IN CASE YOU MISSED IT

Deciphering signs of a heart attack

This story was first published in The Straits Times on June 6, 2013

The most common symptom that my patients worry about is chest pain.

Chest pain can take many forms.

I often have to be like a detective, and try to sniff out the cause. This can be stressful when there is a worry that it could be life-threatening.

However, once we have ruled out a problem with the heart, we should not dump the chest pain into a trash bin. Other causes should still be treated.

The chest pain from a heart attack is classically described as a crushing pain in the middle of the chest, which feels like a heavy stone pressing on the chest. The severe pain is usually unremitting and lasts more than 10 minutes. It may also spread up the neck and down the left arm.

The person feels very ill and breathless and breaks out in cold sweat.

If the chest pain lasts for a much shorter period, then it is probably not due to a heart attack but can still be due to a temporary reduction in the blood flow to the heart muscle - what we call angina. It can occur at rest, during exercise or both.

Other causes of severe chest pain that could lead to death if not treated promptly are aortic dissection and pulmonary embolism.

For aortic dissection, which is a tear in the wall of the aorta, the pain is usually described as a tearing pain that shoots from the front of the chest wall to the back or spine. The patient can also have cold sweat and look very pale and ill.

Pulmonary embolism shows up more subtly as a vague central chest pain or pain in one side of the chest wall. It is associated with a sudden onset of breathlessness.

This is because a blood clot has lodged in an artery of one of the lungs, which leads to the choking off of blood supply to the lung and a drop in oxygen supply to the body.

OTHER SIGNS OF A HEART ATTACK

Women who are suffering from a heart attack do not usually have typical symptoms.

Research has shown that they complain more of breathlessness, dizziness, extreme fatigue and pressure in the upper back or upper portion of the abdomen or stomach.

This may confound doctors who may not immediately pick up that the women are having a heart attack.

Diabetics also have symptoms which are different. Due to nerve impairment from diabetes, they usually do not experience any chest pain but may complain of breathlessness or just some light pressure in the chest.

Another big group of patients have what I call atypical chest pain. This needs a lot of work to sort out.

Many patients describe it as poking, squeezing or fluttering pain. It is usually localised, meaning the patient can point to a spot of pain.

It can last for a few seconds or a whole day and is not associated with any breathlessness or cold sweat.

There are many causes for this.

A young woman recently came to me complaining of chest pain on her left side which lasted two whole days. It was worse when she breathed in.

It was highly unlikely that the 20-year-old was having a heart attack or angina. A chest X-ray revealed pneumothorax, which is an air-leak, in her left lung.

I referred her to a lung specialist who inserted a chest tube to drain the air.

Another common cause is nerve entrapment. The chest wall is supplied by nerves, without which a person cannot feel anything there. These nerves come out from the neck and go down to the chest wall through tight tunnels or narrow spaces.

If these nerves get compressed by the muscle or any fluid retention, it could lead to sharp pain in the chest.

Another patient, Andy, complained of a poking or tingling pain that occurred on and off at various spots all over his chest and sometimes on his left shoulder and arm. The arm had some numbness.

This was likely due to nerve compression. I gave him medication to relax the muscle and to lessen the nerve pain and he felt better. I also recommended that he go for physiotherapy to relax the muscle and move it off the nerve.

FEELS LIKE A HEART ATTACK

Chest pain can also be due to a psychosomatic disorder, defined as a bodily ailment brought on by a mental or emotional disturbance.

Andrea, a 38-year-old executive without any risk factors for heart disease, had difficulty in breathing, numbness of the hands and chest tightness.

The attacks were episodic. All her cardiac tests came back normal.

The way to manage her condition would be through stress management and maybe an anti-anxiety drug.

Other types of pain can mimic heart pain. The oesophagus (food pipe) lies directly behind the heart. Any problems with the food pipe can lead to central chest discomfort.

Another common problem is oesophageal spasm, or a cramp of the food pipe. A person can get it if he drinks too fast or swallows a piece of hard food too quickly.

This rather severe cramp in the middle of the chest prevents him from breathing or talking. It usually improves within one or two minutes.

Acid reflux (back flow of stomach acid) is also common. A patient typically describes it as a burning sensation rising from the stomach to the upper chest, especially when he is lying down.

A person experiencing chest pain should see a family doctor quickly and get an electrocardiogram.

If that test, which checks the electrical activity of the heart, gives a normal result, then we will have time to pinpoint the cause of the chest pain. With the right diagnosis, the problem will be resolved and the patient will feel a whole lot better.

kennethng@novenaheartcentre.com.sg

Dr Kenneth Ng is a consultant cardiologist at the Novena Heart Centre. He specialises in treating heart failure. He was the director of the heart failure programme of the National Healthcare Group from 2003 to 2007.

This story was first published in The Straits Times on June 6, 2013

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