CHEST PAIN
Excerpts from Living Longer With Heart Disease: The Noninvasive Approach That
Can Save Your Life Health Information Press, Los Angeles, CA Copyright by
Howard H. Wayne, M.D., M.S., F.A.C.C., F.A.C.P
Living Longer With Heart Disease: The Noninvasive Approach That Can Save Your
Life can be ordered directly from Health Information Press by calling 1-800-MED
SHOP (1-800-633-7467)
DISEASES AND CONDITIONS THAT MAY CAUSE CHEST PAIN
A large number of conditions other than obstructive coronary artery disease may
cause chest pain. The source may be from other structures and organs within
the chest, the chest wall itself, the spinal column, or the abdomen. Some
diseases will indirectly cause coronary artery disease, that has been present
in silent form for many years, to become symptomatic. In such cases, treatment
should be directed at the primary cause rather than the fact that coincidental
coronary artery disease is causing chest pain. The following is a list of some
of the more common causes of chest pain. It is by no means a complete list.
VASCULAR CAUSES OF CHEST PAIN
Hypertension (high blood pressure) as a cause of chest pain in both men and
women is listed first because it is the single most common cause of chest pain,
including coronary artery disease itself. In other words, more people suffer
from chest pain due to high blood pressure than those who have chest pain
because of obstructive coronary artery disease. Considering the fact that 64
million people in this country have hypertension, and approximately 75% of them
are either unaware of its presence, or are not adequately treated, it is not
hard to understand why so many individuals with high blood pressure are having
chest pain.
Although it is a long known fact that hypertension can cause chest pain, it is
not a commonly known fact. Indeed, most doctors including cardiologists seem
to be completely unaware of it. Complicating this lack of awareness on the
part of doctors is the fact that hypertension may exist for years with both
patient and doctor being unaware of its presence. This is because typically
such patients will have a rise in their blood pressure only during periods of
stress or extraordinary physical activity. At rest, or in the absence of
stress, their blood pressure is normal. Thus, their blood pressure is apt to
be normal during a routine office examination in which blood pressure is
typically taken while the patient is at rest. Eventually the blood pressure of
such patients will become elevated even at rest, but not until there has been
extensive damage to the kidneys, heart, vascular system and brain. This is why
hypertension has been called the "silent killer."
The mechanism of an elevated blood pressure causing chest pain is similar to
the changes that occur when a blood pressure cuff around the arm is inflated.
The pressure within the cuff is transmitted to the arm itself, and directly to
the brachial artery within the arm. When the pressure within the cuff becomes
greater than the pressure within the artery, the artery will collapse and blood
flow will stop. In the case of the heart, when the blood pressure is elevated,
that pressure is transmitted back to the cavity of the left ventricle. The
increase in pressure is transferred to the heart muscle itself. When the
transmitted pressure within the heart wall is great enough, it will cause the
small coronary arteries within the muscle, that are branches and smaller in
diameter than the surface coronary arteries, to collapse. Therefore, blood
flow within the muscle will be reduced or cease altogether, and chest pain will
result.
It should be apparent that if an individual is having chest pain, and a resting
blood pressure is normal, and that patient is made to undergo angiograms,
coincidental coronary artery disease may well be found. The cardiologist is
likely to conclude that it is the coronary artery disease that is responsible
for the patient's symptoms. In such a situation, the patient should purchase a
blood pressure cuff, and take his own blood pressure during episodes of his
chest pain. If he finds his blood pressure is elevated, then he should insist
that his blood pressure be brought down to normal with medications. Obviously,
if medication causes his blood pressure to return to normal, and his chest pain
disappears, then he doesn't need angioplasty or coronary artery bypass surgery.
Finally, it would make sense to investigate the cause of your chest pain before
undergoing angiograms. See additional causes below.
ESOPHAGEAL CAUSES OF CHEST PAIN
GERD or gastroesophageal reflux disease is causes by failure of the sphincter
at the lower end of the esophagus to close properly. As a result, there is
often regurgitation of gastric acid from the stomach into the lower esophagus
producing spasm and inflammation of the lining that may produce chest pain that
is very similar to angina pectoris, including the fact that it may be
precipitated by exertion, and relieved by sublingual nitroglycerine. In fact,
esophageal disorders often coexist with coronary artery disease. Chest pain
from esophageal disorders is usually precipitated by eating of food, or by
lying down after eating, and it can be relieved by antacids and milk. Often it
is accompanied by heartburn and difficulty swallowing (dysphagia). Unlike
angina pectoris, which typically radiates across the upper and mid chest,
esophageal pain tends to be located at the lower end of the sternum
(breastbone) and radiates to the epigastrium. Certain kinds of food more
characteristically produce esophageal pain. These include alcohol, spicy food,
Mexican food, and coffee. Unlike angina, which tends to last less than 5-10
minutes, esophageal pain may last for hours and fluctuate in intensity. GERD
can be effectively treated with proton pump inhibitors such as Prilosec.
Hiatal hernia. A hiatal hernia, also called a diaphragmatic hernia, is an
abnormally large opening in the diaphragm where the esophagus connects to the
stomach. As a result, the upper end of the stomach may herniate into the
chest cavity. This is not likely to occur while someone is sitting or
standing. Consequently, chest pain, when it appears, does so only when the
subject is either lying down or leaning forward after a heavy meal. The chest
pain that develops is a constricting or burning discomfort that appears in the
mid and left chest regions, and may last for 30 minutes or longer. On occasion
it may radiate to the left arm. It may be temporarily relieved by belching or
assumption of the upright position. Sublingual nitroglycerine does not relieve
the pain.
CHEST PAIN FROM OTHER AREAS WITHIN THE CHEST
Lungs: A variety of disorders involving the lung may be associated with chest
pain. Pneumonia is one of the most common, particularly when it involves the
lining of the surface of the lung known as the pleura. Inflammation of the
pleura is called pleurisy. Pleuritic pain tend to be sharp, and of brief
duration when it is present. Typically it may come and go over a period of
hours, and tends to occur only during inspiration. When associated with
pneumonia, it is usually accompanied by a cough and fever. It also may be a
symptom of a pulmonary embolism (see below), the site of metastasis of a
malignant tumor, or a sign of one of the autoimmune diseases such as lupus
erythematosus. Although pleurisy tends to be localized to a relatively small
area of the chest, at times, with the more infectious type, the chest pain may
be generalized and cause shortness of breath.
Pulmonary Embolism: Another major cause of chest pain is a pulmonary embolism.
An embolism is a mobile blood clot that usually occurs after a surgical
procedure, particularly if the patient has been lying immobile in bed for
several days. Immobility and the stress of surgery are associated with stasis
of blood in the lower extremities and pelvis. This encourages the formation of
blood clots in these areas. An injury to the lower extremities also may result
in the formation of a clot, days or even weeks later. Whatever the origin,
portions of the clot may break off and migrate to the lungs. This is most
likely to occur when attempts are made to ambulate a patient in the
post-operative period. Usually such a clot lodges in the small blood vessels
in the lung. If the clot is a large one, it may be associated with coughing up
of blood, shortness of breath, pain intensified by deep breathing, and even
sudden death. The pain associated with a pulmonary embolism may be
indistinguishable from both cardiac ischemia and the pain of an acute heart
attack. Chest pain may be the first clue that a clot is present in the legs
or thighs. In general, prolonged bed rest for any reason encourages the
formation of blood clots in the lower half of the body followed by a pulmonary
embolus. Usually the diagnosis of an embolism can be made by chest x-ray,
however, special tests and procedures may be required in more obscure cases.
Pneumothorax: A pneumothorax is an important cause of chest pain. It occurs
when air perforates the outer surface of the lung forcing ambient air into the
chest cavity. When this happens, the victim suffers chest pain followed by
collapse of the perforated lung and shortness of breath. Usually the pain is
in the lateral chest rather than the center of the chest, and it may be
aggravated by breathing. The diagnosis of pneumothorax can readily be made
with a chest x-ray. It also may be identified on physical examination, if the
doctor takes the trouble to listen to both lungs.
Mediastinal emphysema refers to the presence of air in the central portion of
the chest cavity that contains the heart. Because the air may create pressure
and stretching of the structures and nerves within the mediastinum, severe
chest pain may result. In addition, because the stretched nerves involve the
same nerve roots as the nerves coming from the heart, it may be very similar to
cardiac pain. Usually the pain is more superficial and tends to be modified by
respiration and body position. This disorder can be diagnosed by a chest
x-ray.
Pulmonary Hypertension is a rare cause of chest pain. As you might infer, this
is an elevation of the pressure in the pulmonary arteries. The pulmonary
artery is the artery that exits from the right ventricle. Before it enters the
lungs and branches into tiny blood vessels, it contains unoxygenated, venous
blood. A number of diseases may cause the pressure in the pulmonary artery to
become elevated including various forms of congenital heart disease, mitral
stenosis (obstruction of the mitral valve), chronic lung disease, and primary
pulmonary hypertension. Although primary pulmonary hypertension is an
extremely rare disease, it has recently been found to be a side effect of
certain medications used for weight loss. The chest pain associated with
pulmonary hypertension occurs with exertion and is relieved by rest, and may be
indistinguishable from the chest pain associated with cardiac ischemia.
Indeed, it is thought that the pain seen in this condition is due to ischemia
of the right ventricle. Except for chronic lung disease, the various
conditions giving rise to pulmonary hypertension occur in a much younger group
of people, and the chest pain that develops does not respond to the usual
cardiac medications. The diagnosis of all these disorders can be made from a
careful physical examination, chest x-ray, and even the electrocardiogram.
Aortic Valve Disease: The aortic valve is the exit valve of the heart and all
blood must leave the heart through this opening. Immediately after the aorta
exits from the heart, the coronary arteries arise and supply the heart muscle
with blood. If the aortic valve is diseased and obstructed, the blood flow
exiting from the heart eventually will be reduced, even though the pressure
within the left ventricular chamber becomes markedly elevated. At the same
time, the pressure within the aorta beyond the valve will be reduced, and the
amount it is reduced depends upon how obstructed the aortic valve becomes. If
pre-existing coronary artery disease is present, a previously insignificant
degree of narrowing in a coronary artery may now become very significant. The
result will be a reduction in blood flow and chest pain. Usually, if
significant aortic stenosis is present, the murmur associated with it is
readily heard. Unfortunately, the modern cardiologist has become so technology
oriented that frequently he does not even bother to listen to a patient's heart
with a low technology instrument such as the stethoscope. Even if he does so
conscientiously, the blood flow through the valve may be so reduced that no
murmur can be heard.
Mitral Valve Prolapse has been claimed to cause chest pain. There is no
anatomical reason why mitral valve prolapse should cause chest pain. Because
both this disorder and recurring chest patient pain are so common, mitral valve
prolapse is often discovered coincidentally in the evaluation of a patient with
chest pain symptoms. Also, mitral valve prolapse may accompany obstructive
coronary artery disease; however it is the coronary artery disease that
produces the chest pain and not the mitral valve prolapse.
Pericarditis: This is due to an inflammation of the membrane surrounding the
heart called the pericardium, and is accompanied by unique changes in the
electrocardiogram. Viral and bacterial infections may sometimes involve the
pericardium and will produce chest pain very similar to that seen with cardiac
pain. The pain of pericarditis, however, is aggravated by deep breathing and
influenced by changes in body position. It may cease when the breath is held
or if the victim leans forward. Pericarditis is not a common disorder. Because
of its similarity to cardiac pain, and the unique changes seen on the
electrocardiogram, it easily can be mistaken for an impending heart attack. If
coincidental coronary artery disease is found on an angiogram, and if the
doctor seeing the patient is an aggressive cardiologist, potentially dangerous
coronary artery bypass surgery may be performed that not only is unnecessary,
but possibly harmful to the patient.
Dissecting aneurysm of the aorta is enlargement and separation of the wall of
the aorta, the main artery exiting from the heart. When present, it may cause
chest pain and be mistaken for an acute heart attack. When chest pain is
present, it usually is severe, may involve the back and even the abdomen, and
is a medical emergency. If the artery ruptures through the weakened portion of
the aortic wall, death is immediate. Milder forms of dissection may be
confused with a heart attack but can usually be diagnosed by a simple chest
x-ray. However, if an x-ray is not taken, and the patient is made to undergo
angiograms, there will be prolonged delay during which the aneurysm may
rupture.
Syphilis: While syphilis is rarely seen today, it occasionally does occur,
particularly in individuals who spent their earlier years in undeveloped
countries where this disease is still prevalent. The lesions of syphilis have
a predilection for the ostia of the coronary arteries; that is, where the
coronary arteries exit from the aorta just above the aortic valves. By causing
marked narrowing of the ostia, blood flow is markedly reduced in the coronary
arteries. This will cause chest pain that is identical to that caused by
obstructive coronary artery disease. Surgical intervention as well as
antibiotic treatment of the syphilis are the recommended forms of therapy.
Premature Beats may be accompanied by a sharp, stabbing pain over the heart
area, and occasionally may be associated with a fleeting choking sensation.
Usually such symptoms occur at rest and decrease during physical activity, but
may reoccur when activity ceases.
CHEST WALL PAIN
Cervical Disk: A cervical disk may irritate the nerve roots going to the chest
wall and produce chronic chest pain that is aggravated by walking and certain
body positions. The pain tends to be more superficial than that seen with
obstructive coronary artery disease and is more likely to be present at rest.
Thoracic Outlet Syndrome: The nerves and blood vessels that enter the arm
often have to go through a bottleneck of muscles. If a blood vessel or a nerve
is kinked by a muscle or a rib, arm and chest pain may develop that is
associated with walking. Since exertional chest pain is a hallmark of coronary
artery disease, it is easy to see why confusion may arise. The pain is induced
by swinging of the arms, and can be reproduced by elevating the arm and
rotating it.
Tietze's Syndrome: Inflammation and swelling of the cartilage between the rib
and breastbone (costochondral or chondrosternal joints is known as Tietze's
syndrome. Such chest pain tends to be superficial rather than deep, is
aggravated by breathing, and is very tender if the area is pressed.
Tenderness of the muscles of the chest wall: A variety of factors may be
responsible for tenderness of chest wall muscles including injury from direct
trauma (usually several days before the onset of pain), coughing, and weight
lifting causing a pulled muscle. Usually the chest pain is localized to a
small area, is brief while it lasts, is aggravated by chest wall movements,
turning, twisting and deep breathing, and may last many hours.
Herpes Zoster: A severe skin rash that does not spread beyond the midline, may
cause extreme chest pain in the pre-eruptive stage. Typically the skin is
extremely sensitive over the involved area. Herpes may not be suspected until
the skin eruption actually occurs.
Hyperventilation Syndrome: An extremely common cause of chest pain is the
hyperventilation syndrome. Hyperventilation is simply over breathing as a
result of anxiety or fear. It also has been called panic attacks. Typically
the subject unconsciously starts to breath more rapidly and deeply when under
stress. The over breathing is often interspersed with deep sighs. In its acute
form it will quickly produce a variety of symptoms including lightheadedness,
dizziness, a far away feeling, numbness, palpitations, blurred visions,
flushing, and tingling of the hands and around the mouth. Sometimes the victim
will even faint. In its milder form, the subject may be constantly over
breathing throughout the day. In so doing there is increased use of the chest
muscles. If there is enough overuse of these muscles, they will become painful
producing chest pain. Usually the victim is not consciously aware that he is
over breathing, but rather feels short of breath. When this is associated
with pounding of one's heart, dizziness, blurred vision and the other symptoms
of hyperventilation, it is not hard to understand the panic that may accompany
this disorder. Because the symptoms are due to over breathing and blowing off
of carbon dioxide from the lungs, the chest pain and shortness of breath do not
occur during exertion but rather at rest. Indeed, physical exertion, which
will produce carbon dioxide, makes the victim feel better.
Primary Muscle Pain: This includes some poorly understood disorders that have
been called fibrositis, fibromyalgia, myalgia and neuralgia. The pain of these
disorders tend to be chronic and ill-defined by the patient, are usually not
related to exertion, and are confined to localized areas of the chest in
locations that are different than what is seen with cardiac pain. The patient
is usually more concerned about the significance of the symptoms, and whether
it is a sign of heart disease rather than the intensity of the pain.
Cancer may originate or spread to any structure in the chest including the
heart and cause chest pain. Such pain tends to be continuous and not related
to physical exertion. The diagnosis often may be made by a chest x-ray. Cancer
also may spread to the spine and vertebrae with irritation of the nerve roots
that go to the chest. Such pain may be quite severe and will not respond to the
usual cardiac medications.
ABDOMINAL CAUSES OF CHEST PAIN
Perforation of a peptic ulcer: Bleeding from a peptic ulcer may cause lower
chest pain, a rapid heart rate, low blood pressure, and even
electrocardiographic changes. Thus, it erroneously might be interpreted as a
heart attack. Massive bleeding from such an ulcer will be accompanied by
black, tarry stools and be readily evident. However, if there is low grade,
chronic bleeding, the presence of blood in the stools will not be obvious. The
only symptoms might be discomfort that is mistakenly thought to be coming from
the chest. The fact that the pain is related to food ingestion rather than
exertion usually differentiates the two, but that distinction is not always
clear.
Pancreatitis: Acute inflammation of the pancreas may cause severe chest pain
that although predominantly in the epigastrium, also radiates to the chest.
Such pain is often accompanied by changes in the electrocardiogram. However,
patients with pancreatitis usually have a history of alcoholism and gall
bladder disease. In addition, unlike the pain of a heart attack, the pain of
pancreatitis radiates to the back and can be partially relieved by leaning
forward.
Gallbladder disease: In the acute stage of a gallbladder attack, pain may be
referred to the lower chest. The pain is often severe, steady in character,
and may show changes in the electrocardiogram. Gallbladder colic may also
trigger chest pain in someone with silent coronary artery disease. Chronic
gallbladder disease may produce recurring lower chest and upper abdominal chest
pain. Gallstones are readily identified with an abdominal ultrasound
examination.
Splenic Flexure Syndrome: This is the term given to distension with gas of that
part of the large intestine in the region of the spleen. Because the colon
makes a 90 degree turn at this location, gas may get trapped causing the colon
to distend. Since this location is just beneath the diaphragm, the location of
the pain appears to be coming from the lower left chest. It may be
distinguished from cardiac pain by its intermittent, colicky behavior, and
fluctuations in intensity of the pain. Also passage of flatus gives temporary
relief.
MISCELLANEOUS CONDITIONS CAUSING CHEST PAIN
Abnormal fluid retention: A variety of conditions may cause abnormal retention
of fluid. This may increase the blood pressure and cause a secondary reduction
of blood flow to the heart muscle by compression of the microcirculation
within the muscle. This is due to an increase in pressure within the cavity of
the left ventricle that is transmitted to the muscular walls of the heart, or
it may result from an increase in fluid within the muscle itself causing an
increase in tissue pressure (similar to the swelling that accompanies a local
inflammation). One of the most common causes of such fluid retention is the
use of anti-inflammatory drugs containing ibuprophen or a similar acting
compound. They are popularly called NSAID drugs for non-steroidal,
anti-inflammatory drugs. Such drugs may cause profound fluid retention and
interfere with the flow of urine. The excess fluid usually lodges in the
tissues of the body, and can cause a weight gain of several pounds. Because
this fluid must enter the blood stream to reach the kidney, it can result in
fluid overload and chest pain. I recall one patient who came to see me for a
second opinion because he had been advised to undergo coronary artery bypass
surgery. Although his coronary artery disease had been stable for several
years, in recent months his chest pain had become more frequent. The findings
of his noninvasive examination suggested fluid overload. When asked if were
taking any medication for pain or for arthritis, his eyes lit up and he
replied, "Yes, I take six Advils a day". I told him to stop his Advil and to
substitute plain aspirin. This he did with prompt disappearance of his
symptoms.
Prostatitis: In addition to NSAIDs, fluid retention may occur with a variety of
urinary tract problems which interfere with the formation and excretion of
urine. These include kidney or bladder infections, prostate infections in men
and kidney failure. Many is the patient who has undergone unnecessary
angiograms for chest pain with subsequent coronary artery bypass surgery or
angioplasty for coincidental coronary artery disease, when all they really
needed were antibiotics for their prostatitis.
Stress: Fluid retention as a result of stress also may cause chest pain. A
victim of stress induced fluid retention may put on as much as 5-10 lbs. in 24
hours. Such fluid retention can be eliminated and prevented with diuretics.
Anemia is another unsuspected cause of chest pain. An anemia may have a
variety of origins, and a discussion of these is beyond the scope of this book.
A few of the more common causes, however, are bleeding from a peptic ulcer, a
tumor or polyp in the colon, bleeding hemorrhoids, inadequate nutrition with
lack of iron in the diet, pernicious anemia and chronic kidney disease. If the
blood count is low enough, it will produce such cardiac symptoms as
palpitations and shortness of breath with exertion, chest pain and fatigue. A
simple blood count can readily determine whether anemia is or is not present.
Thyroid Disease: Either an under or over active thyroid can cause previously
silent coronary artery disease to become symptomatic. An overactive thyroid,
or hyperthyroidism, may result in chest pain because the heart is simply
overworking. Typically the heart rate is in the nineties or low one-hundreds
even at rest or while the victim is asleep. Silent coronary artery disease is
usually present in such individuals, but is not symptomatic at normal heart
rates. If there is enough narrowing of the coronary arteries, blood will not
be able to get through at higher rates and chest pain will result. With
hypothyroidism or an under active thyroid, the heart rate will be very slow,
and the function of the heart will be impaired enough so that pain may occur
during exertion. In both of these thyroid disorders, the disease is easily
corrected with appropriate medication.
Cigarette Smoking: There is hardly anyone who is not aware that smoking has
serious side effects. That it can produce heart disease and cancer is now
common knowledge. Many are not aware that smoking also may produce chest pain.
Smoking increases the heart rate, blood pressure and work load upon the heart.
If there is pre-existing coronary artery disease, but with adequate blood flow
at rest, the increased work produced by smoking, as well as the increase in
concentration of carbon monoxide carried by the blood in place of oxygen, may
be enough to produce chest pain.
Medications: Chest pain related to miscellaneous problems with medications:
Many patients with coronary artery disease can live a normal life on a medical
program. They have little or no chest pain, and are not considered as subjects
for angioplasty or coronary artery bypass surgery until their chest pain
returns, or becomes more frequent or severe. The immediate concern voiced by
the cardiologist is that their coronary artery disease is getting worse, and
that an obstructed artery is getting ready to close off. Often the patient is
literally frightened into having surgery. In fact, in the majority of
instances, the recurrence or change in symptoms is rarely due to progression of
the patient's underlying disease, but is often due to a problem with the
patient's medication. A common cause is that the pharmacy where the patient
purchases his medication has substituted a different generic preparation for
one of his prescriptions, and this form may not be as readily absorbed from the
gastrointestinal tract. Or, the patient may have been taking a brand name drug
and the pharmacist substituted a generic form of the drug. At other times the
patient may have developed a tolerance to the medication he has been taking so
that the drug is no longer effective. Some patients will arbitrarily reduce
the dose of a given drug merely because they think they are taking too much
medication. An extremely common problem is seen with diuretics. Often, when
diuretics are initially used, the subject will have to void a great deal. This
is a real problem with many women who have had several children, and no longer
have the bladder capacity they once did. Going shopping and running errands
are particularly difficult. Accordingly, they will only take their diuretic
when they are overloaded with fluid. This result is running to the bathroom
all day long.
It is necessary to explain to such patients that the body takes up fluid like a
sponge. If a sponge is filled with water, it doesn't take much squeezing to
get a lot of water out of it; however, if it is dry, additional squeezing wont
have an effect. The body works the same way. If overloaded, even one diuretic
pill will get rid of a great deal of fluid. If they continue to take the
diuretic, its effect will be diminished and be more tolerable.
Another reason why patients may arbitrarily reduce the amount of medication
they are taking is when they develop a coincidental flu infection or
gastrointestinal problem with diarrhea, and wrongly blame it on their
medication. When they get better, they are convinced that it was the reduction
in their medication that did it, rather than the coincidental and spontaneous
improvement in their illness.
Finally, some patients take their medication too close to meals, and it
interferes with the absorption of the drug. Accordingly, it is important that
someone examine the medical program of a patient to be sure it is correct.
Deconditioning and weight gain: Other factors that can produce symptoms, and be
misinterpreted as progression of the underlying coronary artery disease, are
weight gain, deconditioning, inappropriate timing of exercise, and change in
the weather. At times, for a variety of reasons, patients with stable and
silent coronary artery disease will cease to exercise, and gain a significant
amount of weight. Perhaps it is because they are too busy, they might have
sustained an injury to their back or leg, or they merely may have been on a
vacation. Whatever the reason, weight gain invariably follows along with some
deconditioning. When the patient finally decides to resume exercising, chest
pain returns. Only through careful questioning and weighing of the patient at
each visit can these explanations be uncovered. Another reason for the flair
up of chest pain is a change in the weather. Patients with coronary artery
disease are much more apt to have pain in cold weather than warm. Merely
dressing warmly or avoiding cold wind may be enough to eliminate the occurrence
of chest pain if it is present.
Exercise after eating: Another cause of recurring chest pain is when patients
decide to embark upon an exercise program, but do so not long after eating a
meal. While few people would be foolish enough to vigorously exercise, many
patients think a walk after dinner is acceptable. When they begin to have pain
they become frightened. Merely having them walk before dinner is usually
effective in stopping the pain.
Alcohol: Finally, some patients drink to much. Often it is thought to be
harmless, but close questioning reveals that the patient is drinking as much as
a half a bottle of wine with evening meals. Alcohol is toxic to the heart
making it beat faster and harder. The alcohol may even produce irregular and
ineffective heart beats. The increased need of such a heart for oxygen may be
sufficient to produce chest pain. Cessation of the alcohol is all that is
needed to eliminate chest pain.
It is apparent that patients with coronary artery disease may develop symptoms
for many reasons. While patient and doctor alike become concerned that the new
onset of symptoms, or a change in previous symptoms means an impending
catastrophe, numerous observations and studies have established that emergency
action is rarely necessary, or even indicated. In the author's personal
experience, a recent increase in the degree of coronary artery narrowing is
hardly ever responsible for a change in the patient's symptoms. Consequently,
the common practice of many cardiologists of rushing a patient in for
angiograms, followed by angioplasty or coronary artery bypass surgery is
totally unwarranted. Most of the time, the cause of a flair up in patient's
symptoms can be determined by carefully asking the appropriate questions, and
performing an adequate examination. Too often that is not done, and the
patient is scheduled for an array of high tech tests. Even when those tests
are abnormal, typically there are no prior tests to compare with. Accordingly,
the cardiologist has no way of knowing whether the abnormality found on an
echocardiogram, radioactive imaging study or angiogram is the direct cause of
the patient's symptoms, or is merely coincidental, and there is some other
reason for the patient's complaints. In our modern, hurry-up world where both
patient and doctor expects immediate relief, the outcome is one in which the
doctor urges the patient to undergo immediate surgery. Oftentimes the reason
for such recommendations are more for the benefit of the doctor than the
patient. At times such patients actually may have some temporary improvement
in their symptoms after a surgical intervention. As will be discussed in later
chapters, there are many reasons why a symptomatic patient may obtain relief
that have nothing to do with the surgery or procedure performed. Thus, merely
the fact that the patient feels better does not mean their surgery or
angioplasty was needed.
It takes a great deal of time to sort out all the possible reasons why someone
may develop chest pain. It can take months of treatment to eliminate other
diseases that may result in similar symptoms, or other diseases that cause
previously silent coronary artery disease to become symptomatic. Even when
obstructive coronary artery disease is the source of the patient's symptoms, it
may take many weeks and even months to eliminate their chest pain.
Accordingly, it cannot be emphasized strongly enough that you should never
allow yourself to be rushed into the cardiac laboratory for emergency
angiograms as a prelude for surgery. Nor should you ever accept the
explanation that coronary angiograms are needed to determine the cause of your
chest pain, or whether a heart attack is occurring, or how you should be
treated. Angiograms cannot provide answers to these questions. In contrast, a
variety of noninvasive tests will readily provide such information. This will
discussed more fully in later chapters.
Rarely, a patient may require emergency surgery because of a vascular accident.
Examples are rupture of a muscular wall of the heart, massive leakage of one
of the valves of the heart, rupture of an artery and shock. Such catastrophic
accidents can be readily diagnosed without angiograms. Knowledge of your
disease, what tests are indicated, what tests are not indicated, and what your
various options are for treatment will greatly increase your chances of
receiving the best and safest treatment possible.
Howard H. Wayne, M.D., F.A.C.C., F.A.C.P. Cardiologist
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