Author’s note: This is the second diary in a new series that I will post monthly, on medical topics related to emergency care. If you want to check out the first diary in the series, you can find it HERE, on the topic of “insider tips to improve your visit to the ER”. Some of these diaries will focus on the medical system or process, and some will be disease-specific. My goal , as your friendly neighborhood ER doc to the Daily Kos community, is to provide useful information for this community to stay healthy and get the best results from our medical system. I hope you find it helpful!
The scenario: you are having chest pain
It’s 9 PM, you’re settling down to a good book after dinner, and sudden you feel a strange heaviness in your chest. It’s not exactly a “pain”, but it sure is uncomfortable — and you can’t seem to make it stop. You stretch, get a glass of water, and walk around the living room to shake it off, but the discomfort is persistent. You are suddenly scared. After all, you’ve heard of heart attacks, you’ve had relatives that struggle with heart disease, and you wonder if this could be The Big One. You call 911 for help.
First key insider tip: not all heart attacks start with chest pain
We’ve all seen the guy in the movie who is having a heart attack: he grabs his chest, he winces in pain, and goes all sweaty and pale (here’s a nice example, at approx 0:30 of the clip from a classic movie from my childhood). Here’s the problem: it doesn’t always go that way. Many people with sudden heart attacks don’t experience pain, but rather a dull ache in the chest, or a pressure-like sensation. Some (especially diabetics and the elderly) don’t experience pain at all — they might sense a sudden weakness, or feel suddenly short of breath and nauseated. Scary, right? So how do you know if it’s a heart attack? We’ll get to that, but I just wanted to start off debunking the “pain” myth. When people see me in the ER with their heart attacks, I try to be careful with my words, I ask about “chest discomfort” to broaden the conversation. And my pro tip to you: when you or loved ones are in the ER with chest pressure, don’t say “no” when the medical team asks about chest pain if your chest feels bad but isn’t actually in pain. To the clinical providers, “chest pain” means heaviness, an ache, a soreness — any uncomfortable sensation. Not just sharp pain.
What is a heart attack?
A heart attack (also known by its medical term “myocardial infarction” or “MI” for short) is when a blood vessel to the heart becomes completely blocked. The heart is a muscle, and as such needs a steady blood supply. Heart muscle receives blood via a system of vessels known as the coronary arteries (as an aside, older folks will often refer to a heart attack as “having a coronary”). The coronary arteries are fairly small (only millimeters in internal diameter), and so it doesn’t take much to clog them up (here’s a nice video describing the coronary arteries). Over years, many of us develop blockages inside these blood vessels, not unlike the calcium build-up inside the plumbing of your bathroom.
The debris that blocks our coronary vessels is made from an unholy mix of cholesterol, other fats, calcium, cell debris and other gunk. Every so often, this build-up can tear the inner lining of the blood vessel, which is a big problem. When the inner lining rips, the body detects an injury and immediately forms a blood clot over the tear. It is this blood clot, not the gunk itself, that usually is the cause of a sudden heart attack: The blood clot can quickly block the entire artery, and a piece of heart muscle suddenly doesn’t receive any blood. If the blood flow isn’t restored soon (within minutes to hours) the muscle will die. THAT is a heart attack: a dying part of heart muscle due to a blocked coronary artery.
It is important to make a distinction here, between a “heart attack” and “cardiac arrest”. They are different diseases with different treatments: as described above, a heart attack is when you get a sudden blockage to a coronary artery. The heart usually doesn’t stop beating, the heart attack victims usually doesn’t pass out, and they can talk to you about what they are feeling. Cardiac arrest, on the other hand, is when the heart stops beating altogether — sometimes this is from a heart attack, sometimes it is from other problems that have nothing to do with coronary arteries. In cardiac arrest, the victim collapses to the ground and loses consciousness very rapidly. In 2019 in the USA, most heart attack victims survive, but most cardiac arrest victims die. So be sure not to confuse these terms — it happens all the time on television and increases confusion among the public.
I think I’m having a heart attack: what should I do?
Here’s crucial pro tip: if you are a person at risk (this usually — but not always — means you are over 50 years old, and maybe have some “risk factors” for gunk build-up in your arteries, such as high cholesterol, or high blood pressure, or diabetes) and you experience sudden chest discomfort: don’t blow it off. It happens all the time, and is a major cause of untreated heart attacks. I totally understand why people might ignore symptoms: maybe they think it’s just gas, or maybe they are scared, or maybe they don’t want to bother anyone. Please take sudden chest discomfort seriously, and call 911. Don’t get in the car and drive yourself to the hospital, either. This is the reason that we have the 911 emergency medical system, and this is the right time to use it.
Here’s a second crucial insider tip: aspirin can save your life if you are having a heart attack.
Aspirin — and we need to be clear, we’re not talking about other common pain medication like tylenol or advil or alleve, they are totally different — has a remarkable quality of making blood clotting work less well. Many of you who take aspirin regularly may have noticed that you bruise more easily, or your gums bleed more during dental flossing. That is because of this property of aspirin to inhibit blood clotting. Since heart attacks are mostly FROM blood clots, it makes sense that aspirin might help, and indeed it has been proven to do so. In many ambulance systems, they will give chewable aspirin pills to anyone having chest pain because of this. So if you have a bottle of aspirin in your medicine chest, and you experience sudden chest pain, it’s a good idea to take one right away while you are calling 911. If you don’t have a bottle of aspirin, it’s a good idea to have one handy — buy the full size ones, 325 mg tablets, not the coated 81 mg “baby aspirin”. It will come in handy when you or a loved one has chest discomfort.
OK, I called 911 — now what happens?
When the ambulance folks arrive, they will ask you questions, including when the pain started. That is a crucial piece of information, so if you can make note of when the discomfort began that would be helpful for your care team. They will take your vital signs (blood pressure, heart rate, etc) and also will perform an electrocardiogram (an “ECG” or for some old guys like me, an “EKG” from the original German term “elektrokardiogramm”).
The ECG is absolutely crucial, as many heart attacks show up very easily on the electrical signal generated by the heart. So crucial, in fact, that many ambulance systems in 2019 will actually send the ECG recording directly to the hospital via wireless technology right from your living room. If the ECG shows a heart attack, the hospital can prepare for your arrival, speeding up your care. The ambulance crew may give you a chewable aspirin, place an intravenous line in your arm (an “IV”) and will load you up in the back of the truck. You are now heading to the ER.
I’m in the ER — what happens next?
If your ECG shows clear signs of a heart attack, you may not even go to the ER, but might rather go straight to the cardiac “catheterization lab”, where the magic happens. But let’s assume for the moment that the ECG doesn’t reveal an obvious heart attack. You will be taken to the ER, where the care team will ask loads of questions about your symptoms (pain? difficulty breathing? vomiting?) past medical history (do you have diabetes? high blood pressure? a family history of heart problems?) and will get another ECG.
A really key pro tip: if you have heart tests before, such as a cardiac catheterization (we’ll talk about this below), a stress test, or cardiac echocardiography, keep copies of these tests and bring them to the ER. The ER team will love you for it, and it will really help you get the best care. My advice: when you get the results from one of these tests, take a photograph with your smartphone and keep it in your favorites folder. Or if you prefer low tech: keep a manila folder with key test results and grab it on the way to the ER. Whatever system you prefer, having old test results for the ER is important, because our fragmented health care system doesn’t have a universal health care record (unlike most countries in the wold — “USA! USA!”, indeed) and the ER folks very likely won’t have access to your records.
Most visits to the ER for chest pain do not end up revealing a heart attack. If this is your situation, don’t be upset that you went in the first place even though it was a “false alarm” — this is truly a situation where it is better to be safe than sorry. The ER might decide to watch you overnight in the hospital for additional testing; this is a very common outcome from a chest pain evaluation in the ER. Key insider info: when you go to the ER for chest discomfort, especially if you have risk factors for heart disease (see description of this above), be ready for a possible hospitalization, and don’t fight the ER team if they try to keep you.
If the ER team determines that you are having a heart attack, they will quickly get the cardiology team involved and prepare you for a procedure known as cardiac catheterization, also known as cardiac angiography. This is the crucial treatment of heart attack — the opening up of the clogged blood vessel. In the “cardiac cath lab”, as it is known, the cardiologists will make a small incision in either your thigh or wrist, and snake a small tube through your blood vessels into the coronary artery system. When they find the blockage, they can break through the blood clot using a balloon that sits at the tip of the small tube. By inflating this balloon, they can basically smush the blood clot against the sides of the artery, opening it up once again for blood flow. This is known as “angioplasty”. Sometimes, a piece of metal mesh is placed at the spot as well, known as a “cardiac stent”. After angioplasty, you will be kept in the hospital for at least another day for monitoring and recovery. here’s a video describing the angioplasty and stent procedures.
What if I don’t want to do any of this? What’s the worst that could happen?
Here’s the thing: most people do indeed survive heart attacks, even if they did nothing. But that’s not the attitude you want to have. First, some heart attacks do lead to cardiac arrest, which is a highly lethal outcome. Second, even if you don’t die on the spot, a piece of heart muscle will die from the blocked artery. Your heart will then be permanently weakened, which means you will be more easily fatigued, often short of breath, and unable to enjoy activities like you did before the heart attack. It’s not an outcome you would want.
If a heart attack is treated within an hour or two of onset, outcomes are excellent, often without any residual heart damage. On the other hand, if treated late (6 hours, 12 hours, the next day after the heart attack), damage may be irreversible.
Summary: key points and action items
Heart attacks are common, and there are things you can do to prepare for the worst. Of course, the best thing you can do is work to prevent coronary blockages. That is done by quitting smoking, treating your diabetes and high blood pressure carefully, and getting enough exercise. Prevention of heart disease is an excellent topic, but I’m just a humble ER doc and will leave prevention information to others (or maybe if encouraged I can write about this as a separate diary).
Key things you can do or think about:
* Keep a bottle of aspirin in your medicine chest
* keep records of prior heart tests handy, including stress tests, cardiac catheterization reports, etc
* make sure you don’t ignore symptoms such as sudden chest discomfort
* if you go to the ER with chest pain, be prepared for possible hospitalization
* most people survive heart attacks, but dead cardiac muscle can create lifelong problems
Entire textbooks have been written on heart attacks, so I’m certainly not doing justice to the topic. For this, I apologize, but hopefully these key details are helpful. I’m happy to entertain your questions and comments — so let’s chat. The ER Doc is “in” and ready to see you.