In 2004, the American College of Cardiology and the American Heart Association published guidelines on the management of heart attacks – also known as Acute Myocardial Infractions (AMI) or ST elevation myocardial infarctions (STEMI). These guidelines would have a significant impact on the practice of cardiovascular disease.
An important consideration to these guidelines revolves around definitions that mark time – “time” meaning the onset of first medical contact and the time from contact to reperfusion (opening of the artery with clot busters or balloon catheters). I cannot stress this enough. As soon as chest pain begins, get to the hospital.
If you are having a heart attack, the faster the artery gets open, the better the outcome. In the guidelines, a class I indication (the highest recommendation from the college) on how to get to the hospital is stated: “Patients with symptoms of STEMI (chest discomfort with or without radiation to the arm, back, neck, jaw or shortness of breath, weakness, sweating, nausea or light-headedness) should be transported to the hospital by ambulance rather than with friends or relatives.”
Over the years, I have had many patients with chest pain who have failed to get to the hospital. First and foremost, if you are having chest discomfort, go to the emergency room at your nearest hospital. I could tell you horror story after horror story of patients who failed to get themselves evaluated in a timely manner and suffered the consequences from such a delay. One such example is a male patient who started having chest pain 10 hours prior to going to the hospital. His pain was so severe that he eventually asked his wife to drive him to the hospital. He arrested they were only two blocks away from the hospital, and waited for paramedics to arrive. When he arrived, he was extremely critical. We took him to the heart lab and opened his artery, only to find out later that he had suffered severe brain anoxia. He eventually died.
There were several mistakes made here. First, he should have gone to the hospital as soon as the chest pain started. Secondly, he should have been initially transported by ambulance with experienced personnel. There are many “stand-up” emergency clinics or “minor” emergency rooms that cannot provide full heart services. Most of these facilities waste valuable time and eventually send you to a Level III cardiac care center. Several patients who have gone to “urgent care” emergency rooms with chest discomfort find themselves suffering a more serious heart attack than if they had gone to a major hospital in the first place.
Another cause for delay is patients attempting to call their general doctor, a friend or a family member to ask for advice first. Calls may not be returned for several hours, thus wasting valuable time. If you are having chest pain, go to the hospital immediately. There are emergency room guidelines upon hospital arrival. The hospital and staff have a duty to open the artery in 90 minutes. Referred to as the door-to-balloon time (DTB), it is mandated by both the federal government and the American College of Cardiology. Occasionally, emergency room patients lose time by failing to tell the triage nurse they are experiencing chest pain.
It is vital you find a triage nurse or medic and insist on having an EKG done immediately. The emergency room physician should read the EKG in less than five minutes. If a myocardial infarction (heart attack) is detected, this allows the emergency room physician to activate the cardiologist and cardiac catheterization team. It is then their responsibility to open the occluded artery in a total time of less than 90 minutes.
The ability to perform EKGs in the field and transmit the EKG to an emergency room physician is currently available in San Antonio. This can potentially save on the DTB. The cardiologist and catheter team are actually waiting for the ambulance to arrive. By having the EKG earlier, I have been able to bypass the emergency room, have the patient transported directly to the heart lab and open the artery in 19 minutes – a record that still stands.
Tips on chest pain
More than one-third of patients may visit a doctor’s office with no complaints of chest pain and still have significant cardiovascular disease. Chest discomfort from heart disease is usually described as a pressure sensation. Patients generally say it’s “like an elephant sitting on my chest.”
Breathing becomes extremely difficult. Rather than lasting all day, discomfort comes and goes throughout the day and lasts at least five minutes, if not longer. Patients may complain of shortness of breath or be extremely diaphoretic (sweaty). Patients rarely lose consciousness, but when this happens, it represents a grim prognosis. The arm numbness is generally to the left side; however, it can occur toward the right side. Complaints of general tiredness, fatigue and palpitations may coexist.
Pain that gets worse with breathing is due to an inflammation of the tissue surrounding the heart or lung, respectively (pericardial or pleuritic chest pain). Some patients may describe such discomfort as an up-and-down motion along their breastbone, which actually refers to their esophagus and may be indicative of gastric reflux disease. Pain that occurs after a fatty meal generally refers to the gastrointestinal system – specifically the gallbladder.
Generally, heart pain covers most of the chest. I have had several patients come in and point to a spot on their chest; if the chest pain gets worse with any particular movements, such as moving your arm up and down, this refers to musculoskeletal pain. Musculoskeletal pain may be reproducible. In other words, if you put pressure on the painful area, that elicits the discomfort. A serious cause of chest pain is a pulmonary embolism. This is a blood clot to the lung arteries. The onset is usually abrupt with the patient complaining of painful respirations. Asthma can also cause chest pain with or without signs of wheezing.
Cardiovascular disease (CVD) is currently a major cause of death worldwide. Although cardiovascular disease rates are declining in the United States, it is increasing in virtually every other region in the world. There has been no single factor to the increasing incidence of cardiovascular disease given vast differences in social culture and economics. The challenge is formidable for low-economic countries. Several factors have been highly correlated to cardiovascular disease. These include smoking, serum cholesterol, hypertension, diabetes and physical activity. Differences in the intensity of any factor and how they are managed may explain the differences in rates of disease seen among countries.
Tobacco: Smoking represents a rapidly growing avoidable cause of cardiovascular disease. Worldwide, 1.2 billion people smoked in 2000, and that number is projected to increase to 1.6 billion in 2010. More than 80 percent of current smokers live in low- to middle-income countries. Tobacco causes five million deaths annually, and is responsible for 9 percent of all deaths. Every year, more than 5.5 trillion cigarettes are produced – enough to provide every person on the planet with 1,000 cigarettes. Tobacco cessation programs have been shown to decrease the risk for cardiovascular disease.
Diet: In regard to coronary artery disease, the key dietary factor is an increase of saturated and polyunsaturated fats, which contain atherogenic trans fatty acids. This, along with a decreased intake in plant-based foods, can lead to cardiovascular disease. Although dietary habits vary from country to country, intake of dietary fats tends to be low in many less-developed countries and substantially higher in industrialized countries. Fat contributes to less than 20 percent of calories in countries like China and India, 30 percent in Japan and well above 30 percent in the United States. By decreasing the intake of trans fatty acids, you can decrease your risk for developing cardiovascular disease. But remember: One factor alone may not be enough to reduce the risk.
Hypertension: By far, high blood pressure is a clear risk factor for coronary heart disease and stroke. High blood pressure has been associated with industrialized countries. Studies show people without hypertension from less-developed countries have developed hypertension after moving to industrialized nations. Men and women in India have a prevalence of hypertension of 25.5 and 29 percent, respectively, in urban areas, whereas those living in rural areas have rates that drop down to 14 and 10 percent, respectively. There is an association between increasing blood pressure and advancing age. In the United States, the number of untreated patients over 80 years of age has been declining. In Europe, Central Asia and low-income countries, rates of treatment in this subgroup are much lower. This may explain the higher stroke rates in these countries.
Diabetes: Diabetes represents a strong risk factor for coronary artery, cerebral and peripheral vascular disease. In 2003, 194 million adults, or 5 percent of the world’s population, had diabetes. By 2025, this number is predicted to increase to 333 million. Prevalence of diabetes varies greatly with geographic region, race and ethnic composition. Hispanic Americans have a trend for higher rates than Caucasians. Strong control of diabetes and maintaining a low hemoglobin A1C have been directly related to lower rates for both cerebral and cardiovascular events.
Physical Activity: This probably represents the bi-product of many mechanisms. Lack of physical activity has been strongly associated with ongoing obesity and higher rates of cardiac and cerebrovascular disease. The actual mechanism by which weight loss decreases this risk is still unknown. Lowering blood pressure, lowering serum cholesterol levels or preventing diabetes may be the answer.
Final Note
It was 1976 – my senior year of high school. I was playing football one afternoon as the offensive tight end. The play called was going to the opposite side. Coming off the snap, I was knocked down. No big deal. The play was going to the other side. Little did I know, my running back changed directions and came my way. He was clobbered, and I remember the whistle blowing. My coach had me stand up and gave me an ear full. I remember him saying, “If you get knocked down, get up and go at it again.”
Well, I didn’t think much of what the coach said until four weeks later when he brought up the issue again during half time at the state finals. He asked the team if they remembered the incident where Barbaro got knocked down and failed to get up. The reference was to football, but also to life in general. Don’t ever forget this. When someone says you can’t, or if you fail or get knocked down, get up and try again. I never forgot these words.
Also, I recently had dinner with Priest Holmes, who was at one time the NFL’s leading touchdown runner. He’s a small man in a big man’s game who never said, “I can’t.” Congratulations, Priest, on your induction to the San Antonio Sports Hall of Fame.
Salvatore A. Barbaro III, M.D., practices general and interventional cardiology at his private practice located at 19234 Stonehue, San Antonio, Texas 78258. For more information, please call 210-490-4600.
