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Ticking Off Reasons for Chest Pain

THE BALTIMORE SUN

For five weeks her chest ached, but Rosalie Geisler, 55, did her darndest to ignore it. Then, in the middle of the night, a sharp pain woke her. By morning, it marched down her left arm, leaving her fingertips almost numb.

Mrs. Geisler put it out of her mind and left for her manager's job at the Cake Cottage in Perry Hall. Later, her worried husband arrived with doctor's orders to take her to the hospital.

"I didn't want to come," she says after a team of nurses at St. Joseph Hospital descend on her to hook her up to a heart monitor.

Is she having a heart attack? Gail Cunningham, the emergency room doctor, doubts it after checking Mrs. Geisler's cardiogram and her medical history. But the doctor can't be sure because of her arm pain and a family history of heart trouble.

Only a few months ago, patients such as Mrs. Geisler who experience chest pain but have no clear signs of heart attack would either be sent home or admitted to the hospital for three days of tests. Now hospitals are setting up special units -- pioneered at Baltimore's St. Agnes Hospital -- where this in-between crowd can be conclusively tested in as few as five hours.

Chest pain is the most common kind of pain there is. About 5 1/2 million people go to hospital emergency rooms every year complaining of it. Many of them, including Mrs. Geisler, are terrified when they go in and relieved, if not embarrassed, when they leave. In the end, only 13 percent have had heart attacks.

Trying to identify them the traditional way bogs down ER departments, ties up expensive monitoring equipment, and costs $8 billion to $10 billion each year to hospitalize people who aren't having heart attacks. Even then, doctors don't get them all: Each year an estimated 35,750 people with chest pains are sent home from the emergency room based on factors that make a heart attack unlikely -- their age, type of pain, etc. -- and end up having heart attacks at home, according to the Cardiology Roundtable. Of these, more than 5,000 die.

Reducing heart attacks

"That's one of the reasons you want a chest-pain evaluation unit," says Robert A. Barish, professor of medicine and director of emergency medical services at the University of Maryland. People in the chest-pain evaluation unit at Maryland have actually undergone more tests and a more complete evaluation for heart attacks in 17 hours than past chest-pain patients admitted to the hospital for three days, he says. The cost has dropped by two-thirds, to $1,078, since the unit opened in 1993.

Heart attacks are still the nation's leading cause of death, taking the lives of 600,000 people every year. But doctors hope they can reduce the numbers as hospital emergency departments switch over to a faster, cheaper way to evaluate chest pain and encourage people in pain to come in sooner.

In the last five years, hospital chest-pain units have grown from 50 to about 1,000, and the numbers are doubling every 10 months. There are three in the Baltimore area -- at the University of Maryland, St. Agnes and St. Joseph -- and others are in the planning stages.

Just as the advent of coronary care units -- wings in hospital set up for patients with heart pain -- allowed doctors to focus on heart ailments and discover how to prevent cardiac arrest in the 1960s, chest-pain units hold the promise of treating people before heart attacks occur -- at the first sign of unusual pain.

Dr. Raymond D. Bahr, an emergency room doctor at St. Agnes and the "father" of chest-pain evaluation units, believes that half of the 600,000 deaths from heart attacks are preventable if the early warning signs are heeded. Dr. Bahr, whose treatment methods are copied all over the world, set up the first unit to evaluate and treat chest pain at St. Agnes in 1981, and is largely responsible for the growth of such units nationwide.

Most heart attacks, he says, don't start out with crushing pain. Rather, in the hours, days and weeks leading up to a heart attack, patients have what he describes as "pressure, fullness, burning, ache, within the middle of the chest."

This discomfort "comes with activity and it is relieved by rest. What happens is, people do less. The other thing people do, because it is not pain, is they put off seeing a doctor until it becomes a recognizable heart attack."

The classic description of a heart attack is "an elephant sitting on my chest."

Henry Sabatier, an emergency medicine doctor at Harbor Hospital, had a heart attack while driving his car last November. He remembers it as being almost like a choking sensation.

"The pain was right in the center of the chest," he says, "deep inside, sometimes squeezing, pushing and gripping all at once." It was accompanied by nausea, lightheadedness and breaking out in a sweat -- all signs described in textbooks.

"The only thing I didn't have is pain radiating from my heart to my arm," he says. Dr. Sabatier used his car phone to call 911. He is back at work after bypass surgery.

Chest pains differ

Most of the people who go to the hospital with chest pain have other problems -- ulcers, anxiety, even gas. Or they have been working out too fiercely or raking so strenuously around the yard that their overworked muscles mimic heart pain.

"Heart pain is one of the least likely causes of chest pain," says Dr. Eric Toner, head of the chest- pain unit at St. Joseph.

Being able to distinguish between heart attack pain and other chest pains is nearly impossible, even for doctors. Deaths from misdiagnosed heart attacks account for most of the dollars paid out in malpractice lawsuits against emergency room doctors -- another reason to want a better system to treat people with chest pain.

For every classic case, there is a twist. Some people have normal cardiograms for several hours into their heart attacks, Dr. Sabatier notes. In one study at the Cleveland Mayo Clinic, for instance, only 29 of 67 people having heart attacks were identified through their EKGs.

Also, men are more apt to have "classic signs" of heart attack than women (most likely because the symptoms were developed from male-only studies). Chest pain announcing a heart attack in women and many elderly people is often less severe and more intermittent.

Mrs. Geisler doesn't have the crushing pain that heart attack victims often describe.

In the chest-pain unit at St. Joe's, her heart is monitored and she undergoes a series of blood tests and a stress test.

At her bedside, Dr. Cunningham quizzes her on her medical history. A few days ago, the patient says, she was nauseated and sweating. A fever comes and goes.

The doctor is reassured that her chest hurts more when the doctor presses on it. At first, Mrs. Geisler responds to nitroglycerin, a drug that dilates blood vessels in the heart and is given to heart attack victims to increase circulation and relieve pain. Is the pain in her arm something else? From indigestion? Pneumonia?

A heart attack occurs when vessels to the heart become blocked by plaque, and blood carrying oxygen can no longer pass through. When that happens, the heart muscle around the blocked vessel dies, and dead cells gradually shed into the bloodstream.

To rule out a hidden heart attack in someone whose tests seem normal, doctors test the blood for the presence of enzymes released by dead heart muscle. It takes days to get a complete picture, but if repeated tests on the hour show the levels of these proteins rising, doctors know something is wrong and can act quickly.

Early prevention

Doctors can stop a heart attack in progress and send a patient home with no damage to the heart muscle. They do so by catching the attack early and administering what are known as clot-buster drugs to dissolve fatty deposits that clog the bloodstream.

Or, as in the case of an ashen-faced middle-aged man writhing in pain in the emergency room at St. Joseph at the same time Mrs. Geisler arrived, angioplasty may be the best bet. This process, which clears the blood vessels of clots, is highly effective if done early -- within 45 minutes, doctors made room for him in the hospital's catheterization lab.

About 5 percent of people with heart attacks in the hospital die, down from 30 percent in the 1950s when the only treatment was an oxygen tent and morphine, according to estimates compiled by Dr. Barish. The University of Maryland and St. Agnes are preparing a national study to find out how and whether chest-pain units have reduced it further. Dr. Bahr estimates it may be as low as 1 percent.

The number of people going to St. Agnes has doubled to 4,000 annually since the center opened, largely because of Dr. Bahr's educational efforts. But nationally, two-thirds of people who have heart attacks never make it to the hospital. That is why doctors encourage people with unusual chest pain to have it checked immediately.

The earlier doctors find heart conditions such as angina, the more likely they are to be able to prevent cardiovascular disease altogether. That happened to one of Dr. Bahr's patients last week.

James Gallagher mistook heart pain for indigestion at first because it began on the right side, over his right breast, not in the middle of the chest where he experienced discomfort during an angina attack in 1988, he says.

A customer services representative for Simkins Industries in Baltimore, Mr. Gallagher, 53, started having chest pains at about 6 p.m. one day. When Maalox didn't help, he took three nitroglycerin tablets he had at home. They didn't do anything, either. An hour passed. Remembering Dr. Bahr's "preaching" about early treatment of pain, Mr. Gallagher called the doctor, who told him to come right in.

Mr. Gallagher's EKG was suspicious, but not conclusive. Blood tests show no sign of enzymes indicating a heart attack. Dr. Bahr suspected a blockage, and ordered a procedure in which a balloon is inserted into the blood vessels. Diagnosis: 95 percent blockage of the right vessel, which requires angioplasty to prevent a heart attack. While he waited overnight for the procedure, Mr. Gallagher got medicine to improve blood flow and ease pain. Ultimately, doctors don't expect permanent damage.

Meanwhile at St. Joseph, Mrs. Geisler gets the good news: she is not having a heart attack. She probably has residual pain from the bronchitis she developed last month and Dr. Cunningham gives her an anti-inflammatory. A few days later, she is off to a convention, healthy and happy.

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