ISSN-1059-6518

NON-CARDIAC CHEST PAIN

By Frank Hubbell, DO

Illustrations by T.B.R. Walsh

In the June 2014 edition of the WMNL, the pathophysiology, recognition, and treatment of cardiovascular disease was discussed. With these various illnesses the source of the chest pain is a problem with the coronary circulation of the heart itself. In this issue of the WMNL, we will look at the sources of the non-cardiac chest pain.

Imagine you are working with a group of park rangers in the Rockies when the team gets a call for a hiker in distress. As it turns out, the hiker is reportedly on the same trail as you are, and they are an estimated 3 miles away, about a one-hour hike from you present location. According to dispatch, they were notified via cell phone from the hiking party that one of their members is complaining of chest pain and does not feel as if he can continue on.

Dispatch is able to give you some additional information: the hiker is a 46-year-old male, one of four in their hiking group. The group left the trailhead before sunrise and were taking the most direct route to the summit, in hopes that they would reach the summit before sunset and hike down in the dark with headlamps. They are not prepared to stay out overnight. The other three hikers are all men in their late 20’s. They have known each other for years, as he was their outing club director and their math teacher in high school.

An hour later you catch up with the hiking group. They are sitting together under a large pine tree, sharing some gorp (trail mix) and water. You introduce yourself to the patient and explain that you are a paramedic working with the park rangers. The patient is very glad to see you and seems to be quite relieved.

He states that after hiking for several hours, the incline of the trail became quite steep, and he was having a hard time keeping up with his younger companions. As he pushed onward, he began to develop pain in the anterior of his chest, tingling in his hands and arms, shortness of breath, mild nausea, and began to feel weak, almost as if he was going to pass out. He states that he did recover completely after a five-minute rest, but when he would start hiking uphill again, the symptoms returned after about fifteen minutes. Currently, he feels much better, since they have been at rest for the past hour. He feels that he can walk out, as it is mostly downhill.

The real concern regarding this 46yo male, is whether the chest pain is cardiac or not. If cardiac, he deserves rapid evacuation. If non-cardiac chest pain, then he can most likely walk off the mountain.

You should always err on the side of caution and assume that all chest pain is cardiac until proven otherwise. To sort out cardiac chest pain from non-cardiac chest pain requires a good history, specifically looking for the cardiac risk factors and a good physical exam to try to accurately determine the source of the pain. As you read the descriptions of non-cardiac chest pain types, you will notice that some sources would require immediate evacuation. When in doubt, as stated above, always err on the side of caution and assume all chest pain is cardiac until proven otherwise.

WMN-Cover-27.2

ISSN-1059-6518

By Frank Hubbell, DO

Illustrations by T. B. R. Walsh

Unfortunately, heart attacks and premature death due to heart disease are very familiar problems, not only in the USA, but also, around the world. Very common calls for EMS and for emergency departments in hospitals, they are universal issues. Heart problems occur in all environs, from urban to rural to austere. If you have a heart, you are at risk of heart disease.

US Data from the Center for Disease Control – 2104

Cardiovascular Disease (CVD):

CVD includes:

coronary artery disease (CAD)

hypertension (HTN),

congestive heart failure (CHF)

heart failure

dysrhythmias (irregular heart beat)

valvular disease

stroke – cerebrovascular disease (CVA)

Since 1900, CVD has been the #1 killer in the US except for 1918 (Spanish flu).

600,000 Americans die per year from heart disease.

380,000 Americans die from an Acute Myocardial Infarction – “heart attack.”

1 in 4 Americans or 25% of all deaths in US are due to CVD.

1 in 4 (80 million) Americans have some form of CVD.

Men have a higher incidence of CVD until age 65, then women have a higher incidence.

An estimated 720,000 Americans will have a heart attack in 2014.

Of that number, 515,000 people will have their first heart attack in 2014, and

205,000 people will have a recurrent heart attack.

Cardiovascular Disease Terminology:

Arteriosclerosis: A disease of the arteries with thickening, hardening, and loss of elasticity in the arterial walls.

Atherosclerosis: The most common form of arteriosclerosis, marked by cholesterol-lipid-calcium deposits in arterial linings.

Coronary Artery Disease (CAD): Narrowing of coronary arteries sufficient to prevent adequate blood supply to the heart muscle.

Angina Pectoris: Pain around the heart caused by deficiency of blood supply to the heart.

Acute Myocardial Infarction (AMI): The condition caused by partial or complete occlusion of one of the coronary arteries. Infarct refers to a blood vessel that has been occluded by a blood clot, emboli, resulting in ischemia (lack of blood flow and oxygen) to the myocardial cells distal to the infarction.

Acute Coronary Syndrome (ACS): A collection of symptoms that can indicate a possible myocardial infarction, but before a definitive diagnosis has been made. This includes angina pectoris and acute myocardial infarction.

Clinical Death: Patient without a pulse.

Biological Death: Occurs within 10 minutes of clinical death due to lack of oxygen to the brain.

Sudden Cardiac Death (SCD):

SCD occurs when the heartbeat stops abruptly and unexpectedly, unassociated with any immediate illness or injury.

Most common underlying cause of SCD is a heart attack that results in ventricular fibrillation (V-fib).

80 % of SCD occurs at home; 60% are witnessed.

Approximately 95% of SCD victims die before reaching the hospital.

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