Stephen Bittner Sr., thought he was having heartburn, a whole week of heartburn, heartburn so severe his wife kept asking, "Are you all right?" while he kept popping Rolaids and aspirin and telling her he was fine.
An insurance agent, the 53-year-old man should have known better: He had already lost two brothers to heart disease, and another had undergone bypass surgery. "But I just didn't think it would happen to me," he says. "I thought I was too young."
Besides, the pain wasn't constant; he'd take the pills and eventually it would go away -- "except that this one particular day, it didn't go away, and my wife insisted that I go to the hospital," he recalls.
In fact, Trudy Bittner insisted her husband go to St. Agnes, where people with distress that might be related to the heart are seen in the Chest Pain Emergency Room (CPER) established 10 years ago by Dr. Raymond Bahr, chief of the hospital's coronary care system.
The nation's first CPER, the St. Agnes unit is now one of 64 thathas opened or is in planning stages. It remains the only one in Maryland.
"It's a user-friendly place," says Dr. Bahr: There are no screaming babies, no accident cases, no other diseases or disorders. No one asks for your insurance number until after you've been diagnosed and stabilized. The staff and equipment are dedicated to just one thing -- your heart.
Dr. Bahr is a man with a mission. He wants you to know that heart attacks can be stopped, and the heart muscle rescued, if you get yourself into the hospital for treatment with clot-busting thrombolytic drugs in the first hour after a blockage in a coronary artery begins to starve your heart.
Even more than that, he wants you to know that a lot of heart attacks don't have to happen at all. "Chest pain is the final risk factor for heart attack," he says; the on-again, off-again kind of discomfort that Mr. Bittner thought was heartburn might well be your last warning.
"If we had a 'black box,' like the one investigators look for after a plane crash, for everyone who died of a heart attack, and we could go back over their last 48 hours, a significant number -- 40 to 60 percent -- would have had warning signs," he says. "You go from one bed to another in the CCU [coronary care unit]and the patients will tell you about this 'stuttering' discomfort before the occlusive event.
"But we're programmed -- when symptoms are mild -- to put them on a back burner. People are involved with the busy-ness of the day. They try to tough it out; they don't seek attention. . . . And then they come in crashing."
At the St. Agnes chest pain emergency room, people in cardiac catastrophe are rolled directly from the ambulance into the treatment room. Those who can walk come in through the general ER doors, and are immediately diverted to the chest pain center.
"When you come in here, our concept is that you could be having a heart attack; we put you on a heart monitor right away," says Dr. Bahr. They also give oxygen and aspirin, start an IV, draw blood and take a history of your symptoms.
It could still be that your discomfort is only indigestion, or muscle spasm, or some other problem not related to your heart, and you'll be sent home with a referral to your family doctor; that's what happens in about 50 percent of cases, according to Dr. Bahr.
It could also be that the EKG is normal, but your history is so suspicious that you'll be asked to stay overnight and have a stress test the next day, just to be sure.
Or, you could have come in just intime.
Mr. Bittner had not yet had his heart attack when he arrived at the hospital last July 15. His discomfort, Dr. Bahr determined, was the warning, not the crash. "If he had not come in, he would have blocked completely," the doctor says now. "But he came in early enough that we could cool him off with drugs, and then study him further."
Events moved pretty quickly, Mr. Bittner remembers: "I went into St. Agnes on Sunday; they did a cardiac cath [catheterization of the coronary arteries] on Monday and determined I had blockages in three arteries -- one of them was 90 to 95 percent blocked. On Monday night I went by ambulance to Washington Hospital Center, and the next morning they did a balloon angioplasty" to re-open the blocked channels.
After a period of recovery and rehabilitation, Mr. Bittner went back to work. He remains under Dr. Bahr's care, watches his cholesterol, carries nitroglycerin tablets with him in case of another chest pain attack. "But I've never had to use them," he says.
But not everyone is so lucky. Heart attacks kill 500,000 people a year in this country, in spite of CPR, thrombolytics and healthier habits. Thousands of others survive their attacks, but with diminished cardiac capacity. Those numbers could be cut, drastically, Dr. Bahr believes, ifpeople would stop ignoring their pain -- or other people's.
Dr. Bahr wants families, friends, co-workers, even the ushers at sporting events to pay attention to chest pain, too. He's made "heart-helper" video tapes available at some local video stores to be loaned out free, and has devised an "early cardiac caregiver's oath," in which loved ones promise to try to get you to the hospital if anything is happening in your chest. If using an ambulance embarrasses you, go in a car, he advises -- but let one of your cardiac caregivers drive.
This summer, the National Heart Lung and Blood Institute is coordinating the "National Heart Attack Alert Program," which also emphasizes early treatment of heart attacks.
According to Dr. Michael Horan, associate director for cardiology at the institute, the national effort is aimed at the actual attack rather than the warnings. However, he adds, it's hard to know which it is until you get it evaluated.
The program is also focused, in its early stages, on getting the medical establishment "geared up to thinking a heart attack is as much of an emergency as a gunshot wound," he says.
Establishing a chest pain emergency room is one way to accomplish that, Dr. Horan agrees: "If it can be done, it ought to be applauded."