Syd is 56 years of age and does maintenance work for the local council. Although there is a small amount of clerical work, most of his time is spent outdoors supervising work in parks and gardens.
One morning as he was unloading tools from his truck, he developed a severe pain across the front of his chest. The pain went up to his jaw and he could feel it in both arms. He felt a bit sick with the pain and sat down on a bench. He was a little clammy and broke out into a sweat. After a few minutes it passed off completely and he went back to work.
He was fine for another week or so until he was hurrying up a hill for a bus. The same thing happened. He felt some tightness in the chest like a weight sitting on it. He sat down on a fence and the pain passed. He felt rather tired and decided to return home. He was only in the door a couple of minutes when his wife rang the surgery and brought him down.
Syd smoked 20 cigarettes a day and had done so since he left school. There had been no major illnesses in the past and he had not been to a doctor for at least 10 years. His father died of a heart attack at age 60, and he has a brother with angina. He was a little overweight and his blood pressure of 165/95 was moderately elevated. There was nothing abnormal to find on examination and his cardiograph was also normal.
When I quizzed him further about the pain, he said that he had been getting milder feelings in the chest for a few months but he had put it down to indigestion. I explained to Syd and his wife that he had angina and that it could be a little unstable. I decided that it would be safer if he was admitted to hospital for assessment by a cardiologist.
As a precautionary measure I gave him a dose of aspirin, and and some Anginine to have with him in case he had further pain. After a couple of phone calls he was admitted to the coronary care unit for observation. He was commenced on specific medication for angina and appeared to be settling well. However, he had a further episode of pain while walking around the ward and it was decided to proceed to coronary angiography.
Syd was shown to have a critical narrowing of two coronary arteries, and after discussion with the specialists he had coronary artery bypass surgery. He has done extremely well and after several weeks he was back at work. He remains on low-dose aspirin and is now a non-smoker.
There is nothing mysterious about the heart; it is basically a pump that pushes blood around the body. To function, it needs a blood supply of its own and this is provided by the coronary arteries. When we exercise, the heart muscle needs more blood for it to work harder and pump out a greater volume. If the coronary arteries have become narrowed and cannot provide the extra supply to the heart muscle, pain in the chest may occur. This pain is called angina. The actual narrowing of the coronary arteries is due to a build-up of fatty deposits and calcium called plaque.
Angina is usually felt across the chest, sometimes radiating into the neck and jaws. It may also be felt in the back or extending down the arms. The essential feature of angina is the relationship of the pain to exertion. Some people experience angina whilst walking up a hill; it might be necessary to slow down and rest for a while until the pain subsides. Angina may also occur with emotional upset, excitement or sexual intercourse. Anything that calls on the heart to work harder can provoke angina.
When angina becomes unstable the pain tends to occur with less and less exertion. This requires urgent specialist attention because it could indicate that the person has a critical narrowing of one or more coronary arteries and is heading towards a myocardial infarction or heart attack.
It has become clear in recent years that myocardial infarctions also occur without an underlying severely narrowed coronary artery. Typically, an area of plaque ruptures, a clot forms and the artery may become completely blocked. When this occurs the pain is often very severe and will not go away; the person may feel very ill and even collapse. Myocardial infarction is a medical emergency and immediate transport to hospital is advised, preferably by ambulance. The shorter the time getting to hospital the better the outcome. That first hour is critical. Sometimes the very first sign of coronary artery disease is sudden death.
Some people find it difficult to distinguish between heart pains, indigestion and even muscle strains. If there is any possibility of heart pain get a doctor to sort it out. Nobody will think you have overreacted if you turn up in casualty with chest pain. A careful history and medical examination is performed because it is important to exclude other conditions as well. Tests like an electrocardiograph (ECG) and blood tests help to sort out whether the pain is coming from the heart. If there is any doubt about the diagnosis, the cardiologist may perform an exercise cardiograph or more sophisticated tests like a nuclear heart scan.
There are a variety of excellent medications available for angina. Anginine tablets dissolved under the tongue relax the coronary arteries, and allow more blood to reach the heart muscle. Relief is usually very prompt. Often it is better to anticipate the pain and take the Anginine prior to exertion. Frequently a headache is felt because the scalp vessels also relax. This type of medication is also available in sprays, long-acting tablets and even stick-on patches.
Several additional types of medication are available for angina. It is common for a person to be on oral medication, a long-acting skin patch and occasional Anginine. It should be remembered that Anginine tablets expire a few months after they have been opened, and need to be regularly replaced; they do last longer if they are kept in the fridge.
If there is unstable angina or if the symptoms are not readily controlled with medication, the cardiologist is likely to recommend a coronary angiogram. After a local anaesthetic to the groin, a catheter is inserted into the main leg artery and threaded up the aorta into the heart. X-ray dye is then injected into the openings of the coronary arteries. The precise anatomy of the arteries can be visualized, in particular the extent of the narrowing. A decision can then be made as to whether coronary bypass surgery is required.
The operation involves taking small lengths from a vein in the leg and grafting them onto the coronary arteries, bypassing the main areas of narrowing. Sometimes an artery from the forearm or from inside the chest wall can also be used. It may be necessary for several grafts to be performed.
Frequently the angiogram shows a rather tight narrowing along a small portion of a coronary artery. In this situation an angioplasty might be recommended. Under X-ray monitoring a balloon-tip catheter is positioned inside the narrowed portion and then inflated, thereby widening the artery back to the size it should be. Sometimes a spring-like coil is inserted into the narrowed portion to keep the artery open. Several other techniques have been developed to widen these shorter narrowings. Often a good result can be achieved without the need for bypass surgery.
The steadily falling death rate from coronary artery disease appears to be mainly due to people taking notice of risk factors. Better control of blood pressure, stopping smoking, reducing weight, and keeping an eye on blood cholesterol levels are all important. Although there have been great advances in the medical and surgical treatment of angina, it is so much better to avoid the condition in the first place.
* If chest pains are occurring with less and less exertion, the angina is probably becoming unstable. Urgent review by the doctor is required. Assessment by a cardiologist and admission to hospital for further tests is likely to be suggested.
* Severe chest pain which is not relieved by rest or Anginine may be a sign of a myocardial infarction, or heart attack. The safest option is to Ring 000 for urgent ambulance transport to hospital.
Web links: www.heartfoundation.com.au