chest pain…now what

Tuesday, November 22, 2016

Bruce Arians, the Arizona Cardinal coach, had an eventful weekend and ended up batting .500 with a loss to the Vikings and a win for his heart. After returning home, he developed chest discomfort and rightfully so, made his way to the ER where tests were done to sort out the cause of the chest pain. Rightfully so, because the medical world spends lots of time, effort and money to convince people that chest pain is not normal and potentially could be deadly. Getting chest pain checked out is not something that should be delayed.

Once you get to the hospital, the science of diagnosis mixes with the art of medicine and a healthy dose of Las Vegas probability gets thrown into the mix to decide how much or how little needs to be done to make the diagnosis. If a heart diagnosis is suspected the full force of hospital technology may come raining down on the patient. It is just the suspicion of atherosclerotic heart disease (ASHD) also known as coronary artery disease (CAD) that sets events in motion.

The first step in sorting out chest pain is taking a history. It is the story of the pain that is most important: what it feels like, what brought it on, where it radiates, and whether there are other symptoms including shortness of breath, sweating or nausea. The doctor may try to find risk factors for the patient having narrowed arteries: is there a history of high blood pressure, high cholesterol, diabetes or smoking? What about family history? Or does the patient have a previous history of heart attack, stroke or peripheral artery disease.

If, after taking the history and examining the patient, the doctor thinks that the pain is not cardiac, then the story ends there. Of course, there are other killer causes of chest pain that have to be considered, including pulmonary embolus (blood clot in the lung) and aortic dissection (tearing of the main artery as it leaves the heart), but if the story is not consistent with major disaster, clinical skill allows the doctor to diagnose and treat other things that can cause chest pain, from chest wall injuries to pneumonia to reflux esophagitis.

But if there is worry that the cause of the pain comes from the heart, the next step is an EKG to look for signs of a heart attack. The heart is an electrical pump and if narrowed arteries can’t supply enough blood, that part of the heart conducts electricity differently and those changes can be seen on the EKG tracing. A heart attack means that a blood vessel is completely blocked and the next step is opening the artery either with clot busting drugs or a trip to the cath lab where a cardiologist can open the artery with a balloon and place a stent to keep the artery open.

If the EKG is normal, the next step is to look for heart muscle that is under stress; perhaps an artery not completely blocked but narrow enough not to get enough blood to meet the muscle’s needs so that it begins to ache or hurt. Blood test can measure chemicals (troponin) leaked from heart muscle cells that are irritated, but it takes at least 4-6 hour for troponin to accumulate in the blood to be detectable. Most often, people arrive in the ER within that time frame, so one troponin test begets another beyond that 4-6 hour to make certain the test remains normal.

If the EKG and troponin are normal, the worry is not yet done. Perhaps the heart artery is narrowed enough to cause pain but not narrow enough to cause damage. That might mean a patient at risk for a heart attack in the near future. The next step is imaging and stressing the heart. This testing may be done immediately but can also be safely delayed f0r 24-48 hours. And there are numerous ways to look at the heart, from a stress test on a treadmill, to chemical stress tests, to stress echocardiograms (ultrasound of the heart) and CT or MRI of the heart and finally, the gold standard, heart catheterization, the same procedure used in a heart attack but this time used to look for a narrowed artery.

Chest pain is a big deal because one only gets one heart and it has to last a lifetime. Showing up to a doctor’s office or ER complaining of chest pain will most likely get you to the front of the line. Aside from dying, that heart muscle can be electrically very irritable and puts the patient at risk for sudden death from ventricular fibrillation, a fatal heart rhythm. While Cardinal fans bemoan the loss of a football game, Coach Arians came through with a bigger win later that evening and lived to have his team play another Sunday.


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not all collapsed lungs are punctured

Tuesday, November 15, 2016

It seems that Rob Gronkowski of the New England Patriots is teaching us about medicine, one injured body part at a time. This week it’s about the pneumothorax he sustained after a hard tackle and there is a reminder that the press tries hard but sometimes needs help getting the medical terminology just right. Gronkowski has been reported to have either a collapsed lung, a punctured lung, or both. But while all punctured lungs will result in a pneumothorax, not every pneumothorax is due to a punctured lung.



Normal Anatomy


Right Lung Pneumothorax

Let’s start with normal anatomy. We breathe like a bellows. The ribs swing out and the diaphragm, the muscle separating the chest and abdomen pushes down allowing air to be inhaled and sucked through the mouth and trachea into the lungs. Exhaling reverses the process. The lungs have to slide along the inside of the rib cage to inflate and deflate and for this to happen, both the lung and the ribs have a slippery lining called the pleura. The two are stuck together by negative pressure and should the seal between the two linings break, part of the lung can fall away from the chest wall and collapse. This is a pneumothorax (pneumo=air + thorax= chest) or air in the chest where it doesn’t belong.

Most often a pneumothorax happens spontaneously, when a bleb or weakened portion of lung leaks and breaks the negative pressure seal. It can happen in tall thin young people or in people with end stage COPD whose lungs are more fragile. A pneumothorax can also happen due to trauma and the jagged edge of a broken rib can damage lung tissue causing a leak. This is the punctured lung scenario that was reported to have happened to Mr. Gronkowski, though the broken rib idea wasn’t mentioned. Punctured lungs can also happen because of penetrating trauma like from a gunshot or stab wound and they have their own issues and complications.

The diagnosis is usually made by chest x-ray. In trauma, like Mr. Gronkowski, the x-ray is meant to look for the complications of the chest wall injury, including pneumothorax and pulmonary contusion, or bruising of the lung. Specific ribs x-rays tend not to be taken since it doesn’t really matter whether the ribs are bruised or broken…it’s all about what’s happening underneath. And for the doc, underneath may also include the upper abdomen, since the ribs protect the organs just below the diaphragm including the liver and spleen.

pneumothorax 2

Arrows show the collapsed lung edge pulled away from the ribs

The treatment of a pneumothorax depends upon how much of the lung has collapsed and whether the patient can tolerate the loss of lung function. If the percentage is small and the patient is doing well, delivering enough oxygen to their blood and not complaining of significant shortness of breath, watchful waiting may be the treatment of choice and the body will absorb the air and the lung will re-expand on its own.

If the pneumothorax is too large or if the patient is not doing well, the air in the pleural space between the two linings can be removed, either one time with a needle or by placing a tube into that space and sucking the air out under negative pressure causing the lung to expand. The tube may be left in place for a day or two to allow the lung to heal and the situation to settle down. Some people need operations to repair the weak areas of the lung to prevent repeat events and sometimes the damaged lung area is purposefully irritated so that it will scar down and adhere to the chest wall to prevent further collapse.

Not all collapsed lungs are easy to treat; they can be recurrent and treatment failures happen. There are also life threatening complications, including tension pneumothorax where the damaged lung tissue does not seal off and enough air flows into the pleural space to cause the heart to shift and prevent it from beating properly.

Since it appears that Mr. Gornkowski’s pneumothorax was small, the treatment was watchful waiting and if repeat x-rays show that the air has been reabsorbed, the ability to return to play will depend upon how much pain he has from his chest wall. Bruised ribs hurt and it can be tough to take a deep breath, and twist and turn. For mere mortals, chest wall pain can last a few weeks and can make routine daily activities tough to accomplish. For pro athletes, playing through pain is an expectation, as long as damage won’t result from ignoring the body’s message to rest.  And here is where the athlete and the doc share the same credo…first do no harm.

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