Heart muscle pain (angina) is likely to be the first warning of blocked coronary arteries, the cause of most heart attacks. While there are no infallible guidelines about whether a chest pain is heart-related, it generally takes a particular form. Heart discomfort is rarely a sharp, stabbing pain. The textbook description of angina is a feeling of heaviness, pressure, tightness or aching in the chest, usually accompanied by shortness of breath. The pain generally goes away when you stop exerting yourself, and it frequently isn't especially severe. People experiencing a heart attack often feel they are being squeezed by a vice or a heavy weight has been placed on their chest. Others report a stabbing, knifelike or burning sensation. The pain is prolonged, usually lasting for 30 minutes. The pain can also last for hours. The pain does not lessen or increase with changes in the position of the body, nor is it relieved with rest. Some patients experience no chest pain. Some patients describe pain radiating down the arms (usually the left arm) with a tingling sensation in the wrists, hands, and fingers. Others report pain in the shoulders, neck, and jaw. It may just be uncomfortable pressure, fullness, squeezing or pain in the center of the chest lasting more than a few minutes. The pain may spread to the shoulders, neck or arms. It may be mild to intense. It may feel like pressure, tightness, burning, or heavy weight. It may be located in the chest, upper abdomen, neck, jaw, or inside the arms or shoulders. There may be chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath. Often, there is anxiety, nervousness and/or cold, sweaty skin, paleness, or pallor. Sometimes there is increased or irregular heart rate. The pain can also radiate to the teeth and back. Additional symptoms include indigestion, nausea, vomiting, palpitations, cold perspiration, weakness, dizziness, cough, fainting, dry mouth, anxiety and a sense of impending doom. In general, men and women experience the same symptoms of a heart attack; although women might describe chest pain differently. For men it might be more localized, while chest pain in women can be described as diffuse. Although many heart attack victims report some form of chest pain, people over age 75 and diabetics often do not feel chest pain and may only feel like they are having indigestion or shortness of breath. However, persons under age 75 can also have silent heart attacks which do not involve chest pain. Certainly, not all of these signs occur in every attack. Sometimes only a few symtoms are present or they go away and return.

    CALL 911, THEN DO PRE-HOSPITAL CARE If you are experiencing chest discomfort and any of the above symptoms, you or someone close to you should call an ambulance immediately. Use 911 or your local emergency number. If the person is able to take ONE aspirin, and is NOT already taking other heart medicine, do so IMMEDIATELY. This significantly increases chances for survival. If you are not sure if you are having a heart attack, call your doctor immediately. There is a strong tendency to deny the possibility of a heart attack. Denial and delaying medical treatment can cost you your life. Research shows that one in three people die from a heart attack within the first few hours of experiencing chest pain. Making the decision to get to a hospital early is often the single most important factor in determining survival. In particular, people over 75, diabetics, or people with a history of previous heart attack must seek medical attention immediately. These patients should seek immediate medical attention even if they are only experiencing nausea or shortness of breath without chest pain. If you have been given nitroglycerin tablets by your doctor, put one under your tongue when the symptoms begin and repeat at five minute intervals for a total of three doses. If the symptoms have not disappeared within 15 minutes, call an ambulance immediately. Do not take nitroglycerin tablets unless directed by a doctor, as it can cause much more harm than good.


    If you are with someone whose heart has stopped beating, call 911 or your local emergency number. Administer cardiopulmonary resuscitation (CPR) immediately. CPR will supply oxygen to parts of the body until the ambulance arrives. Even if you don't think you are doing it correctly, continue until medical help arrives.


    Call 911 FIRST and then begin cardiopulmonary resuscitation (CPR).


    You can have a heart attack without knowing it. The nation's longest-running heart study suggests that about one heart attack in four produces no symptoms - or at least none that the victim associates with a heart problem. These so-called "silent heart attacks", however, are only the most extreme case of a still more prevalent condition called "silent ischemia" - a chronic shortage of oxygen - and nutrient-bearing blood to a portion of the heart. Both conditions put their victims at significant risk. The cause of ischemia, silent or otherwise, is almost always atherosclerosis - the progressive narrowing of the heart's arteries from accumulations of cholesterol plaque. In most instances, this reduction in blood supply generates a protest from the heart - the crushing pain called angina. But in perhaps 25 to 30 percent of heart attack victims, there were no previous symptoms of these gradually developing blockages. The Framingham heart study, which has followed 4,000 Massachusetts men for more than 40 years, has found that 25 percent of their subjects' heart attacks go unnoticed until their annual EKGs detect their after-effects. The absence of pain, however, doesn't mean an absence of damage. The heart has a built-in reserve capacity, allowing it to suffer a certain amount of scarring and weakening from a heart attack and continue to meet the body's needs. But further ischemia or another heart attack - even a mild to moderate one - may prove fatal, because that reserve capacity is no longer there. Even those who survive another heart attack are at increased risk of becoming cardiac cripples, disabled by congestive heart failure or arrhythmias - heartbeat irregularities. There is no way of predicting absolutely who is a candidate for silent ischemia, but, statistically, the greater the number of risk factors for coronary artery disease that you have, the more likely you are to be a candidate. Those risk factors include some you can't control - your age, sex and genetic predisposition to atherosclerosis - and those you can influence, like diabetes, high blood pressure, high blood cholesterol, smoking, lack of exercise and obesity. As a rule of thumb, you should undergo a screening for silent ischemia if you have any three of these factors working against you - a man over age 50 who smokes, or a post-menopausal woman with a ten-year history of diabetes and chronic unfavorable blood cholesterol levels, for instance. The screening for undetected ischemia is a medical history and physical examination and a cardiac stress test - a workout on a treadmill while your heart function is monitored. It's a painless and inexpensive way to learn whether the beating of your heart is accompanied by the inaudible ticking of an atherosclerosis time bomb that could kill you.


    Angina is a protest from the heart muscle that it isn't getting enough oxygen because of diminished blood supply. A heart attack is simply the most extreme state of oxygen deprivation, in which whole regions of heart muscle cells begin to die for lack of oxygen. If the blockage in the arteries serving the heart muscle can be cleared quickly enough - within the first few hours of the onset of the attack - the permanent damage can be held to a minimum. That's why it is so vital to seek medical attention quickly if you feel the sort of pressing pain or heaviness described above. There is a 90 percent probability that pain of this type is angina. And even if it goes away, the artery blockages that caused it are still there - and will grow progressively worse.


    The heart requires oxygen to function properly. The blood inside your heart does not supply oxygen to the heart muscle---special blood vessels on the outside of the heart, called coronary arteries, feed the heart muscle. Three major vessels and many smaller vessels do this job. When one or more of the major vessels is obstructed for (usually due to blood clot formation in the blood vessel lumen), blood cannot reach the heart muscle beneath the block, restricting the supply of oxygen to the heart. Within 20 minutes of not receiving blood and oxygen, the heart muscle begins to die, leading to a heart attack. A heart attack results in the loss of function or contractility of the damaged portion of the heart.


    The heart works like a large pump and consists of a bag comprised of muscle with blood vessels leading in and out. The blood flows from your lungs, where it picks up oxygen, into your heart and gets pumped out to the rest of your body. Once the blood has delivered its oxygen to the tissues, it returns to your heart and gets pumped back out to the lungs.


    Treatment goals at the emergency room are to decrease the demands on your heart and prevent and treat complications. An IV (intravenous catheter) will be placed in a vein. This is usually the best way to administer fluids and medications. Even if blood levels of oxygen are normal, oxygen is generally administered to decrease the workload of the heart and make oxygen readily available to the body. A urinary catheter might be inserted to help monitor the input and output of fluid from the body. Your doctor will use the following information to determine the severity of your condition and the treatment of choice: previous medical history, physical examination, an electrocardiogram (ECG OR EKG), and the level of pertinent chemicals in your blood. Physicians will want to know what type of chest pain you may have experienced previously. They will also want to know whether you have had a heart attack in the past, surgeries, and if you take any medications. (It is useful if a family member has knowledge of medication dosages.) This information will help physicians determine whether the pain you are feeling is due to a heart attack. If you are having a heart attack, rapid pulse, changes in blood pressure, crackles in lungs, and abnormal heart sounds might be found on physical examination. The ECG (or EKG) is a test that records the electrical rhythm of your heart. Wires (or leads) are attached to the chest, arms and legs using pads with gel or tape. This procedure is not painful. Specific changes in the ECG alert the physician that a heart attack is occurring. EKG monitoring is generally started immediately since life threatening dysrhythmias (defective rhythm) are the leading cause of death during the first several hours following an acute heart attack. Blood tests provide an indication of heart muscle damage. When some of the heart muscle dies, the dead cells release chemicals into the blood. One chemical that is routinely evaluated is creatinine phosphokinase (CPK), specifically the MB isoform. This enzyme is found only in heart muscle cells. Another chemical which is becoming more widely evaluated is troponin T, also found only in heart muscle cells. The levels of these chemicals present in the blood can tell doctors how much heart muscle has been damaged and when the heart attack might have first occurred.


    If ECG results determine that you are having a heart attack, your doctor will try to use medications to help the heart. Several of these drugs are specifically designed to prevent further blood vessel obstruction (aspirin and heparin). Others, such as oxygen and nitroglycerinare, are designed to decrease the heart's work load. Nitrogylcerin decreases pain and reduces the heart's requirements for oxygen. Calcium channel blockers and beta blockers also decrease requirements for oxygen. Digitalis is given to improve the heart's ability to pump. You might also be given morphine for pain management. Patients might be prescribed anti-arrythmics (depending on the abnormal heart rhythm) and diuretics such as lasix. If your doctor finds a specific pattern on the ECG while you are having chest pain and you have no other complicating condition (such as bleeding or a brain tumor), you will probably receive a thrombolytic. This is medication is given intravenously to dissolve blood clots that might be causing the blockage in your heart vessels. Thrombolytics are usually given within 30 minutes of arrival in the emergency room or possibly even in the ambulance. Intravenous heparin is often given with the thrombolytic drug or immediately thereafter to help prevent the blood clots from reoccurring.



    Your physician may request a cardiac catheterization. A thin catheter (plastic tube) is inserted through a vein or artery in the arm or leg and is guided into the coronary arteries of the heart. This test can measure how much oxygen is in the blood, blood pressure, and can provide information about functioning of the heart muscles, valves and arteries. A dye can be injected through the catheter and obstructions can be identified by observing the dye flow.


    If thrombolytic therapy is not indicated or it did not relieve heart attack symptoms, your doctor may decide to treat you with angioplasty. Angioplasty can be performed during a cardiac catheterization. Angioplasty consists of a small balloon being placed at the site of the coronary blockage and blown up with air. This causes the material forming the blockage to be compressed along the wall of the vessel. The inflated balloon can also cause the vessel to stretch, making it wider so more blood can flow through. It can also cause cracks in the blockage that will allow more blood to flow through. The patient is mildly sedated during angioplasty and most people report feeling only minor discomfort. A dye is injected into the patient's arteries which allows the doctors to monitor the patient's blood flow and determine the site of blockage. The tube with the balloon, known as a catheter, is inserted at the site of an artery in the patient's groin area. The catheter is moved along the artery until it reaches the blockage. The balloon is then inflated for a period of a few seconds to a few minutes, then deflated. Blood flow is monitored to insure adequate reperfusion or restoration of blood flow. Sometimes the balloon will to be reinflated at the same site or at another site. Sometimes a stent is placed at the site of the balloon. A stent is a rigid tube which prevents the vessel from collapsing or a blood clot from forming at the site of the blockage.


    If angioplasty is unsuccessful, the position of the block is difficult to access by angioplasty, or you have blockages in two or more major vessels, the doctors may decide to treat you with bypass surgery. In this procedure, a piece of vein is taken from the patient's leg or an artery from the patient's chest is used to enable blood to go around, or bypass, the blockage. Several blocks can be bypassed at the time of surgery.

    Bypass surgery is invasive. Bypass patients will have general anesthesia and will not be awake for the surgery. Pre-operative medications are often administered to bypass patients by mouth, injection, or IV. During bypass surgery, the patient's chest bone is separated, and the ribs are spread apart in order to allow access to the heart. During surgery, blood circulation and breathing functions will be taken over by a heart-lung machine. The operation usually lasts between two and six hours. A bypass graft is performed to reroute blood flow around the blockage. Veins used in bypass surgery are usually taken from one of the legs or an artery is taken from the chest wall (internal mammary artery) to complete the graft. A newer technique, Minimally Invasive Bypass Surgery, requires a much smaller incision in the chest (only three inches) instead of sawing through the chest bone. An artery from the patient's chest is used to bypass the blockage. Only about 10 percent of patients are candidates for this type of surgery, which is less painful and involves a shorter hospital stay.