Features May 2007 Issue

Was That a Heart Attack?

Sometimes symptoms are so subtle that patients get sent home untreated. Help your doctors get to the root cause with proper communication.

Up to four percent of patients who arrive in the emergency room with heart attack symptoms are mistakenly sent home with an undiagnosed acute heart attack, according to an article published in a recent issue of

Archives of Internal Medicine. The article demonstrates how blood tests interpreted as "normal" and inconclusive readings from an electrocardiogram (EKG) can lead to failure to diagnose a heart attack.

"About one third of all heart attacks are Ďsilentí heart attacks, meaning that people had no history of heart trouble and didnít recognize they were having one," says Cleveland Clinic cardiologist Richard Krasuski, M.D.

He divides heart attack patients into three categories:

High-risk, with clear symptoms, EKG (heart rhythm) abnormalities, and a "story" suggestive of a serious heart problem

Intermediate-risk, with inconclusive results from stress testing and even from invasive tests like angiography

Low-risk, with nothing suggestive of a heart attack, normal blood test results and pain that is reproducible through certain activities or a physical exam

"Some people have no risk factors, but we find that even with the most stringent policies some patients just donít get recognized as having heart damage," Dr. Krasuski says.

During a heart attack, the blood supply to part of the heart muscle, or myocardium, is severely reduced or stopped when one or more of the coronary arteries supplying blood to the heart becomes blocked, often by a blood clot caused by plaque that breaks off within an artery wall. The resulting ischemia or oxygen shortage causes damage and potential death of heart tissue.

If you feel you have suffered a heart attack, remember that communication with caregivers is vital. "Be as specific as possible," says Dr. Krasuski. "Describe in as much detail as possible your present symptoms and any symptoms you may have had previously. Itís very important to tell them whether you have heart disease or have had heart surgery. Sometimes itís hard to recall all of that, so if you have a heart history, put it on a laminated card in your wallet. Write down the work done on your heart, which vessels may have been bypassed, whether you have had angioplasty or stents, and what kind of stents. That information is invaluable to emergency personnel, since it can be difficult to get records quickly from other doctors or hospitals."

Dr. Krasuski also recommends that you call 9-1-1 if you experience heart attack symptoms, then chew and swallow four baby (80 mg) aspirin (do not take coated aspirin, which take hours to get into your system). "If there is a question, donít disregard the warning signs. Take the aspirin before the ambulance gets there," he says.

Once at the hospital, several things will quickly happen: youíll receive multiple EKGs, blood samples will be taken and rushed to the lab to check for evidence of heart damage, and youíll be placed on a heart monitor to record data on heart rhythm disturbances. Most likely, you can expect to stay in the hospital between 24 and 48 hours. Doctors might put you through a stress test on a treadmill. Youíll also have an oxygen tube inserted in your nose and a nitroglycerine pill placed under your tongue to reduce your heartís workload and balance your heartís oxygen supply with the demands placed on it. Finally, you may receive clot-busting medication or be sent to the cardiac catheterization lab for angiography testing. Everything is done in a very short period of time. "The longer the wait, the greater the risk to the heart muscle," says Dr. Krasuski.

If you are sent home and still think you had a heart attack, seek further medical attention. "If someone sent you home in the morning and you still have symptoms, call your primary care physician or your cardiologist if you have one. They know you best," he says.