This is the second in a series on chest pain and chest pain emergencies.

You’ve developed jaw pain and profuse sweating, and a sense of dread.  You know something is wrong.  Now what?!!

Well, that depends on where you are.  If you are in a rural area, you may not have a lot of choices, so you will have to head to the nearest facility.  But in a more metropolitan area, the choices you have may significantly change your treatment options and subsequent outcomes.

In the case of an acute heart attack, or acute coronary syndromes, as we mentioned in our previous post, “time is heart muscle.”  Doctors have only a short window to treat coronary ischemia before permanent, irreversible damage is done.  This is the underlying principle which guides the care of all patients presenting with chest pain syndromes (including atypical chest pain).  Multiple large studies in several countries have demonstrated that better short-term care produces more likely long-term survival when the treatment is initiated within three hours of the onset of symptoms.  These results were recently supported by one large Japanese study published in the May 2012 British Medical Journal.

The consistent results of these studies have led to the development of the American Heart Association (AHA) guideline recommending a “door to balloon” time of less than 90 minutes.  This means that hospitals must see, triage and treat all patients with chest pain within 90 minutes, or less, with balloon angioplasty which is the gold standard for care.  Failure to meet this criterion results in stiff penalties in compensation.  These guidelines have been adopted around the world as the standard of care for reducing morbidity and mortality.

“Balloon angioplasty” is a procedure where a doctor threads a catheter through a vein in either the wrist, or the groin, to open a blocked artery in the heart.  However, not all hospitals and clinics have angioplasty facilities, which are expensive to maintain and require an on-site interventional cardiologist and support staff.  This is particularly true in rural areas, and to some extent, even in some larger cities in Mexico.  For people in smaller communities, you may not have a choice of where to go.  But for city-dwellers, choosing the wrong facility means a delay in treatment as the initial facility evaluates you, and then waits to transport you to another, better equipped hospital.  (Reference a case study of this situation in our article, Heart Attack – a Woman’s Way.)

This is why it is important to know before-hand where to go if you suspect that you, or a loved one, is having a heart attack.  It’s not as straight-forward as it sounds.  Here in Mexicali, a city of 1.5 million residents, there are only four facilities with cardiac catheterization labs, and none of these are located in the large, public facilities.

Coronary Angiography

During this procedure, the patient receives sedation, but will remain conscious.  A wire is then threaded from either a blood vessel in the wrist, or the groin, to allow access to the large central arteries, and the heart itself.  After the wire is in place, a small plastic catheter or tube is positioned over the wire into the artery, and the wire is removed.  Through this wire, the cardiologists can administer medications, and instruments to manipulate the heart and blood vessels.

The cardiologists then use the catheter to inject radio-opaque dye into the coronary arteries to visualize blood flow, which is called coronary angiography.  Areas that are not seen well during this procedure are the areas of blockages known as coronary atherosclerosis.

In the cath lab with Dr. Leonardo Monge

Today, I visited the cath lab at Hispano Americano Hospital in Mexicali.  I joined Dr. Monge and his business partner, Dr. Raul Aguilera in the cath lab for a scheduled coronary angioplasty and stent placement for a patient who had recently had a heart attack.  This patient had received an emergency intervention the previous month, but had complained of continuing symptoms on exertion at a follow-up appointment.

After being brought to the cath lab, the patient was draped from head to toe.  Dr. Monge quickly maneuvered the C-arm into place, and places the angiography catheter.  Once he injects radio-opaque dye, we see that the patient’s previous stent has no obstructions, or thrombus.  In reviewing the films, however, another large blockage in a different artery is seen and that is what Dr. Monge suspects is causing the patient’s current symptoms.  Dr. Monge and Dr. Aguilera quick deploy another stent to the narrowed area, widening the artery to increase blood flow.  The whole procedure takes about thirty minutes.

Afterward, the catheter is removed, and a heavy bandage is placed at the insertion site in the patient’s groin.  After a brief recovery period, the patient will be admitted for overnight observation before returning home.  The overnight stay is mandated because of the location of the catheter and the use of blood thinners for the procedure which create a risk of serious bleeding.  Doctors and nurses will monitor the patient for several hours to ensure there is no evidence of internal bleeding, or any damage to the insertion site.

Post angioplasty

After staying overnight, the patient is discharged with several medications to help slow the progression of blockage formation, and to prevent the stents from becoming clogged.  This component of treatment is critical, since angioplasty and stent placement are stop-gap measures for a continuing disease process.

Remember: There is no cure for coronary artery disease, but diet and exercise along with medications, angioplasty and surgery can make it manageable.

In our next article, we will discuss some of the medications used to treat coronary artery disease.

I never meant to end up in Mexico!  At least, it wasn’t in the grand scheme of things to do in my life.  But sometimes things don’t follow our best laid plans and it all works out just fine.  A couple of years ago, I had a steady practice in my native Virginia and was planning a vacation to Cartagena, Colombia.

I am one of those restless people.  I love my job as a nurse practitioner and taking care of people, so my vacations seldom live up to the idea of getting away from work.  As a result of my Cartagena vacation trip, I ended up writing my first book about medical tourism, and while there I got hooked on all things Latin American.

A year later, when my boss at the practice in Virginia announced to me that he was planning to retire from surgery, I knew that it was time to continue my Latin American journey.  I returned to Colombia, for six months this time, and wrote two more books.  My feelings were ambivalent about leaving when I returned to the United States, but I was, as always, ready and eager to get back to the business of taking care of people.  I was thrilled to find a position within my specialty that sounded ideal.  It was on the other side of the country from my Virginia home, but that didn’t seem like an enormous obstacle for a “dream job.”

Unfortunately, dreams are sometimes fantasy, and the job was a nightmare of the worst sort where naked ambition fostered overt hostility, back-biting office politics and a lot of career-destroying potential.  I was the seventh person in that position in just a few years time, and they never let me forget it.  But, the major drawback was that instead of being able to care for people, I was basically expected to “process” them and move on.

Processing people is not something I am able to do – it goes against my fundamental sense of decency and all the reasons I became a nurse in the first place.  So, no one was “processed” during my term at the facility, but I moved on, all right!  Previously, I had interviewed a surgeon in Mexicali, Mexico as part of the research for one of my writing projects, and from the first meeting, I was impressed with his drive, his compassion and his surgical skills.  When I found myself in that awful place, feeling trapped and hopeless – I reached out and asked for help.

I asked if I could study with him while I regained my bearings and healed from my disastrous experience.  Thankfully, he graciously agreed.  He has been my lifeline, along with my husband, as I make plans to return to school this fall to get my doctorate and to get back to my patients and the career I love so very much.

In the meantime, I am having a wonderful time improving my Spanish, rounding on my patients, and learning about the endemic thoracic diseases of northern Mexico, which differ quite a bit from what we see in Virginia.

Mexico and its people have been my saviors, and my time here has made me a better provider and a better person.  In return, I want to share my experiences so others can get a truer sense of Mexicali, and all that this beautiful country has to offer.

Part of the mission is to provide objective and unbiased information for potential medical travelers.  Kristin’s research has led to two publications on the medical services in Colombia.  At present, she is looking at facilities closer to home in Mexicali, Mexico, as she studies with a local thoracic surgeon.

A believer in transparency and objectivity, Kristin’s work is independent of outside organizations, physicians, facilities and is entirely self-funded with the exception of occasional financial gifts from her parents, who encourage and support her work.

She also invites questions and comments from interested readers through the “Contact Us” option at the top of the page.  She is also known as the “Traveling NP (Nurse Practitioner)” and maintains several blogs on both thoracic surgery, www.cirugiadetorax.org and general surgical information and travel at www.cartagenasurgery.wordpress.com.  Click here to download Kristin’s latest book on surgical tourism in Mexicali.

This is the first in the series on chest pain emergencies.  During this series we will talk about recognizing symptoms, where to go, what tests or treatments to expect, and what medications you may receive.

Detection of a problem.

The development of chest pain, or other abnormal sensations in the chest, should always be considered a potential medical emergency.  In medicine, we take these indications very seriously and consider them to be cardiac in nature, until proven otherwise.  It is critical that people be able to identify the possible signs and symptoms of chest pain emergencies so that they recognize the need to seek emergency medical attention.

Time is the enemy!

I cannot emphasize this enough!!  The best way to treat a heart attack is to prevent it, by treating the condition known as acute coronary syndrome (“ACS”) before it leads to a heart attack, or destroys cardiac tissue.  In cardiac conditions, just like with strokes, time is the enemy as we have only a short window to administer medications and treatments aimed at preserving heart muscle.

Acute Coronary Syndrome versus Heart Attack: What’s the difference?

I often use the following analogy when talking to my patients to explain the difference between ACS and heart attacks, and the treatments used for both.  Think of a houseplant you forgot to water before you went on vacation.  Now if your vacation is short, and you return soon enough, the soil may be dry, the leaves may be brittle, but the plant can be saved by watering it.  But if you head off to Europe, and when you return your plant is brown, shriveled and the leaves are crumbles; the plant has died, no amount of water is going to bring it back.  It’s the same with your heart.  If a patient presents early with symptoms caused by a lack of blood flow to the heart muscle, and we restore blood flow, the heart survives with minimal damage.  But if patients come to the hospital after having symptoms for hours or days, the area of the heart affected will be dead.  That area, depending on its size and location in the heart, determines whether the patient lives or dies.

What is “chest pain?”

The term, “chest pain” in itself is misleading, as many people, particularly women and diabetics do not experience the symptoms that that are typically depicted during a heart attack (“myocardial infarction”).  For this reason, these individuals have a greater likelihood of dying during a heart attack.  In fact, several studies show that despite new treatments, and faster interventions, two-thirds of women presenting with a heart attack will die from it.  When these people do present for medical assistance, because the symptoms are atypical, it is often several hours or even days after symptoms began.

Often, after visiting a doctor or emergency room, patients feel embarrassed and may minimize symptoms.  Do not be embarrassed.  You know your body – if you think that this “indigestion” feels different it’s important, so tell us.  In fact, we have a special name for these symptoms – we call them “chest pain equivalents.”

The classic symptoms of angina (chest pain) are:

–        Pain or pressure in the chest behind the breastbone.  It is often describes as “a weight on my chest.”

–        This sensation may radiate to the arms or jaw.

–        Sweating or clammy feeling.

–        Weakness or dizziness.

But I would like to add to the list, based on the experiences of my patients:

–        Reflux or indigestion symptoms, particularly when unrelated to recent food consumption, or different from previous experiences.

–        Nausea.

–        Numbness sensations in chest, arm, face, even the earlobes.

–        Fatigue (sudden onset).

–        Swelling of the feet (called edema).

–        Shortness-of-breath, which may be worsened by laying down.

–        Dyspnea on exertion – if you notice over the previous weeks or month that you can no longer do normal activities without becoming short-winded or fatigued, this is a very important symptom.

It is important to note, that the vast majority of patients I’ve treated had actually been experiencing symptoms on and off for several months, so let’s clarify indigestion symptoms, and remember, when in doubt – head to the hospital.   If pizza always gives you indigestion, but you haven’t eaten pizza, or it feels different from the indigestion from pizza, this may be angina or your chest pain equivalent.  People often tell me, “I thought I was just out of shape,” or “I was just getting old.”  Symptoms that develop over a course of weeks, or months, are not normal and are not a normal part of aging.

Timing of symptoms is important.

If your symptoms start with activity, i.e. you walk up stairs and start having heartburn symptoms, or your ear goes numb, or you feel nauseated when you go for a walk, this may be a sign that your heart is struggling rather than the onset of a digestive problem.  If these problems awaken you from sleep, be very concerned – this is one of the hallmark signs of an impending heart attack and is called, “angina at rest.”

But what if I get to the hospital and it is just heartburn?  Then I will feel silly.

Better silly than permanently disabled, or dead.  Try feeling lucky instead, since that’s what you are.  Cardiovascular disease is one of the leading causes of death worldwide, so raising an alarm about chest pain is not silly – ever!  If doctors are able to rule out an acute coronary event, they will likely want to schedule you for some additional testing.  Just because your symptoms weren’t caused by “the big one” doesn’t mean that you don’t need to be screened for underlying cardiac disease to prevent future cardiac problems.

And if, the tests come back with normal results, it’s an excellent time to treat that indigestion that prompted you to see us in the first place!!

Next time, we will talk about where to go if you are experiencing these symptoms.