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Medical Information

When you want, or need, to know more than the superficial, such as when you are

where there is no access to a physician.

Prototypically: Medicine at Sea

Comments/Disclaimer

This medical information is provided for education purposes only. I am making no attempt to practice medicine over the internet. This is being written to give some basic knowledge for those that are physically isolated from access to professional medical care, such as sailors at sea. This is to help in deciding whether an emergent medical condition exists, how to initially deal with it, and whether evacuation is needed. It is by no means exhaustive or meant to replace personal medical attention. Please do not contact me regarding your personal condition. Over the years I have received many emails from people asking for help with their personal chest pain, or whatever. Sometimes they write during acute pain. This is ridiculous. You can't practice medicine over the internet. If I find their email, after it has been filtered by my spam filter, it may be days or weeks later. My response, if any, will be to contact their regular provider. Even a bad doctor in person is better than an email. Please use this information in the spirit in which it is intended.

Sincerely, Mark R. Anderson, M.D.

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Please also see:

Is my chest pain a heart attack?

If not, what is it?

The links above are intended to be less focused on the heart attack as the consideration.

Mark Anderson, M.D. 2000

v 1.5

April 6, 2010

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Note: I am discussing here primarily the typical presentation of symptoms, with some reference to the variable presentations. The human body is not that simple and often diseases present in unusual ways. This information is meant to give more than the very superficial information given in other sources, but is by no means intended to suggest that you not discuss your problem with your medical provider. It's meant to discuss some of the thought processes and decision points a physician uses when presented with an individual patient. The patient may or may not be able to adequately self-reflect on their own symptoms and may or may not be comfortable with the risk of uncertainty. This information is not meant to be authoritative or complete. It's meant to be a starting point. I hope you find the information useful and use it in the spirit in which it is attended.

One thing to keep in mind: The uncommon presentation of the common problem is more common than the common presentation of the uncommon problem.

For a more general discussion of chest pain go to the Evaluation of Chest Symptoms.

What is a 'heart attack'?

Not all 'attacks' of the heart are heart attacks? Huh? I mean things like palpitations, irregular heart rhythms, fast or slow pulses, high blood pressure, heart failure, angina pectoris, and heart failure are not heart attacks. A true heart attack is an acute coronary syndrome (ACS) in which the circulation to a part of the heart is being blocked off by clot and heart muscle is trying to die. Death of tissue is an infarction, therefore the medical term for a completed heart attack is a myocardial infarction (MI). Fortunately, these days we can often reestablish blood flow to dying heart muscle with blood thinners and clot busting medication before the muscle dies. We can abort the heart attack in process if we act quickly enough.

Here's a brief description of "typical" heart pain. ( i.e. Ischemic Heart Disease)

It's a pressure, squeezing or dull ache felt in the center of the chest (i.e. not over the heart). If it is brought on with exertion and relieved by rest it is particularly suspicious for angina pectoris. Often the individual will not call it a pain, just a pressure or tightness, and may demonstrate it by holding a fist over their breast bone. It may radiate to the neck, teeth, arms, back or, more infrequently, the upper mid abdomen. It may only appear in those other places. (In other words, there may be no chest pain.) The association with exertion, or fright/anger or after meals is important. Pain triggered by exertion is the most suspicious. Angina pectoris is heart pain due to a shortage of blood and oxygen to the heart muscle. It's reversible and is relieved by rest or medications such as nitroglycerin (NTG). Untreated angina pectoris (pain without damage) lasts less than 15 min. (assuming you stop and rest). When the pain is not relieved by rest and especially if it is associated with nausea, vomiting, shortness of breath, cold sweats, dizziness or palpitations and the longer it lasts, (over 30 min.) the more likely it has progressed to a heart attack ( ACS or MI) with damage or death of heart muscle. Sometimes, particularly in women, the elderly and the diabetic, there may be no pain but just the other associated symptoms or a sense of overwhelming fatigue. Several other things may precisely mimic, or be mimicked by, heart pain. Most common would be esophageal pain or an ulcer. Less commonly it's mimicked by acute lung problems (potentially fatal), rupturing or dissecting aneurysm (highly lethal), gall bladder attack, pericarditis (inflamation of the sack around the heart) and others. Each of these other possibilities have their own 'typical' presentation and it's necessary to weigh the evidence of one vs. another to arrive at a presumptive diagnosis.

If you have know angina, you should recognize that a change in your typical angina can mean a progression of disease that may proceed to MI. Changes include more frequent angina, angina caused by less exertion, angina at rest, and angina that is more difficult to relieve by nitroglycerin.

If you think you're having a heart attack, take one regular old fashioned aspirin (not acetaminophen/Tylenol). The aspirin makes your platelets, those blood cells that form clots, less sticky. Hence clot is less likely to form or enlarge and this simple aspirin reduces your risk. Then use your best judgement to either promptly call your physician or an ambulance. Strongly consider the ambulance if the pain is close to typical, (as described above), and lasting longer than 30 minutes.

Congestive Heart failure (CHF): CHF is a failure of the heart to be able to pump as much blood as is demanded of it and the blood backs up. If this is new, it may have been triggered by a heart attack, which may have been "silent". CHF may also develop slowly over time, or suddenly in the setting of some physical stress such as severe infection or high blood pressure that is out of control. Typical symptoms include: abnormal shortness of breath with exertion, worsening breathing if you lie down, (so there's a desire to sleep seated or propped up on a few pillows), waking up at night short of breath, and needing to get up at night to urinate more than once . As both sides of the heart progressively fail you also get swelling in the legs. Sudden severe attacks produce extreme shortness of breathe, the victim wants to sit bolt upright and there may be pink frothy sputum. Listening to the lungs there is usually a wet crackling sound.

There are two very serious causes of non-cardiac chest pain that need to be considered. Both can kill virtually instantaneously, or live and require special treatment. Fortunately they're both infrequent to rare.

First, pulmonary embolus (PE). This is caused by a blood clot from deep vein thrombophlebitis (DVT). So first you have to have phlebitis, and things like being bedridden, or prolonged seating (e.g. by a plane flight), CHF, leg injuries, and birth control pills increase that risk. The DVT may show up as a swollen tender red warm calf, but symptoms are sometimes very subtle. In any event, the PE usually shows up as sudden onset of chest pain on one side of the chest or sudden shortness of breath. The pain may increase with breathing, the pulse usually quickens and variable degrees of being short of breath develops. The result can be sudden death, or quite mild symptoms. What may separate this from other causes is suddeness of onset, risk factors, and lack of injury or systemic symptoms like fever , etc. Unfortunately, this can be a very subtle and difficult diagnosis to make unless it's first thought of and specifically tested for.

Second is dissecting aneurysm, and this is rare enough that less than one a year shows up in the average emergency room. An ACS/MI is probably at least a hundred times more likely. Anyway, typically this is sudden severe central chest pain that radiates through to the back. It may travel down the arms and even legs. It generally occurs with a long history of high blood pressure. Certain people, e.g. those with Marfan's Syndrome (what Abraham Lincoln had) are quite susceptible. Though often very dramatic, (like getting hit in the back with a baseball bat), it can be much more subtle. Pain in the back with a hypertension history is the most significant clue.

Other causes of chest pain: This is extremely cursory, but the following guidelines are usually correct. If it clearly hurts to breathe, i.e. the actual movement of breathing hurts, (rather than a sensation of not being able to get enough air), then the problem is almost always in the lungs (e.g. pneumonia or pneumothorax) or chest wall (ribs and muscles.) If you can find an area of the chest that is tender to the touch and pressure there reproduces the pain, then the problem is not your heart, and generally in the chest wall. If you can find a position or movement that clearly causes the pain, it's also usually in the chest wall, but occasionally in the lungs or (rarely) pericarditis. If swallowing, burping, specific foods or regurgitation is associated with the pain, and/or the pain is clearly of a burning quality, then it's generally due to a gastrointestinal cause, usually esophageal. Gastro Esophageal Reflux Disease, (heart burn with or without esophageal cramp) is probably the most likely thing that closely mimicks true heart pain. Plus there are a zillion other causes.

Email: capn-shanghai@comcast.net

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