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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
 Gastroesophageal
reflux disease
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.
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