Posted by Bill Sandweg on 04 May 2020.
One of the cases we see over and over again is that of a patient, usually a man, who presents to the emergency department or to an urgent care facility with what turns out to be a myocardial infarction (“MI”) but who is sent home without treatment. Myocardial infarction is the medical name for a heart attack. The cases we see almost always have a bad outcome. Either the patient goes home and dies or goes home and suffers further heart damage due to inadequate flow of blood to the heart. How does this happen over and over again, especially when MI is so high on the list of things the health care providers at these facilities are looking for? The answer is found in the human body.
An MI occurs when the heart muscle does not get enough oxygen to meet its needs. The heart receives its oxygen from the blood flowing to it through the coronary arteries. Any significant blockage or reduction in that flow will produce a pain response by the heart. If the flow is diminished but the heart still has enough oxygen to stay alive, the heart can usually be restored to full function by restoring the flow of blood. On the other hand, if the flow is too low, heart tissue will begin to die from lack of oxygen. That dead tissue never comes back to life. If the amount of dead tissue is large enough, the heart can’t pump enough blood to sustain life and the patient dies. If it is not so large that it is incompatible with life, the patient will survive but the pumping function of the heart will be diminished. The amount by which the pumping capacity is diminished depends upon how much heart tissue died.
The image above is what most of us think of when we think of an MI. There is a sudden onset of crushing chest pain. The image above can be misleading. It shows a classic presentation of an MI. Not all MI’s have a classic presentation. People who experience a sudden onset of crushing chest pain and go the the emergency department are almost never sent home without treatment. Those patients with classic signs of an MI are tested. They are given an EKG, which looks at the electrical waves in the heart. It often shows a heart attack, if one is in progress. These patients also have blood drawn to see if there are any markers in the blood due to heart muscle injury. If either of these tests is positive, it usually proves the existence of an MI and the patient is admitted and treatment is begun immediately. Even if these two tests are negative or inconclusive, these patients are usually admitted to the hospital for observation. These are not the cases we see over and over in our office.
The cases we see are the ones in which there is an MI but the presentation is unclear. The pain response by the heart to diminished flow of blood through the coronary arteries is quite variable. Sometimes, it is crushing chest pain. Sometimes it is felt as pain running down the left arm or up into the jaw. Sometimes it feels like indigestion. There may be vomiting. Sometimes the patient just doesn’t feel well and is not sure what is going on. To make matters even more complicated, there are many causes of chest pain that have nothing to do with the heart. They may be the result of a cold, the flu, a pulled muscle or GERD.
Distinguishing these non-cardiac causes of chest pain or discomfort from those which are cardiac related is a real problem for emergency departments and especially for urgent care facilities. Usually, urgent care providers are instructed to send anyone with what may even possibly be chest pain to a hospital emergency room where they are far better equipped to test for an MI and to treat one, if it is found to exist. In spite of this, we see patients who presented to an urgent care facility with chest pain who are diagnosed with some benign, non-cardiac cause and sent home. We also see the same thing, although it is a little less common, with chest pain patients who go to the emergency department.
EKG’s are not foolproof. Six to seven percent of patients having an MI will have a normal EKG. Around 1% will have an abnormal EKG, even though they are not having an MI. The blood tests for markers of muscle damage need time to become positive. If the patient arrives at the emergency department too soon after the start of an MI, the blood test may be normal or only slightly elevated. All of this coupled with the vagaries of human nature mean that some patients who are having an MI will be sent home without treatment.
Here are some practical suggestions. First, any chest pain should be taken seriously. This is especially true, if you are older, male or have risk factors for coronary artery disease. Ladies, don’t assume because you are female that you are immune from an MI. More and more women are developing coronary artery disease. Don’t delay waiting to see if your chest pain/discomfort is going to go away. Don’t drive yourself anywhere. Call 911. Patients who arrive at the emergency department by ambulance with chest pain complaints get priority treatment that you may not get, if you arrive by private car. Don’t go to an urgent care facility. At best, you will be wasting time as they will send you to the emergency department anyway. At worst, they won’t recognize a developing MI and may send you home.
I hope you never need this information but, if you do, I hope it is helpful.