Types of Patients II: Chest pain/Cardiac

One of the easiest ways to get attention in the ER is to clutch your chest and complain of chest pain. Mention the proverbial elephant sitting on your chest and a sense of impending doom and you will find yourself on an expressway through triage to a monitored bed quicker than most.

Unfortunately, as explained previously, this is a good hop to the front of the line for a bad reason. Chest pain patients may have an emergent health crisis that, in turn, may have devastating negative outcomes. Impending doom? Not surprising.

A cardiac patient typically feels "crushing" pain to the chest which may radiate to the back, neck, or the left arm. The patient typically indicates the location of the pain by placing a fist on the chest, not pointing with the pinkie finger. This patient may complain of shortness of breath, nausea, and diaphoresis (sweatiness).

What is happening to this patient?

If the patient is suffering a cardiac event, the pain is the result of coronary arteries that have narrowed or been blocked, thereby reducing or eliminating blood supply to the cardiac muscle. The resultant ischemia (lack of oxygen), muscle injury, or muscle death is the source of the pain. In this case, time is muscle, and the quicker blood flow is returned to these areas of the heart the less damage that is done.

When blood flow to a large part of the cardiac muscle is immediately eliminated, sudden death may occur. "Dropping dead of a heart attack" is just that; so much of the heart is instantaneously damaged such that the heart can no longer function properly. It usually does not stop; it enters into a chaotic rhythm that is not sustainable of life. Ventricular fibrillation and/or ventricular tachycardia are lethal rhythms and the only way to "fix" them is with electricity.

"All clear?" Zzzzzap!

If this happens outside of the hospital, the chance of survival is slim, <10%. These patients usually do not arrive in the ER, they die in the field; or, if they do come in--via ambulance, etc.--they are usually already dead. Patients who arrive dead, despite what families and friends think, almost always stay dead.

If a sudden heart attack occurs in the hospital, chances of survival improve, but not drastically. Cardiopulmonary resuscitation (CPR) and automatic external defibrillators (AEDs) were developed to attempt to improve survival.

In my ER, we follow the American Heart Association's guidelines for chest pain patients, or patients with Acute Coronary Syndrome, as it is called by the AHA. Such a patient must be assessed by a nurse, have an EKG done, receive oxygen, have an IV started preferably with a blood draw, and have a medical history taken within 15 minutes, at which time the physician should see them.

Physicians orders to a nurse might include aspirin (a blood thinner), sublinqual nitroglycerin (under the tongue, a coronary artery dilator) or as an intravenous drip, perhaps morphine (for severe pain but also reduces cardiac oxygen demand) and a beta blocker (lowers the blood pressure). Laboratory blood work to look for elevated cardiac enzymes (enzymes released in the blood stream because of a cardiac event, especially muscle injury and/or muscle death) will be ordered, and perhaps a portable chest x-ray, the latter to evaluate for any anatomical abnormalities like an enlarged heart, etc.

In cases where acute myocardial infarction is confirmed (by EKG or by laboratory values), clot busters may be administered. This medicine is like Drano. Got a clogged coronary artery? Retavase can open it (perhaps). This therapy carries with it a host of possible negative side-effects (e.g., cerebral stroke), but if it is offered, many patients choose it regardless because most realize that die now or stroke later...which would you choose?

Do patients present complaining of chest pain who aren't experiencing a cardiac event? Many, perhaps most. But why?

There are several conditions that may mimic cardiac chest pain. Indigestion is the classic. We call it GERD, gastro-esophageal reflux disease, a.k.a. heart burn. (Notice the cardiac reference in the common parlance for this illness.) Esophageal spasms can also produce chest pain.

Other patients may claim they are having chest pain because they realize it brings them to the front of a long line of patients waiting to be seen. This behavior is usually recognized for what it is, but the same protocol is usually followed because despite how many times the patient may cry "wolf," sometimes there really is a wolf.

Erring on the side of life-saving is always a good thing. At least I think so.