Ticking Off Reasons for Chest Pain

September 19, 1995|By Patricia Meisol | Patricia Meisol,SUN STAFF

For five weeks her chest ached, but Rosalie Geisler, 55, did her darndest to ignore it. Then, in the middle of the night, a sharp pain woke her. By morning, it marched down her left arm, leaving her fingertips almost numb.

Mrs. Geisler put it out of her mind and left for her manager's job at the Cake Cottage in Perry Hall. Later, her worried husband arrived with doctor's orders to take her to the hospital.

"I didn't want to come," she says after a team of nurses at St. Joseph Hospital descend on her to hook her up to a heart monitor.

Is she having a heart attack? Gail Cunningham, the emergency room doctor, doubts it after checking Mrs. Geisler's cardiogram and her medical history. But the doctor can't be sure because of her arm pain and a family history of heart trouble.

Only a few months ago, patients such as Mrs. Geisler who experience chest pain but have no clear signs of heart attack would either be sent home or admitted to the hospital for three days of tests. Now hospitals are setting up special units -- pioneered at Baltimore's St. Agnes Hospital -- where this in-between crowd can be conclusively tested in as few as five hours.

Chest pain is the most common kind of pain there is. About 5 1/2 million people go to hospital emergency rooms every year complaining of it. Many of them, including Mrs. Geisler, are terrified when they go in and relieved, if not embarrassed, when they leave. In the end, only 13 percent have had heart attacks.

Trying to identify them the traditional way bogs down ER departments, ties up expensive monitoring equipment, and costs $8 billion to $10 billion each year to hospitalize people who aren't having heart attacks. Even then, doctors don't get them all: Each year an estimated 35,750 people with chest pains are sent home from the emergency room based on factors that make a heart attack unlikely -- their age, type of pain, etc. -- and end up having heart attacks at home, according to the Cardiology Roundtable. Of these, more than 5,000 die.

Reducing heart attacks

"That's one of the reasons you want a chest-pain evaluation unit," says Robert A. Barish, professor of medicine and director of emergency medical services at the University of Maryland. People in the chest-pain evaluation unit at Maryland have actually undergone more tests and a more complete evaluation for heart attacks in 17 hours than past chest-pain patients admitted to the hospital for three days, he says. The cost has dropped by two-thirds, to $1,078, since the unit opened in 1993.

Heart attacks are still the nation's leading cause of death, taking the lives of 600,000 people every year. But doctors hope they can reduce the numbers as hospital emergency departments switch over to a faster, cheaper way to evaluate chest pain and encourage people in pain to come in sooner.

In the last five years, hospital chest-pain units have grown from 50 to about 1,000, and the numbers are doubling every 10 months. There are three in the Baltimore area -- at the University of Maryland, St. Agnes and St. Joseph -- and others are in the planning stages.

Just as the advent of coronary care units -- wings in hospital set up for patients with heart pain -- allowed doctors to focus on heart ailments and discover how to prevent cardiac arrest in the 1960s, chest-pain units hold the promise of treating people before heart attacks occur -- at the first sign of unusual pain.

Dr. Raymond D. Bahr, an emergency room doctor at St. Agnes and the "father" of chest-pain evaluation units, believes that half of the 600,000 deaths from heart attacks are preventable if the early warning signs are heeded. Dr. Bahr, whose treatment methods are copied all over the world, set up the first unit to evaluate and treat chest pain at St. Agnes in 1981, and is largely responsible for the growth of such units nationwide.

Most heart attacks, he says, don't start out with crushing pain. Rather, in the hours, days and weeks leading up to a heart attack, patients have what he describes as "pressure, fullness, burning, ache, within the middle of the chest."

This discomfort "comes with activity and it is relieved by rest. What happens is, people do less. The other thing people do, because it is not pain, is they put off seeing a doctor until it becomes a recognizable heart attack."

The classic description of a heart attack is "an elephant sitting on my chest."

Henry Sabatier, an emergency medicine doctor at Harbor Hospital, had a heart attack while driving his car last November. He remembers it as being almost like a choking sensation.

"The pain was right in the center of the chest," he says, "deep inside, sometimes squeezing, pushing and gripping all at once." It was accompanied by nausea, lightheadedness and breaking out in a sweat -- all signs described in textbooks.

"The only thing I didn't have is pain radiating from my heart to my arm," he says. Dr. Sabatier used his car phone to call 911. He is back at work after bypass surgery.

Chest pains differ

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