If I Work up from bed with Central Chest pain

If I woke up with central chest pain

If I woke from bed at late night or early in the morning what should I do? Though I know chest pain may arise from many sources like muscle, ribs (chest bone), esophagus (food pipe), lung or pleura but possibility of heart attack requires exclusion. As there are so many causes of chest pain I would wonder of its many possible causes might be responsible. So, what would I do? What should I do?

Obviously, a myocardial infarction is a possibility, but it is by no means the most frequent cause of such pain-heart burn is also common for such type of pain. Nonetheless, myocardial infarction should be assumed until proved otherwise. I am fully aware about the early complications of heart attack. If heart attack is the correct diagnosis, I need very urgent attention to relieve of my pain, to treat cardiac arrest should it occur or to restore blood flow through the totally blocked coronary artery by thrombolysis or immediate balloon therapy. As I am a cardiologist and I am aware about the consequences of heart attack I might be expected to act more promptly. But would I? A survey was conducted by Julian DS to assess the behaviour of the cardiologists in seeking help after heart attack. The behaviour of ten world-renowned cardiologists who had heart attacks revealed that the average time they took to call for help was 48 hours but the average member of the public takes 1-1. 5 hours to summon help after heart attack. This indicates that knowledge may lead to denial rather than a rational response. Big men usually perform big blunders. But as I am definitely not a world famous cardiologist I am sure that I will call for help earlier. If I decide to call some body that should I call? I believe a cardiologist will be better choice if available because they are well acquainted with the modern therapy and intervention techniques appropriate to patients with heart attack. They might be superior to others regarding management of cardiac pump failure or rhythm disturbances. In one study it was found that cardiologists used more resources and achieved better outcome than general physicians in the treatment of acute myocardial infarction. There are at least three possible explanations for this better outcome. The specific aspects of care by cardiologists were responsible for the better results. Because of additional training and experience, cardiologists are more likely than other physicians to treat patients of heart attack with thrombolysis, beta blockers, aspirin, nitrates and heparin medications that are associated with improved survival. Third the differences in the use of coronary angiography and revascularization procedures may also have contributed to improved survival. So I will call a cardiologist or help. I must go to a hospital by an ambulance. If pain is not that much severe, even then I will not drive myself. I may call some body to drive for me if immediate ambulance service is not available.

While waiting for the ambulance, should I take anything? Should I take aspirin? It has already been documented that tablet aspirin alone can reduce the fatality rate by 23% after heart attack. Certainly all patients with myocardial infarction as well as those with unstable angina ought to take aspirin. So to take a tablet of aspirin at this time would be sensible as I do not have any contraindication of taking this tablet like peptic ulcer. If I had nitroglycerine tablet or spray, I would put one under my tongue. I may try this medicine few times for relief of severe chest pain, knowing it fully well that nitroglycerine tablet or spray may fail to relieve the pain of heart attack.

What word I hope for when I arrived hospital? I will expect very prompt base line evaluation of my present condition by a competent doctor along with Electrocardiogram. Let us suppose that I have had a infarction, what further treatment should I receive? Definitely relief of pain by morphine injection is the first priority followed by restoring patency in the blocked coronary artery by thrombolysis (blockage dissolution by injection of thrombolysis agent). Thrombolytic injections are now easily available in most of the coronary units in our country and abroad. I would want the best treatment for restoring patency of my blocked coronary artery. I know that thrombolytic injections (e.g. streptokinase, r-tPA, APSAC etc) can reduce risk of death by 25% in addition to the benefit provided by aspirin if given within 6 hours of heart attack. I also know that aspirin and streptokinase injection together can reduce death by 42%. So I will prefer to have streptokinase injection as soon as possible after heart attack. I would expect my doctor is well aware about latest drugs recommended by American College of Cardiology for heart attack and he will commence those medicines as and when required.  I would like to be accommodated in a well designed coronary care unit, where I would have comfortable bed and continuous ECG monitoring system for at least first 24 hours from the inception of chest pain. I would wish to have competent doctor/nurse inside the CCU all the time that are capable enough to cope with life threatening arrhythmias (heart irregularities). I would wish to be treated by beta blockers, ACE inhibitors and nitrates. After heart attack visitors could be troublesome. These so called well wishers can do harm but can not do well. So I should strictly control visitors during first few days of attack.

I would wish to be transferred from the coronary care unit (CCU) to an intermediate care unit (ICU) or in a well equipped cardiology ward after 24-48 hours of admission. If I had an uncomplicated course, I would want to be out of bed the day after admission, gradually increasing my activities over the next few days with the hope of discharge on 6^th or 7^th day of admission. During first few days of hospitalization I would expect to be provided with a rehabilitation programme tailored to my cardiac function. When my condition will be stable I would expect that concerned cardiologist will explain to me and my family about the nature and severity of my condition. During leaving hospital and future plan of treatment. My wife and close family members should be fully informed about the state of my health and the various aspects of life that would need to be modified in the of the limitations imposed by the damage to the heart and measures necessary to minimize the risk of a further heart attack. After heart attack I must always be on standard drug therapy for secondary prevention of coronary artery disease. The drug regimen will probably include beta blocker, aspirin, ACE inhibitor and nitrates. The above mentioned drugs have been proved to be effective in reducing death after heart attack in different world standard randomized trials. I am well aware about the risk of high cholesterol as far as possible. It has been found that if cholesterol level can be brought down below 150 mg% the formation of further coronary block can be prevented. But in reality it is very difficult to bring down cholesterol below that level. But I will have to try as far as possible in lowering blood cholesterol level. I must avoid 5 things as far as possible. They are beef fat, mutton fat, egg yolk, big prawn and any oil that solidifies. Do I require drug for reducing my blood cholesterol? What level of cholesterol justifies treatment is not yet established, but if after adequate diet control it exceeds 200 mg% I should be advised to go on a lipid-lowering agent like statin or gemfibrozil or fibrate.

Is it mandatory to have coronary angiogram after heart attack? Do I really need it? Coronary angiogram after heart attack is a controversial area, and practices vary enormously between and within countries. Some cardiologists recommend routine coronary angiogram after heart attack for important decision making like angioplasty and CABG (bypass operation). But I think my cardiologist will not be so aggressive. Preferable I should undergo non invasive tests like exercise stress tests are positive I should go for coronary angiogram. If one of these future treatment. I would expect that my cardiologist will take proper decision depending on the angiogram report. He will select one from three modalities of treatments e.g. only drug or balloon therapy or by pass operation.