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‘Doctor, I Think That I Might Be Having a Heart Attack’

heart-bandaid-stockIn this issue of The American Journal of Medicine, Kahn et al report on closely observed and studied patients with eosinophilic esophagitis who presented with exertional chest discomfort that might have led to a diagnosis of angina, or possibly even myocardial infarction. This is one more entity in a long list of diseases that can produce chest pain and which might be confused with the discomfort of ischemic heart disease (Table). In fact, only a modest percentage of patients who present to the emergency department or the clinic complaining of chest discomfort actually are eventually found to have myocardial ischemia causing their pain syndrome. This presents a major clinical conundrum for the examining physician: Does this patient have a potentially life-threatening condition, that is, rest angina or an acute myocardial infarction?

In many, if not most cases, a careful history and physical examination will disclose the noncardiac nature of the discomfort. For example, the pain associated with pleurisy is invariably made worse with deep inspiration. Pericardial pain is also usually made worse by deep inspiration or lying prone on the stomach or the back. Gastrointestinal discomfort secondary to reflux disease often occurs following ingestion of food or beverages. And finally, the absence of atherosclerotic risk factors, such as young age in the 2 patients reported by Kahn et al1 in this issue of the AJM, make myocardial ischemic pain very improbable but not absolutely impossible. For example, the hockey player (case #1) suffered chest trauma that might have caused a dissection in one of his coronary arteries that could have later impaired coronary blood flow and led to exertional myocardial ischemic discomfort. The thoughtful and complete evaluation that this patient received eventually led to the correct diagnosis with effective therapy.

In part because of media campaigns to inform the public concerning the dangers of delayed therapy for acute myocardial infarction, the medical community sees and evaluates many patients with noncardiac chest discomfort, at considerable financial cost. Because as many as 25% of the US population may at one time or another experience chest discomfort, the potential for health care cost is immense. Chest pain units are one way to approach this large problem. These specialized units seek to evaluate patients who come to the emergency department in a rapid and accurate manner. The goal of these units is to decide quickly which of the arriving individuals actually may have myocardial ischemia as the etiology for their discomfort and which patients have a much more benign etiology. The first group is admitted to the hospital for further evaluation, while the second group is discharged home with appropriate outpatient follow-up instructions. For several years, my current institution has employed this strategy, resulting in far fewer patients admitted to the coronary care unit with a diagnosis of “rule-out myocardial infarction.” The physicians and the hospital administration believe that there has been a marked improvement in our initial management of these patients as a result of the chest pain unit.

The take-home message from the article by Kahn et al1 and my comments above, is that physicians still need to take a careful history followed by a thoughtful, and at times focused, physical examination in patients who present with the complaint of chest discomfort. Only a minority of these individuals will have ischemic heart disease causing their pain. Distinguishing patients with myocardial ischemic pain from the vast majority of individuals with noncardiac pain is one of the most important tasks that a physician is called upon to perform.

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–Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)

This article originally appeared in the January 2015 issue of The American Journal of Medicine.

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