Chest Pain and Heart Attacks – Here Is What You Do

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Over the last few days, there has been tremendous discussion on social media about a tragic case where a young family man allegedly died of a heart attack that was not diagnosed in time.

I thought it would be appropriate for our readers to have an understanding of what a heart attack is and what you must be doing if you have ‘heart pain’.

Now, if you are currently suffering from chest pain and sweating and are reading this article just to learn more about chest pain, then stop right away and call your doctor!

However, if you just wish to learn more for other reasons, then read on….

What Is Chest Pain?

Chest pain is a symptom of a number of different conditions, and is typically described as a discomfort in the chest.

The type of chest pain can vary from patient to patient, and is often described as ‘crushing’, ‘tightening’, ‘heavy’, ‘pricking’ or ‘sharp’, though many people have different ways of describing the pain.

Chest pain can affect any part of the chest, and the part affected can sometimes indicate as to what the underlying cause is. For example, chest pain that affects the mid-line of the chest is sometimes acidity related pain.

What Are The Causes Of Chest Pain?

Chest pain can be due to a number of causes, and can range from simple indigestion to serious problems such as a heart attack or pulmonary embolism (clot formation in arteries of the lungs).

Some of the common causes are listed below –

Causes Of Chest Pain
  1. Myocardial infarction (heart attack)
  2. Pulmonary embolism (blood clot in the arteries of the lungs)
  3. Aortic dissection (a tear in the major artery i.e. aorta)
  4. Myocarditis (inflammation of the heart muscle)
  5. Pericarditis (inflammation of the pericardium – a thin protective layer surrounding the heart)
  6. Acid peptic disease (indigestion / acidity)
  7. Gall bladder stones (biliary stones) – patients often have associated abdominal pain.
  8. Muscular or skeletal problems such as costochondritis (inflammation of the rib cartilage)
  9. Skin rashes such as herpes zoster (shingles)

In this article, I have only discussed heart attack and what you must do if you think you are having one.

Myocardial Infarction (Heart Attack)

This is the most worrying cause of chest pain, and require emergency treatment in most cases.

How Do I Know If I Am Having A Heart Attack

Before I explain how you can figure out if you are having a heart attack, let us discuss what a heart attack is first.

What Is A Heart Attack?

A heart attack is a condition where the blood and oxygen supply to the heart muscle is cut off due to blockage of one or more arteries. There are different types of heart attacks which you can read about here.

A heart attack is the result of the development of a blood clot within a heart artery. This blood clot blocks the flow of blood to the heart muscle, leading to damage of the cells and tissues in it.

Heart attack

Patients recover from a heart attack if timely treatment is administered. Heart attacks can cause serious complications, one of which is a cardiac arrest and sudden death.

In a nutshell, the way to identify a heart attack is listed below –

SYMPTOMS OF A HEART ATTACK
  • Central chest pain – described like a ‘big stone on the chest’. The pain is usually present at the upper half of the chest.
  • Radiation of pain to the jaw, neck, mid-back or shoulder – The same type of pain that is felt in the chest is also felt in these areas.
  • Profuse sweating – This is a very typical symptom in patients having a heart attack
  • Nausea or vomiting
  • Lightheadedness or giddiness
  • Shortness of breath
  • Feeling of impending doom / panic response / anxiety

Another easy way to identify if you or someone is having a heart attack is the ‘rule of 4 P’s

Pain in the chest radiating to the shoulder and jaw

Pale skin

Perspiration i.e. sweating

Pulse being rapid and weak

Please note that the above table lists what is described typically in text books, and some patients who suffer from a heart attack may either have very atypical symptoms or no symptoms at all.

We spoke with Dr B G Baliga, senior cardiologist at Fortis Hospitals and director of Baliga Diagnostics Pvt Ltd in Jayanagar, Bangalore regarding the symptoms of a heart attack. “A majority of the patients complain of central chest pain radiating to the shoulders (especially the left shoulder), root of the neck, mid upper abdomen and back. There is profuse sweating, difficulty in breathing, nausea, vomiting, palpitations and sometimes giddiness”, says Dr Baliga.

However, not all patients will experience these typical symptoms. Dr Baliga says “patients with a long history of diabetes can have ‘silent’ heart attacks and might not experience any symptoms at all. They may experience minor symptoms such as tiredness, fatigue or mild chest discomfort.

These symptoms are often neglected by the patient as indigestion or a minor problem. It is important to take extra care in these patients as a heart attack can be missed in them”.

Many patients who suffer from a heart attack might have experienced some form of ‘warning sign’ a day to a week before such as chest pain when walking or mild discomfort or uneasiness in the chest when climbing stairs. However, there may not be such symptoms at all.

The table below will guide you as to what to do if you think you are having a heart attack.

WHAT TO DO IF YOU THINK YOU ARE HAVING A HEART ATTACK
  1. STOP WHAT YOU ARE DOING AND CALL FOR HELP – YOU SHOULD CALL FOR AN AMBULANCE OR YOUR FAMILY DOCTOR IMMEDIATELY. ALTERNATIVELY, GO TO THE NEAREST HOSPITAL IMMEDIATELY. DO NOT WASTE TIME AT HOME.
  2. IF YOU HAVE A 325 mg SOLUBLE ASPIRIN, THEN TAKE IT IMMEDIATELY. SOLUBLE ASPIRIN MUST BE CHEWED. DON’T TAKE ASPIRIN IF YOU ARE ALLERGIC TO IT OR HAVE ANY RECENT HISTORY OF BLEEDING ESPECIALLY IN THE STOMACH.
  3. PUT A TABLET OF SUBLINGUAL NITRATE (SORBITRATE) UNDER YOUR TONGUE IF IT HAS BEEN PRESCRIBED TO YOU PREVIOUSLY.
  4. SIT IN A COMFORTABLE POSITION, IDEALLY ON THE FLOOR LEANING AGAINST A WALL WITH YOUR KNEES BENT AND THE HEAD SUPPORTED AGAINST THE WALL (THIS WILL REDUCE THE CHANCE OF INJURY IF YOU COLLAPSE).

IF YOU ARE A FAMILY MEMBER, MAKE SURE YOU ADMINISTER THE ABOVE STEPS TO THE PATIENT. MAKE SURE YOU WATCH THE PATIENT’S PULSE AND CONSCIOUSNESS LEVEL. TALK TO THEM AND REASSURE THEM CONSTANTLY.

DO NOT FEED THEM ANYTHING (INCLUDING WATER) AS THEY MAY VOMIT.

“Around 50% of people who delay seeking treatment at a hospital do not survive, and this is the most common cause of death following a heart attack”, says Dr S Venkatesh, Senior Interventional Cardiologist at Fortis Hospitals Bannergatta road. “Making sure you get the right treatment on time can be life-saving, and can significantly reduce the risk of death”, he stresses.

In an article written on his blog, Dr Venkatesh comments – “Always keep a few chewable aspirins 325 mg at home in case of emergency. Make sure you chew the aspirin, not swallow it”.

 What Happens Once I Reach Hospital?

Once you reach a hospital, you will be moved straight to casualty (emergency department) where you will be attached to a cardiac monitor and your blood pressure will be checked. An electrocardiogram (ECG) will be performed IMMEDIATELY on arrival.

An ECG is a good tool to diagnose whether a patient is having a heart attack or not. It can be normal in the very early stages, but if the clinical suspicion of a heart attack is high, repeat ECGs will be performed every 10 – 15 minutes to see if new changes evolve over time. If new changes are seen, it is likely that the pain is due to a heart attack.

Studies have shown that the first ECG has a low sensitivity in picking up a heart attack (ranging from 28% to around 60%) , and that further ECGs will be needed if there is a high clinical suspicion. (see references at end of article). The ECG changes also depend on the total duration of chest pain.

Once a heart attack is diagnosed, patients will be administered high doses of blood thinner tablets (aspirin and clopidogrel) along with blood thinner injections (heparin). Painkillers such as morphine may be given. Blood tests will be done to confirm elevation of cardiac biomarkers (enzymes that are released from the heart muscle into the blood stream when it is damaged).

An echocardiogram may be performed to assess the extent of damage to the heart muscle. This may be normal sometimes.

The patient is then moved to the coronary care unit (CCU) for further management.

“Once a diagnosis of a heart attack is confirmed by clinical presentation, ECG changes, Echocardiographic assessment and cardiac biomarkers, the patient is taken to the cardiac catheterisation laboratory (called ‘cath lab’) for coronary angiography. This is done following a detailed discussion with the patient and the family”, says Dr Baliga.

The angiogram will determine the artery  that is blocked, and life-saving coronary angioplasty (called primary angioplasty) is then performed on-table. Angioplasty is always performed after obtaining consent from the patient or their family members. “With a success rate of over 90%, primary angioplasty can reduce the chances of sudden death from a heart attack from 50% to less than 4%” says Dr Venkatesh.

In cases where the patients presents late to hospital, alternative medical therapies are considered. This can include a series of drips and injections that thin the blood and dissolve the clot. This will re-establish the circulation to the heart. However, a majority of these patients will require subsequent angiography and some will need angioplasty before discharge from the hospital.

You can learn more about angiography here – Click here.

You can learn more about angioplasty here – Click here.

A 5 day stay in hospital is mandatory, unless there are any complications which would require additional stay. Patients who receive timely treatment often do well. However, some patients may have irreversible damage to the heart muscle despite receiving timely treatment.

Once discharged, patients will be on heart protection medicine for the entire duration of their lives.

Making A Plan

  • Always make sure that you and your family are ready for an event like a heart attack.
  • Keep a few tablets of 325 mg chewable Aspirin at home. You never know when you might need it.
  • If a family member suffers from a heart attack, then action must be taken in a step wise and fluid manner so that the patient can reach the hospital as soon as possible.
  • You could draw up a plan and stick it on your refrigerator if you want, or any where else you think is appropriate so that even the maid can see it. Keep the numbers for an ambulance service handy.
  • Alternatively, a taxi service is also useful.
  • Make note of hospital emergency numbers, particularly that of the larger hospitals that are located near your residence.

 

If you or a loved one is suffering from chest pain, then do not delay taking action. Either call your doctor straight away or visit the nearest hospital to make sure it is not a heart attack.

Learn More About Heart Attacks Here

Useful numbers

102 for ambulance


References

1. McGuinness, J. B., T. B. Begg, and T. Semple. “First electrocardiogram in recent myocardial infarction.” BMJ 2.6033 (1976): 449-451.

2. Fesmire, Francis M., et al. “Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain.” Annals of emergency medicine 31.1 (1998): 3-11.

3. American college of emergency physicians. Clinical policy: Critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina. Ann Emerg Med. 2000;35:521–525.

4. Young GP, Gibler WB, Hedges JR, et al. Serial creatine kinase-mb results are a sensitive indicator of acute myocardial infarction in chest pain patients with nondiagnostic electrocardiograms: The second emergency medicine cardiac research group study. Acad Emerg Med. 1997;4:869–877.

Updated February 2017 by Dr Vivek Baliga

Dr Vivek Baliga B

Dr Vivek Baliga B

Consultant Internal Medicine at Baliga Diagnostics Pvt Ltd
Dr Baliga is a consultant in Internal Medicine with an interest in diabetes and cardiovascular disease. He received his training in the United Kingdom where he completed his post graduate training and his doctorate. He then completed his MBA from University of Phoenix, USA. He has completed the post graduate program in Cardiology from Johns Hopkins University and participated in the Advanced Certificate Course in Diabetes from the Cleveland Clinic, USA. He is the managing partner of Baliga Diagnostics, Bangalore. He is also the founder of HeartSense and is a keen advocate of patient empowerment, having written almost every article on this website and more. In his spare time, he enjoys running and spending time with his son. Find Dr Vivek Baliga on LinkedIn here - http://heartsense.in/linkedin.
Dr Vivek Baliga B

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