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Heart Disease

Heart Disease

Heart disease can encompass many different type of ailments that involve the heart.  However, when we speak of “heart disease” we commonly mean coronary artery disease that could lead to (or has led to) heart attacks.  Inadequate blood supply to the heart muscle results in major and minor areas of ischemia and infarction.  This results in damage to the heart muscle, either on a large scale (major heart attack) or over time on a smaller scale, which leads to inadequate functioning of the heart.  Inadequate functioning typically manifests as congestive heart failure (CHF), or it causes the rhythm of the heart to be compromised (atrial fibrillation or worse, sick sinus syndrome and dysrhythmias necessitating the use of pacemakers or AICDs (automated implantable cardioverter-defibrillator).

Healthy Heart

So what happens?  As your bad cholesterol rises in your blood, the excess is deposited onto/into the artery/arteriole walls.  If your diet is high in sugar/carbs, your insulin level remains elevated.  High insulin levels contribute to hypertrophy (thickening) of the artery walls, and worsens your cholesterol profile.  This causes the artery to harden, and narrow.  Typically the blood vessels are elastic and can adjust and absorb the variations in pulse pressure in the artery.  But if their walls are thick, and their lumens narrow, the force with which the heart must beat to push the blood through the narrow vessels remained elevated – causing high blood pressure.  As the heart has to work harder to push the blood against increasing levels of resistance, the muscle hypertrophies (grows larger) to get stronger.

At first, the hypertrophic heart is more efficient.  The increased muscle mass helps push more blood through the narrow vessels as designed.  But as time passes, the thick heart requires so much oxygen and so many nutrients, the coronary arteries become inadequate.  After all, they too are affected by the plaques, thickened walls and narrowed lumens.  So the hear t muscles gradually begins to starve…and die.  This results in muscle fibers that are now scar tissue instead of elastic cardiac muscle.  The heart begins to increase its size.  Like a rubber band that stretched, the more it’s stretched, the stronger the contraction….at first.  But a large heart requires so much energy to contract and move blood around that the vessels are unable to provide needed energy, and the fibers themselves become overstretched leading to inefficiency.

Inefficient cardiac contractions, coupled with elevated necessary energy to pump blood through narrow arteries, together with inadequate blood supply to the heart muscle itself to complete the task…along with stretched out muscle fibers, means that the cycle of heart failure ensues.  And this is in the absence of a heart attack.  If there is infarction (blockage of a heart artery resulting in death in some of the muscles in a part of the heart), this process is accelerated.

Congestive heart failure is when the heart is so big, and the effort to pump blood around the body is so great, that the heart cannot do it.  This leads to a back-up of blood (which contains oxygen, nutrients, water, everything needed for life).  This backup causes the water component of the blood to seep out of the blood vessels everywhere in the body (because the pressure becomes so high in the vessels as a result of back-up).  Water in the lungs causes shortness of breath as large portions of the lungs are unable to participate in gas exchange.  Back up and oozing out of water into the tissues in the lower extremities causes the edema we see in the legs, scrotum, and lower abdomen.  This extra water is not filtered out by the kidney because the water needs to be in the blood vessels for the kidney apparatus to register it as excess.

Symptoms include shortness of breath with minor exertion.  There’s orthopnea (inability to lie down on your back flat because the extra fluids that are usually pulled down to the lung bases by gravity when you’re upright, begin to rise as you lay flat.  This causes a sensation of drowning, and the need to sit up).  Chest pain as your heart continues to try and circulate blood around the body, but becomes fatigued as in it’s stretched out, enlarged state, it is unable to perform well for long periods of time – especially with inadequate blood supply due to compromised coronary artery function.

As the heart is stretched out, and the blood supply to the pacemaker cells in the atria are affected, the beat rhythm is affected.  Various dysrhythmias develop such as atrial fibrillation, preventricular contractions, sick sinus syndrome, bradycardias (slow heart rates), and sometimes ventricular fibrillation – which causes the entire heart to just vibrate, and blood is not pushed through systematically.  This causes death rapidly as the brain (and the heart itself) is starved for blood.

Next time:  What happens in the emergency room when you come in with shortness of breath or chest pain that might be related to your heart issue.

Heart Disease - What Happens In The ER When You Have Chest Pain?

If you have a history of cardiac disease, you may already know the signs and symptoms of heart attack.  Heart disease can manifest in many different ways – and varies based on your age, gender, and co-morbid diseases.  Also, there are various things that can go “wrong” with your heart.  A common disease, coronary artery disease, is when the arteries that supply your heart with blood (which contains nutrients, oxygen, food, water) become clogged.  Congestive heart failure happens when your heart cannot pump blood effectively around your body (and this is caused by various processes).  Also, there are a host of electrical problems that can affect your heart’s ability to pump in an orderly fashion.

When you come into the ER with chest pain or shortness of breath, one of our primary goals is to make sure your heart is not malfunctioning.

In the ER we are focused on quickly identifying any immediately life-threatening issues.  Heart and lungs are at the top of the list.  So when you first come in, it’s important to concisely indicate whether or not you have any underlying cardiac or pulmonary issues, and you need to tell the triage nurse that you’re having chest pain and/or shortness-of-breath.  Refrain from trying to share too much – as it’s important for your chief-complaint to be clear.  And understand that the ER staff is only interested in addressing life-threatening issues – so chronic pain, old rash, vaginal discharge, etc., will only serve to distract from, or diminish your main issue.

After this *brief* history taken by the triage nurse, your vital signs will be obtained.

You will then be placed on a gurney, and an EKG (electrocardiogram) will be performed.  This EKG is taken to the doctor, and if there is any indication of something immediately life-threatening going on, you will be brought right back and placed on a monitor.

If the EKG looks okay, the triage nurse will take into consideration your past medical history, the severity of your complaints, your vital signs, your prior visits into our ER, and try and determine how sick you are when compared to the other patients who are waiting.  So, if you’re a healthy person, with no cardiac risk factors, have visited our ER multiple times with various ‘body-aches’ and pains, and your vital signs are normal – you might be determined to be better off (i.e. can wait a bit longer than) another patient who suddenly cannot move the left side of his body.   In this case, you may actually be sent back out to the waiting room.  Note:  This decision is not based at all on whether or not you have insurance, and/or can pay the ER bill.

Once in the back,

  • you’ll be placed on a cardiac monitor.  This consists of the ER tech or nurse applying stickers strategically on your chest and attaching cables to those stickers.  The cables transmit the electrical pattern your heart emits to a machine that records the signal.  This signal is in turn transmitted to a central location at the nurses’ station where it is monitored and recorded.

  • The nurse or tech will start an IV to allow us to have access to your vein and blood.

  • During this process blood will be drawn so we can check your electrolytes, cell count, cardiac enzymes, plus other labs as appropriate based on your history.  Don’t be surprised if we take 4-5 vials of blood!

  • Oxygen via nasal cannula may be administered – depending on your oxygen saturation level, history, and the nature of your chief complaint.

  • The nurse assigned to you may attempt to obtain more information from you and/or your family.

  • After this information is collected, it is entered into the medical record by the nurse.

  • The physician reviews the data entered by the triage nurse, the nurse taking care of you, EKG, and pulls up any old medical records from prior ER visits (if they are available).

  • Typically an aspirin is given (depending on your medication list), and nitroglycerin tablets under your tongue to help relieve chest pain (and at times, nitroglycerin may be given if there is a component of congestive heart failure present).

This is all done as protocol even without the physician evaluation in many ERs.

Once the physician has reviewed everything and/or has time, s/he will come evaluate you.  A few more (or many more) questions will be asked.  And an exam will be performed with the heart and lungs being particular areas of interest.

In most circumstances the labs will come back okay, the chest xray will be okay, and the EKG will be okay.  This is expected because our protocols are designed to capture everyone having a heart attack or other emergency condition.  This means, there will be large numbers of patients who have nothing serious going on.  In these (common) instances, your primary care physician (or the physician covering for your primary care) will be contacted, and you’ll be admitted to the hospital for observation and serial lab draws to make sure your cardiac enzymes stay negative (normal).

Next time:  What happens when your cardiac enzymes are POSITIVE, and what does that mean for you?