Heart Pain and Heart Attack

How is The Heart Pain?

Pain due to ischaemic heart disease (IHD) is quite unique in its character, distribution and behavior. Doctors call such pain as Angina Pectoris.

What is Angina Pectoris?

Angina means crying and pectoris means chest. So angina pectoris means nothing but crying of the heart. If a baby does not get enough milk, he cries like that if heart does not get enough oxygen through blood flow, it also cries. A patient with angina usually describes the pain as a tightness, a fullness, a heaviness, a feeling as if their chest is in a vice, or a dull aching discomfort. As a rule, it is provoked by exertion, although it can occur at rest if the victim is experiencing a great deal of emotional distress. Usually heart pain is confined to the centre of the chest, and occupies an area about the size of a hand. Sometimes it may spread across the whole chest. Occasionally it may radiate to the neck, jaw, left shoulder and along the inside of the left arm. The feeling starts gradually; within 30-60 seconds it intensifies until the victim is forced to stop whatever he is doing. These symptoms often appear during exertion, after eating, during sex, in cold weather or under stress. As a rule, the pain disappears within a few minutes of stopping the activity, although occasionally it may last longer. Putting a nitroglycerine (GTN) tablet under the tongue or spraying nitroglycerine causes relief of the pain within few minutes.

Types of Heart Pain

Doctors Usually Divide The Heart Pain (Angina Pectoris) into Two Categories :

  1. Stable angina
  2. Unstable angina

Stable refers to the predictable appearance of chest discomfort with a certain amount of extortion. For example, walking fast or up a slight incline usually produces symptoms, but they never occur when you are walking at a slow pace on level ground. It disappears promptly with rest, and its severity, duration, and precipitating causes do not usually change over a period of years. In contrast unstable angina is alarming. Sometimes it is the herbinger of death. So it requires immediate attention. In layman term unstable angina means when the patient gets chest pain at rest.

Canadian Cardiac Society (CCS) Classifies Heart Pain in To 4 Categories :

  1. CCS Class-1 angina- This means the patient gets chest pain only during marked physical exertion and promptly relieved by rest.
  2. CCS Class-2 angina-It occurs after moderate exertion and relieved by rest.
  3. CCS Class-3 angina- Chest pain occurs after mild physical exertion. Even routine household activities may precipitate such type of angina.
  4. CCS Class-4 angina- Class 4 angina means pain at rest.

Unstable angina is Class 4 angina. Unstable angina describes two situations. In one, pain occurs in patients with no background of prior symptoms. In the other case of unstable angina, individuals with previously stable angina will experience changes in their symptoms, the pain may be more severe, lasting longer; or it may appear with less exertion than before.

Except these types of angina there are some special varieties of chest pain. If patient gets pain just after taking food, it is called postprandial angina. Chest pain after taking food is very suggestive of significant ischaemic heart disease (IHD). Some patients awake from sleep at night due to chest pain, this type of pain is called nocturnal angina. Patient may experience pain in lying condition, which is termed as angina decubitus. Emotional stress may precipitate heart pain, called variant or Prinzmetal angina.

Stable angina does not require urgent medical attention; however, unstable angina needs immediate care. Furthermore, the circumstances under which angina takes place also will govern how the problem should be treated. For example, chest discomfort that is noted only rarely, and then only with extremes of exertion, need not be handled with the same urgency as angina triggered by walking across a room.

How is The Pain of Myocardial Infarction (Heart Attack)?

The pain of heart attack is similar in location, radiation and character, but is far more severe and prolonged. Such pain may be described by patients as crushing in intensity or a feeling as "if some one were sitting on my chest." Although usually described as a squeezing, choking, or heavy pain, it may also be characterised as a stabbing, knifelike, boring, or burning discomfort. The pain is usually located in the central chest and may spread frequently to both sides of the chest, with predilection for the left side. Often the pain radiates down the inner aspect of the left arm, producing a tingling sensation in the left wrist, hand, and even fingers. Some patients note only a dull aching pain or feeling of uneasiness of the wrists in association with severe central chest pain. In addition to the pain, other symptoms are usually present in a heart attack. Heart attack pain may be accompanied by breathlessness. Patient feels difficulty in breathing. Pain may be associated with profuse sweating. Patient may develop vomiting or nausea (vomiting tendency). The victim commonly becomes very pale or ashen in color and may feel faint on standing up. You should suspect a heart attack with moderate to severe pain lasting beyond 15-20 minutes and in the absence of a specific cause. This requires immediate medical attention.

Anginal Pain vs Heart Attack Pain

Anginal pain usually starts after exertion and is relieved by rest. In contrast heart attack pain may start at rest and even during sleep. Heart attack pain is more severe than anginal pain and it is not relieved by rest. Anginal pain usually responds to GTN tablet under tongue or GTN spray but Myocardial infarction (heart attack) pain remains unabated even after taking multiple GTN tablets. So if you are a known case of angina pectoris and if your pain does not respond to 'Zl3 GTN tablets, please consult your doctor or go to the nearest hospital immediately.

What to Do in a Heart Attack?

If you have the kind of chest pain just described, you may be having a heart attack. So seek medical assistance immediately. Many people delay seeking medical help thinking the pain will go away. This could be fatal. More than half of all deaths from heart attack occur in the first few hours. Valuable time may be lost in initiating proper treatment. The earlier a heart attack victim gets to the hospital the better are the chances of survival and more importantly the possibility of saving extensive muscle damage.

If You Suspect That You Are Having a Heart Attack Take The Following Steps :

  1. If you are not sure whether the chest pain is a heart attack or not, call your doctor immediately and describe your symptoms carefully.
  2. If your doctor can not be reached, go to the nearest hospital at once.
  3. Do not drive to your doctor/hospital on your own. Instead, ask your immediate family member/driver or friends to take you to the hospital.
  4. Avoid exertion and stay calm.
  5. If you have been a heart patient before and have nitroglycerine tablet (GTN) or GTN spray with you, sit down or lie down and put one GTN tablet underneath your tongue or spray GTN inside mouth. If the pain is not relieved within five minutes, you can take another GTN tablet or GTN spray. If there is still no improvement, you should then seek medical attention immediately.

Why is Time Important after Heart Attack?

Undue delay in seeking medical advice after heart attack can lead to unfortunate fatal outcome. Every body must realise that first few hours after heart attack is crucial. Most of the deaths occur in this period and proper treatment can prevent fatal outcome. So please do not make great mistake. There are few scientific reasons why heart attack patient must go to hospital immediately:

  1. Deaths due to electrical instability (irregularity of heart beat) are very high during early hours of heart attack and this can be immediately treated by counter electric shock (DC shock) if you are inside a coronary care unit. This type of irregularity is fatal if not treated urgently. If you are inside a coronary care unit this fatal electrical instability can be managed even by a nurse or medical technician. A timely action may save your life and it is usually completely reversible.
  2. Heart attack is always due to blockage of one of your coronary artery (blood solidifies inside your coronary artery and this solidification of blood is called "thrombus"). Now-a-days medicines are available which can dissolve the thrombus/clots and restore normal coronary artery flow and prevent further damage. These medicines are called thrombolytic agents (which dissolves thrombus). These agents are expensive but they are very rewarding. These agents are now available in our hospitals. So, it is a real hope against extensive heart damage. They can reduce the fatality by 45 per cent along with aspirin (2). But this injection is only effective if they are given in the early hours of heart attack. There are some evidence that if these injections are given within one hour they may completely reverse the heart attack. These medicines are usually administered within six hours of the heart attack. After six hours their efficacy is doubtful. So, if you report to hospital after six hours you are certainly going to miss this magic bullet.
  3. At the inception of heart pain you may have minimum damage to your heart muscle. So, if you report to hospital early the further damage may be prevented by using drugs like intravenous injection of heparin and GTN/Isosobide di nitrate. Early intervention preserves your heart function. So, seek medical attention immediately after suspecting heart attack.

Can You Have Heart Attack Without Chest Pain?

Yes, this is possible. In certain instances you may have heart attack without chest pain. In some patients, particularly in the elderly, myocardial infarction (heart attack) is manifested clinically not by chest pain but rather by symptoms of breathlessness, vomiting tendency, profuse sweating and severe weakness. So, if an old man suddenly develop breathing difficulty or sweating or sudden onset of weakness, the possibility of heart attack requires to be excluded. Unrecognised or silent myocardial infarction (heart attack) occurs more commonly in patients with diabetes. Sudden onset of breathlessness or severe weakness in a diabetic patient is alarming and it requires thorough heart check up.

What is Silent Ischaemic Heart Disease?

Sometimes it may happen that you have gone to a doctor for routine heart checkup but you do not have any chest pain or previous history of heart disease and after doing ECG your doctor tells you that you are having heart disease. Sometimes ECG may be done for other reasons like preoperative risk stratification or to fillup insurance company protocol or preemployment check up or during annual confidential report time and it is found that your ECG is abnormal. If you do not have any chest symptoms but your ECG reveals abnormality, you must have a thorough cardiac check up. If you do not have chest pain it does not mean that you can not have block in your coronary artery. Some people inspite of having block in heart circulation do not have chest pain. This means that you have disease but your "warning system" is defective. Silent ischaemia is one of the causes of sudden death. Why some patient get severe pain and other do not is not well recognised. But probably it is due to the variability of individual pain threshold. Pain threshold varies from person to person. Some are afraid of taking a simple injection but some can stitch there own wound himself. Possibly some patients do not have angina inspite of having significant ischaemic changes in ECG.

If your ECG is abnormal it does not always mean that you are having block but it is a genuine suspicion. Some people may have abnormal ECG since birth and it is called normal variant ECG (that means functional deviation from the normal status). Even then if your ECG is found to be abnormal at routine check up, you must undergo adequate examination to exclude or to establish coronary artery block. You must remember that a fire may remain hidden under ashes for a long time but it may burst at any time. So, beware of it and do not neglect.

What is Syndrome "X"?

If the medical scientists can not dig out the cause of any disease or fail to solve any other medical problem they use the term "X". In reality X means cause is not known. Some people get angina or angina like chest pain without any blockage in their coronary artery. This is called syndrome "X". Their rest ECG is usually normal. In 20 per cent of cases their stress test (ECG during walking) may be positive for heart pain. These patients complain of chest pain but their coronary angiogram is normal without any block. Now question is that why these people get angina like chest pain though they do not have any block. There are certain explanations; in coronary angiogram we can only see the large arteries but we cannot see smaller arteries so there is possibility that these patients are having disease in these small vessels (arteries) which cannot be seen in angiogram. Second possibility is that these patients may have abnormal vasodilator reserve which means that they cannot dilate and constrict their coronary arteries like normal people. These type of chest pain with normal ECG and normal coronary angiogram is frequently found in women. This can lead to multiple medical consultations and be responsible for a great deal of anxiety. Some researchers have found that 66 per cent of patients with chest pain simulating heart pain with normal coronary artery have some psychiatric (mental) disorders. Their long-term prognosis is very good. They usually do not develop heart attack. These patients require assurance and proper psychological counseling and analgesics for relief of pain. Calcium antagonist group of drugs like nifedipine, diltiazem, amlodipine work excellently in this situation. Tricyclic antidepressant may be effective in some patients. Behavioral therapy may teach the patient with pain how to function more effectively.

Why The Heart Attack Frequently Occurs in The Morning?

The incidence of heart attack is high in the early morning. This is called circadian periodicity. The peak incidence of heart attack is at about 9 AM. This view has been confirmed by WHO. Other recently published studies also found that the time of onset of myocardial infarction (heart attack) displays a circadian variation, with the peak occurrence in the early morning between 6 AM and noon. There are several well recognised explanations why heart attacks are more common at morning time. Increased frequency of heart attacks may be due to increased morning blood level of certain hormone like cortisol and increased blood catecholamines such as adrenaline and nonadrenaline. During morning time blood also solidifies easily (thrombus formation) due to increased platelet aggregability. Heart rate and blood pressure also remain high at early morning as compared to afternoon. For those above mentioned reasons heart attacks occur more frequently at morning time. But this type of morning peak may not be seen if the patient is already taking aspirin or beta blocker drugs or if the patient is a smoker or known to have diabetes.

What is Sudden Cardiac Death?

Sudden cardiac death is defined as unexpected death that occurs within one hour of onset of symptoms. But the time interval from onset of symptoms to death has been defined by some investigators as less than minutes but by others as up to 24 hours. Nearly 75 per cent of all sudden deaths occur at home; 8-12 percent at work. About 90 per cent of sudden cardiac deaths are caused by IHD (heart attack). n

Submitted By

Dr. Baren Chakraborty FCPS, FCCP, FACA, FRCP
The author is Associate Professor of Cardiology.

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