die.
What symptoms accompany a heart attack?
A heart attack will present with symptoms like chest pain/discomfort which typically occurs on the left side of the chest, but can be anywhere between the neck and the umbilicus. It is often described as a squeezing pain or heaviness.
Pain may sometimes be felt in either arm, the jaw, teeth, neck, upper abdomen or back. With a heart attack you are also likely to have difficulty breathing, nausea or vomiting, sweating, dizziness or loss of consciousness/collapse. Rarely, some people collapse (cardiac arrest), usually because of an electrical heart rhythm problem, causing the heart to stop beating.
This is often fatal if it occurs outside of hospital as it requires immediate performance of cardiopulmonary resuscitation (CPR) and special electric shock (defibrillation) to treat. Sometimes the chest pains may wax and wane and this may cause patients to ignore them only to worsen dramatically for example in the night.
How is a heart attack diagnosed?
There are two main types of heart attacks – an ST elevation myocardial infarction (STEMI) and a non ST elevation myocardial infarction (NSTE-ACS). STEMI occurs due to complete blockage of an artery and time is of essence in opening up the blocked artery to prevent death and complications.
The diagnosis of STEMI is made by performing a test on electrical activity of the heart (ECG) within 10 minutes of patient arrival. Blood will be taken for heart enzymes but the doctor will not wait for the results to initiate treatment.
An NSTE-ACS occurs due to partial blockage of an artery. The blockage is however severe enough to cause some muscle damage. An ECG may have some abnormalities, however usually the diagnosis is made on finding elevated heart enzyme levels called troponin. The turnaround time for the test from the lab is approximately one hour.
What is the treatment for a heart attack?
For complete blockage (STEMI), the blocked artery should be opened up as soon as possible. Two options are available:
Primary Percutaneous Intervention (Primary PCI) – This procedure is performed in the cardiac catheterization laboratory (cathlab), which is a special x-ray suite. An interventional cardiologist passes a thin catheter through the wrist or groin into the heart and a special dye (contrast) is injected into the heart arteries (coronary arteries) – this is called a coronary angiogram and can help to visualize blockages in the arteries on the x-ray.
Once the problem is identified, a thin balloon is passed into the blockage and expanded allowing the artery to open. A metal scaffold (stent) is then placed inside the artery to keep it open. This procedure re-establishes blood flow to the heart muscle. This is the gold standard treatment for heart attacks and if done early provides the best results.
The second treatment is a clot busting/dissolving drugs or thrombolytic – These are medications that are injected into a vein and work by circulating in the bloodstream and dissolving the clot in the heart. This treatment works most efficiently when given within 3 hours of developing chest pain. While thrombolysis is a very effective treatment, it may fail to reopen the artery thus necessitating the patient to be taken for angioplasty anyway – rescue PCI.
The risk of bleeding is relatively high with thrombolysis, since it circulates in the whole body. Bleeding in the brain is the most serious consequence and the doctor will go through a checklist for thrombolysis before administering the drug. Patients who are at high risk of bleeding may not be candidates for thrombolysis.
When can I resume physical activity after a heart attack?
Survivors of heart attacks are commonly anxious about subsequent physical activity, exercise and indeed getting back to work. In view of this all our patients undergo cardiac rehabilitation which is a set of activities that helps recover their physical health.
It also helps patients who are not physically active get more confidence to start an active lifestyle. Cardiac rehabilitation is a set of graduated physical activities given by the physiotherapies over a duration of six weeks. It monitors heart, blood pressure, workload of the heart in watts. Most people can get back to work in a month after developing a heart attack.
What about sexual activity?
Most people have anxiety about returning to sexual intimacy after a heart attack. It is good to discuss with your cardiologist when it is safe to resume sexual activity. For most people, this may be possible once they can tolerate a moderate amount or physical exertion. Generally, this is after at least two to four weeks of having a heart attack.
Some of the medications prescribed for your heart may interfere with your sex drive or ability to maintain an erection and achieve an orgasm. If you feel this may be the case, please bring it up with your cardiologist to see if there are alternative medications. You should not stop any of these medications on your own accord.
Medications which contain nitrates (e.g. nitroglycerine tablets, patches and sublingual sprays) may cause dangerous drops in blood pressure if taken together with medicines that treat erectile dysfunction such as sildenafil (Viagra) and tadalafil (Cialis). You should always discuss with your cardiologist before you use any of these medications.
Are medications for heart attack lifelong?
Some of the key medications after a heart attack include blood thinners. These medications prevent clots from forming in the stents. Indeed, they are important even when a stent is not put on; clot formation is the main mechanism through which a heart attack occurs. Aspirin should be continued lifelong but the second blood thinner would be stopped approximately a year after the heart attack. Some physicians may recommend longer usage.
Medication for cholesterol is usually given over the long term, with the goal being to get the LDL cholesterol to below 1.4mmol/L. If this goal is not attained additional medication is required. If patients develop side effects from any medication they should discuss with the physician before stopping so that alternative medication could be prescribed.
In addition to these medications, patients will be given medication to treat blood pressure and diabetes if these are present.
What else should the heart attack patient know?
Tobacco is a major cause of heart attacks and patients who smoke are encouraged to quit because continued use of tobacco in any form increases the likelihood of recurrence. Many hospitals have tobacco cessation programs that help patients with these.
Patients are also encouraged to adopt heart healthy diets, which include foods rich in fruits and vegetables. Regular exercise in the form of walks, jogging and aerobic exercise 5 times a week for 30-45 minutes is recommended.
The Writer, Dr Mzee Ngunga, Is a Consultant Interventional Cardiologist at Aga Khan University Hospital, Nairobi.
