Chest pain or discomfort can be a sign of a serious, life-threatening condition and should be evaluated promptly, with minimal delay. It is critical to go to a hospital with a proper pathway for managing acute coronary syndrome.
This is a set of evidence-based steps that guide the patient, family, health care professionals and other hospital staff on the efficient management of chest pain. It helps ensure early identification of life-threatening conditions.
Key takeaways
- Chest pain that develops over a few minutes to an hour needs urgent evaluation at a hospital that can treat heart emergencies.
- An ECG should be done within 10 minutes of arrival, and treatment for a STEMI starts without waiting for blood results.
- Primary PCI is the gold standard treatment. Thrombolysis (clot-busting drugs) is the alternative.
- Nitrate heart medicines and erectile dysfunction drugs such as Viagra and Cialis can cause dangerous drops in blood pressure if combined.
What should I do if I develop chest pain or discomfort?
Chest pain, especially if it develops within a few minutes to an hour, needs urgent evaluation to rule out serious causes. Go to a hospital capable of diagnosing and treating acute heart emergencies. Head to the emergency department (casualty) and tell the medical staff immediately that you are experiencing chest pain or discomfort. Use the fastest means possible to reach the hospital.
What should I expect in the emergency department?
The nurse and doctor will measure your blood pressure, pulse, oxygen saturation and temperature. They will ask a few questions about your chest pain, examine you, and perform an electrocardiogram (ECG), a recording of the heart’s electrical activity. All of this should happen within 10 minutes of your arrival.
The ECG forms the basis of early decision-making. It helps the doctor decide whether you are having an acute heart attack known as an ST elevation myocardial infarction (STEMI). This is a heart attack caused by total blockage of an artery supplying the heart muscle, and it requires prompt treatment to restore blood flow.
Other tests you can expect include blood tests for heart enzymes, blood counts and electrolytes, a chest X-ray or CT scan, and an echocardiogram (an ultrasound of the heart).
What is a heart attack?
A heart attack occurs when deposits in the arteries cause a blood clot to form, partly or completely blocking the artery. This slows or stops blood flow to the area of heart muscle that the artery supplies. If the blockage is prolonged, the muscle can become damaged or die.
What symptoms accompany a heart attack?
Heart attack symptoms include chest pain or discomfort, which typically occurs on the left side of the chest but can be felt anywhere between the neck and the navel. It is often described as a squeezing pain or heaviness. Pain may also be felt in either arm, the jaw, teeth, neck, upper abdomen or back.
You are also likely to have difficulty breathing, nausea or vomiting, sweating, dizziness, or loss of consciousness and collapse.
Some people suffer cardiac arrest, where the heart stops beating, usually because of an electrical rhythm problem. This is often fatal outside hospital because it requires a special electric shock (defibrillation) to treat. These presentations highlight the need to seek urgent evaluation for any chest pain or other symptoms suggestive of a heart attack.
How is a heart attack diagnosed?
There are two main types of heart attack: ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS).
STEMI occurs when an artery is completely blocked, and time is of the essence in reopening it to prevent death and complications. The diagnosis is made with an ECG within 10 minutes of arrival. Blood will be taken for heart enzymes, but the doctor will not wait for the results to start treatment.
NSTE-ACS occurs when an artery is partly blocked, though severely enough to cause some muscle damage. The ECG may show some abnormalities, but the diagnosis is usually made by finding raised levels of a heart enzyme called troponin. The laboratory turnaround time for this test is approximately one hour.
What is the treatment for a heart attack?
For a complete blockage (STEMI), the artery should be opened as soon as possible. Two options are available.
Primary Percutaneous Coronary Intervention (Primary PCI). This procedure is performed in the cardiac catheterisation laboratory (cathlab), a special X-ray suite. An interventional cardiologist passes a thin catheter through your wrist or groin into the heart. A special dye (contrast) is injected into the coronary arteries, which is called a coronary angiogram and shows the blockages on X-ray. A thin balloon is then passed into the blockage and expanded to open the artery, and a metal scaffold (stent) is placed inside to keep it open. This restores blood flow to the heart muscle. It is the gold standard treatment for heart attacks and gives the best results when done early.
Thrombolysis. These clot-busting drugs are injected into a vein and circulate in the bloodstream to dissolve the clot in the heart. Thrombolysis is very effective, but it may fail to reopen the artery, in which case the patient still needs angioplasty (rescue PCI). Because the drug circulates throughout the body, the risk of bleeding is high. Bleeding in the brain is the most serious consequence, so the doctor will go through a checklist before giving the drug. Patients at high risk of bleeding may not be candidates for thrombolysis.
When can I resume sexual activity after a heart attack?
Many people feel anxious about returning to sexual intimacy after a heart attack. Discuss with your cardiologist when it is safe to resume. For most people, this is possible once they can tolerate a moderate amount of physical exertion, generally at least two to four weeks after the heart attack.
Some heart medications may affect sex drive, or the ability to maintain an erection and reach orgasm. If you suspect this, raise it with your cardiologist, who may be able to suggest alternatives. Do not stop any of these medications on your own.
Medicines containing nitrates (such as nitroglycerine tablets, patches and sublingual sprays) may cause dangerous drops in blood pressure if taken with medicines that treat erectile dysfunction, such as Viagra and Cialis. Always consult your cardiologist before using any of these medications.
Know your risk before symptoms start
A heart attack often follows years of silent damage to the arteries. Conditions such as diabetes, high blood pressure and high cholesterol can go undiagnosed for a long time, a pattern Khusoko has explored in Kenya’s Metabolic Disease Crisis Hides in Plain Sight. Regular screening is one of the best ways to catch these risks early, long before chest pain appears. For more on the issues shaping care in Kenya, browse Khusoko’s health and wellness coverage.
Related reading on Khusoko
- Kenya’s Metabolic Disease Crisis Hides in Plain Sight
- Kenya to Make Monthly HIV Prevention Pill Alimatravir
- More Health & Wellness stories
By Dr Mzee Ngunga, Consultant Interventional Cardiologist at Aga Khan University Hospital, Nairobi
