Understanding Chest Pain: Part 3 - Heart Attack & Aortic Aneurysm

In the previous article we discussed two common heart conditions, relevant to the First Aider or First Responder; Heart Attack and Angina.

But chest pain can manifest in a range of signs and symptoms and can represent a bewildering array of other conditions, from the trivial to life-threatening:

	
				Region
				Possible Causes
				
  Cardiovascular
 •  Angina Pectoris

•  Myocardial infarction ("heart attack")

•  Dissecting aortic aneurysm

•  Heart failure

•  Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain

Pulmonary (MI)
 •  Pulmonary embolism

•  Pneumonia

•  Haemothorax

•  Pneumothorax and Tension pneumothorax

•  Pleurisy - an inflammation of the pleura (lining of the chest cavity) which can cause painful respiration

Gastrointestinal
 •  Heartburn

•  Indigestion

•  Hiatus hernia - a protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm

•  Neuromuscular disorders of the oesophagus	

Chest wall
•  Chest wall injury

•  Nerve damage

•  Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease

•  Breast conditions

•  Tuberculosis

Psychological
 •  Panic attack

•  Anxiety

•  Clinical depression

•  Hypochondria

In this article we will look at two cardiac conditions that can manifest in chest pain.

Heart Failure – this is generally a chronic and worsening condition which the casualty will probably be aware of. Whilst not immediately life threatening it is reasonable common, especially in the elderly.

Aortic Aneurism – XXXXXX

The Spectrum of Cardiac Conditions

Many cardiac conditions are functions of lifestyle; long term health problems which lead to atherosclerotic or arteriosclerotic problems or high blood pressure (hypertension). The most significant factors include:

Smoking
· Alcohol
· Poor diet
· Lack of exercise / sedentary work or lifestyle
· High stress
· Age
· Being male
· Family history
· Diabetes or other causative medical conditions

With this in mind, knowing your casualty will already help you form an opinion of what the cause of their chest pain might be; fit young, healthy people tend not to have cardiac disease!

Heart Failure

The prevalence of heart failure slowly increases with age until about 65 years of age, and then more rapidly. In the UK, the prevalence of heart failure is estimated to be about [NICE, 2018a]:

1 in 35 people 65–74 years of age.

1 in 15 people 75–84 years of age.

Just over 1 in 7 people 85 years of age or older.

The average age at first diagnosis is 76 years of age (1)

The incidence of heart failure in Europe is about 5 per 1000 person/years in adults and prevalence is 1–2% in adults: increasing from around 1% for those aged under 55 years to over 10% for those aged over 70 years (2)

Heart failure is a typically chronic condition characterised by reduced cardiac output - the rate and volume of blood circulated by the heart. This can be caused by any of the heart diseases mentioned above but also by:

· Other heart diseases such as myocarditis

· Hypertension

· Heart valve abnormalities such as leaking or reverse flow back into the chambers

· Arrhythmias; ineffective heart rhythms

· Cardiac tamponade - a build up of fluid in the sac surrounding the heart, inhibiting effective contraction and relaxation of the heart muscle preventing the ventricles from filling fully with blood.

When the pumping function of the left ventricle (which supplies the aorta with oxygenated blood to the rest of the body) cannot keep up with the input from the left atrium (bringing freshly oxygenated blood from the lungs via the pulmonary veins) the heart attempts two compensate by two possible mechanisms:

· Increase in heart rate

· Increase in size of the left ventricle

These compensatory mechanisms are not sustainable in the long term. Heart failure may occur in the left ventricle independently or in both ventricles.

Left ventricular failure, unable to keep up with the input from the pulmonary veins, forces blood to back into the lung tissue, making them stiffer and less compliant. This often manifests in difficulty breathing (dyspnoea), typically when laying flat.

Further increase in pulmonary capillary pressure can force fluid into the alveoli causing pulmonary oedema, severe dyspnoea, decreased gaseous exchange and hypoxia.

Right ventricular failure can be caused by COPD, pulmonary embolism, heart valve disease and left ventricular failure, causing central venous pressure increase(as the right ventricle is less able to shunt incoming blood to the lungs – causing pitting oedema in the lower limbs, starting at the ankles but progressively worsening up to the knees as their condition deteriorates over time.

Signs and Symptoms

· Shortness of breath - typically occurring when lying and eased by sitting upright.

· Sometimes with a dry cough.

· Fine crackles or wheezing on inhalation

· Frothy, pink sputum

· Distended jugular veins as a result of increased venous pressure

· Swollen ankles may indicate right sided heart failure

· Pale or cyanosed skin

· Agitation or restlessness

· Fast heart rate and breathing, high blood pressure

Treatment

· Encourage the casualty to sit upright – or into a passion they prefer to assist breathing.