28 March, 2024

Chest Pain: A Nightmare

Introduction:
While chest pain is classically associated with a heart attack, there are certain things worth noticing.

Not every chest pain is a heart attack, and not every heart attack presents with chest pain. There is always some level of diagnostic uncertainty that doctors take into account before reaching a conclusion.

If we leave out uncommon scenarios, there are 2 common causes of potentially lethal chest pain. Heart attack is one, and blood clot in the lungs (called pulmonary embolism) is another, with heart attack being much more common. Apart from these, many other causes of chest pain exist, ranging from simple muscle pain, which typically doesn’t require any major intervention, to more significant ones that need medical attention. Needless to say, any chest pain should prompt medical attention where lethal causes of chest pain must be evaluated and ruled out in a time-sensitive manner.

What should I do if I have chest pain or discomfort?
The best course of action is to visit the nearest emergency room and get checked up. Chest pain due to a heart attack can have varied presentations, and it is difficult to exclude heart attack by the basic nature of pain itself.
*While you may be tempted to provide “first aid” at home, it is not advisable to do so routinely. Someone may suggest giving a Sorbitrate tablet, Aspirin, or something else. The limited benefits of these drugs are offset by the imposed delay for hospital transfer.

What should I expect if I visit an emergency room with chest discomfort?
A doctor will take a detailed history of symptoms, assess risk factors for heart attack, and request basic blood tests, electrocardiogram (ECG), and a special blood test to look for any suggestion of heart damage. An echocardiogram (heart ultrasound) and chest x-ray may be performed on a case-by-case basis.

Based on the initial impression one of the following may happen:
Scenario 1: The physician determines it is a heart attack, a kind that requires immediate intervention either with clot-dissolving medicine or angiography followed by angioplasty. Angiography is favoured over clot-dissolving medicines here due to its superior efficacy and lower bleeding risk. Such a kind of heart attack is referred to in technical terms as STEMI (ST Elevation Myocardial Infarction). Here, time is muscle, which means the sooner you intervene, the more heart muscle you will be able to save. We are talking about minutes here, not hours or days.

Scenario 2: The physician determines it is indeed a heart attack but not the STEMI kind. Such heart attacks are treated with medicines, ICU stay overnight, followed by angiography after 1-2 days depending on the patient’s health status.

Scenario 3: It is unclear if it’s a heart attack or not. In this case, few medicines are started (on the assumption that a heart attack is present; better safe than sorry), the patient is admitted to an observation unit or an ICU, and is reassessed periodically till a definitive diagnosis is made (typically about 24 hours).

Scenario 4: It is not a heart attack but can be a clot in the lungs (Pulmonary Embolism). A blood test and an emergent CT scan can be done to diagnose this problem.

Scenario 5: It is neither a heart attack nor a pulmonary embolism. From here on, medical decisions become individualized and differ for different patients.

Another aspect is worth mentioning. Chest pain due to heart attack presents in many forms. Most commonly, it’s a dull aching sensation over the chest, sometimes confusing with ‘gas’ pain. Few people don’t have chest discomfort but rather have discomfort in their upper back, neck, jaws etc. Due to varied symptomatology and grave consequences of leaving a heart attack undiagnosed, it is always better to err on the side of caution and seek immediate medical attention if the above-mentioned symptoms arise, particularly in males aged 40 and above or those who smoke or have diabetes. Worst case scenario, you will lose some of your time and money, but in return, you will get either a diagnosis or peace of mind knowing nothing significant is there.

I am sure I didn’t answer all your questions on this topic. Feel free to message me with your queries; I will happily answer them.

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