Monday, June 27, 2011


To continue with the Monday series, let us consider the issue of chest pains, a very common complain to a family practice clinic or cardiac clinic.
Of course, chest pains frighten the patient because of the fear of death, knowing that people with chest pains may be suffering from a heart attack, and so may die.
When face with chest pains, a patient must try his / her best to remember the events surrounding the onset of chest pains ( what brings it on, what relieves it ), the duration of chest pains and any other associated discomforts with the chest pains.
It is always good to remember that over the chest, there are about 5 important organ systems, viz the musculoskeletal ( muscle and bones and joints ) system, the nervous systemm ( the nerves and nervous, emotional disorders ), the pulmonary ( lung system ), the gastro-intestinal system ( stomach, gullet, gallbladder ), and of course the heart and great vessels. Anyone of these organs can cause chest pains. I usually tell my patients that it is often impossible to completely diagnose the chest pains, because we have no means of accurately pin pointing the cause of the chest pains. Sometimes, the pains may have dual cause, for example, the monir gastritis could trigger a severe emotional response because his office colleague have just collapsed and died following a squash game. In fact the most important clue to the diagnosis of chest pains is the history. Chest pains that come on effort, and is relieved within 5-10 mins by rest, maybe due to heart artery blockage. We call this angina. We sometimes add that besides being relieved by rest, it can also be relieved by sublingual GTN. The other chest pains without those cardinal features ( chest pains on talking, chest pains on hunger, chest pains on stretching the muscle, chest pains on deep breathing, chest pains following a blow to the chest ) are unlikely to be from heart artery disease. Chest pains not from heart artery disease, invariably do well long term and are seldom the cause of death. So always remember if there is a pattern. What brings the pain on, and what relieves it, is a great help to us. Chest pains on effort ( like climbing stairs, jogging, cleaning the windows, playing badminton, etc ), and relieved once you stop, rest, that one, please take note and visit your friendly GP.
We also give weightage if chest pains occur in the context of someone likely to have heart artery disease. Chest pains in someone with two or three coronary risk factors, must never be ignored, even if the features are not characteristic. As we all know, coronary risk factors include cigarette smoking, diabetes, hypertension, dyslipidemia, family history of coronary artery disease. Of course, patients with previous established coronary artery disease ( previous angioplasty, previous CABG, previous heart attacks, previous angina ), must have their chest pains thoroughly investigated.
Generally speaking, if the chest pains have any of the possible features of angina, and in the context of someone, who is likely to have angina, that chest pains must receive full attention.
Check ups for someone who may have heart artery disease, should include, an ECG, a full blood profile and a stress ECG. In patients who are unable to stress, perhaps a stress echo, or othe forms of nuclear imaging. These are the standard test.
The stress ECG, does two things for us. Firstly, it helps us to find out the reason for the chest pains, including excluding important heart artery disease ( should the chest pains be negative ). Yes, you can still have heart artery blockage without it showing on the stress ECG, but those heart artery disease are usually relatively minor and not life threatening. So, a stress ECG also helps us to separate out those heart artery blockages that is potentially deadly, and those that can be managed medically. In fact, many of us will not do an coronary angiogram to delineate the coronary anatomy, unless there is inducible ischemia ( stress ECG positive ), unless the reason to do an angiogram is so compelling ( and cash from angiogram, is not a compelling reason ).
I suppose, I should say a word about the CTA ( CT scan with angiogram ). In 2011, at the present stage of our understanding, and present stage of the machines available, there is no role for the use of the CT angiogram, to screening the population for heart artery disease. Besides the cost ( about RM 2,700 ), there is the radiation risk ( 500 chest X-ray equivalent ), and the rpesence of false positives ( thereby ending up with many unnecessary angiograms, and maybe even unnecessary angioplasties. Heart artery disease, when they are assymptomatic ( not giving chest pains ), and are stress ECG negative, do very well with medical therapy, like life style modifications and stains, and aspirin. In this category of people, all the evidence seem to suggest that medical therapy is as good as angioplasty or bypass surgery. CT angiogram, should be used to exclude heart artery disease, meaning that if my CT angiogram is normal, it is very, very unlikely that I have any heart artery disease. It is NOT a good tool to diagnose heart artery disease. It is true that with time ( over the last 10 years, we are seeing better and better scan machines coming into the market, so that eventually we will have machines with a high degree of accuracy, and low level of radiation. Eventually.
Lastly, I must mention that we advocate a strategy, where males above 40 yrs and females above 50 yrs ( post menopausal ), should go for a routine medical check-up, including ECG and stress ECG, in a n attempt to pick out occult, important heart artery disease. This is because, the majority of patients with important heart artery disease, do not know that they have it. It is silent, and so we depend on ischemia producing test to pick it up. Non-ischemia producing test have a high level of false positives. Patients with no symptoms, and a negative stress ECG are either normal, of does not have any high risk heart artery disease.
Well, keep a healthy cardiac lifestyle. Not to smoke, eat wisely, exercise regularly and maintain your ideal body weight. The old cliche is true, prevention is much better than cure.

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