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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