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Bill Klaproth (Host):  The American College of Cardiology has recognized Eisenhower Health for it’s demonstrated expertise and commitment in treating patients with chest pain. So, let’s learn more with Dr. Khoi Le, a Cardiologist and Dr. Euthym Kontaxis, Medical Director of the Tennity Emergency Department at Eisenhower Health. Dr. Kontaxis and Dr. Le, thank you so much for your time. Dr. Kontaxis, let’s start with you. Eisenhower Health has just been reaccredited as a Chest Pain Center. Why is this important?

Euthym Kontaxis, MD (Guest):  We’ve been reaccredited. We’ve been a Chest Pain Center for a number of years and it’s critical to the comprehensive management of patients with heart disease from patients who have mild chest pain all the way to patients who are having an acute heart attack or an arrythmia. We are meeting standards of care in terms of time of treatment, outcomes, et cetera. So, being a Chest Pain Center means we meet these standards on a regular basis.

Host:  Well that is really good to hear and the accreditation recognizes Eisenhower with primary percutaneous coronary intervention or PCI and resuscitation. So, what is PCI?

Dr. Kontaxis:  PCI is basically a complicated way to say that an artery is cannulized with a catheter and it goes up into the heart, the cardiologists are able to open up blood vessels using different equipment. So, we have a very rigorous PCI program. We have Interventional Cardiologists that do very complicated procedures to help open up blood vessels and provide proper blood to the heart when it is occluded or damaged.

Host:  So, then what happens in the Emergency Department when someone comes in with heart attack symptoms?

Dr. Kontaxis:  The main thing is how do you come to the Emergency Department. So, whether it’s coming by ambulance, oftentimes if they are coming by ambulance, the EMS will let us know that they think the patient is having a heart attack and we start the process of alerting the cardiologist in the cath lab that we may have a patient that needs intervention. So, your treatment and your process actually starts before you get here. So, that’s why we ask people who are having chest pain or think they may be having a heart attack to call 9-1-1 because the process of treatment actually begins before you get to the Emergency Department.

When a patient comes to the emergency Department with heat attack like symptoms, we have a process by which the patient receives an EKG within eight minutes of arrival. We call it a code 8. The patient gets an EKG within eight minutes of arrival and a doctor reviews the EKG immediately in order to assess whether the patient is having an acute ST segment elevation heart attack which really is an acute heart attack that’s very evident on the EKG. If that is identified, then initiation of treatment begins with settling the pain down, starting medications that will protect the heart, alerting the cath lab where the PCI is done and calling the cardiologist so that they are available to do the procedure.

Host:  So, let me ask you this then. It sounds like there’s a cardiologist always available in the Emergency Department to diagnose and treat heart attack patients. Is that right?

Dr. Kontaxis:  No, actually, ER physicians are very good at diagnosing acute heart attacks and initiating treatment. In fact, they did a study of reading EKGs of acute heart attacks and the Emergency physicians actually do a little better than the cardiologists. But they are specialists who can actually treat the patient acutely. So we work as a team. So, what happens is, we start the treatment, alert the cath lab, alert the cardiologist and have the patient stabilized within 30 minutes of arrival so that way the cath lab can prepare for the patient and our goal and we meet it almost every time is to have the patient in the cath lab within 30 minutes of arrival.

This kind of teamwork is essential to helping a patient with an acute heart attack. So, it starts with as I said, EMS, so if the medics are telling us the patient is having a heart attack, and they transmit it to us remotely; we can then alert the cath lab before even the patient arrives. We have techs and triage nurses that are very adept at stabilizing the patient, getting them settled, starting treatment. Our nurses, lab and x-rays are done rapidly, and we usually transport the patient to the cath lab with the physician and we are met there by the cardiologist.

Host:  So, you’re describing a full team approach here.

Dr. Kontaxis:  Absolutely.

Host:  So, do Emergency Department staff then have special training in cardiac treatment?

Dr. Kontaxis:  Absolutely. So, emergency physicians who are boarded in Emergency Medicine have specific training in the treatment of acute cardiac emergencies as well we have ongoing simulations and reviews and training. So, our nursing staff, techs and doctors almost quarterly do some sort of simulation or review of current treatment plans. We revise our protocols on a regular basis to meet the current standards and ne developments. We review all the cases on a monthly basis. So, every heart attack case that comes in is reviewed by a team of Emergency physicians and Cardiologists and nurses so that we can see how we can improve, and we do some special training with our residents as well called simulations. So, they can learn the process in a safe environment so that when the real thing happens, they’re ready.

Host:  So this whole story you’re telling us is really interesting from the minute the paramedics get there, information is coming back to the hospital. So, it sounds like speed is really important and you focus on that. So, how important is it to quickly diagnose a patient with heart attack symptoms?

Dr. Kontaxis:  Well it’s essentially critical. A lot of times, people say time is muscle. So, in terms of a heart attack, the longer the heart muscle goes without blood flow, the more damage is done. And when damage is done to the heart muscle, it can result in the heart muscle not being able to pump as well which is congestive heart failure, it can result in injury to the conduction system of the heart so you can have arrythmias. So, our goal is to minimize the damage caused by a lack of blood flow to the heart. And so, we’ve found that if within 30 minutes of arrival, if we can get them to the cath lab, and our cardiologists can open up the vessel with under 60 minutes of arrival, that our outcomes are excellent and people don’t suffer damage to their heart, depending of course how long they’ve waited to come in.

But the goal of course is when you’re having acute chest pain and you have risk factors and you think you might be having a heart attack; you call 9-1-1 and you get in right away so within an hour you’ve arrived at the hospital and then within 45 minutes, you’ve had your vessel opened; the injury to the heart muscle is minimal at that point.

Host:  So, time is muscle. We all need to remember that. Thank you Dr. Kontaxis. And Dr. Le, let’s bring you in and talk more about the human aspect of this on an individual basis. So, let’s talk about heart attack symptoms. What are the warning signs of a heart attack?

Khoi Le, MD (Guest):  Most people Bill will have severe chest pressure. It’s not so much chest pain but most people describe it as a pressure, a tightness, an oppressive feeling but they’ll definitely feel like something is wrong and it typically is located under the breast bone, the sternum or slightly to the left of that. In some people, that discomfort can radiate. It can spread up towards the neck, towards the jaw and typically it’s the lower jaw, not the upper jaw. It can also go into the left arm and usually it’s in the inside portion of the upper left arm, the part closer to the chest. But and so that pressure is the most common symptom. But there can be associated symptoms as well like nausea and sweating and in particular shortness of breath is always concerning to us.

Host:  Right. So, is the main cause of heart attack, coronary arterial disease and what is that?

Dr. Le:  Coronary arterial disease refers to the build up of plaque or cholesterol deposits in the wall of the vessel and what that leads to Bill is a gradual narrowing or restriction of the opening of the vessel and so the consequence is that you deliver less blood flow through that constricted or narrowed vessel. And that can be a gradual process that occurs over years or it can happen very acutely when that cholesterol deposit leads to a sudden fissuring or a break in the lining over it and exposes the blood to this fat deposit which the blood really doesn’t like and it tries to seal off that break right away by forming a blood clot and then it’s that blood clot itself which abruptly occludes the vessel.

Host:  Okay and then what is angina?

Dr. Le:  Angina refers to the chest discomfort which we were just talking about. And so, typical angina is like classic chest discomfort is that pressure, that chest pain, the tightness and then there are in the medical parlance, there is something we call atypical angina and that can be symptoms that are equivalent to angina that they are in the sense that they are also caused by the heart not getting enough blood flow and that can just be tightness around the neck, aching in the lower jaw, or it can just be shortness of breath with exertion. And those sometimes cardiologists will refer to as anginal equivalence.

Host:  So, this tightening of the chest or pain in the chest, is this something that can come and go? Is that a warning sign or is it usually when you get it, it stays there and for a long time?

Dr. Le:  Yeah, well for some people, it can just be brought on by exertion. So, angina or chest discomfort fundamentally Bill, it’s a supply and demand mismatch, right? So the heart needs more oxygen than it’s getting and when it’s not getting enough, then just like any muscle, it starts to cramp up or cause pain. And this is the heart’s way of saying I’m not getting as much oxygen as what I need to do what you’re asking me to do. So, it can come and go depending on the exertion but that’s when the demand increases but you can have a situation where you have a heart attack, and the demand hasn’t increased but the supply is suddenly reduced dramatically. So, as long as you have that supply and demand mismatch; you can have a problem.

Host:  So, then what is a myocardial infarction or a heart attack?

Dr. Le:  Yeah so, a myocardial infarction refers to damage that’s done to the heart muscle. Because this supply and demand mismatch has persisted for long enough to cause damage. Now when people say heart attack, you know obviously, it’s a really scary term for folks and I think it’s important to realize that it’s like saying car accident. So, there are all kinds of car accidents. There is that head on collision on the highway that’s just awful, but you can also park too close to somebody in a shopping center and someone opens the door and dings your car. Well that’s also a car accident but obviously it’s not of the same kind if consequence. And heart attacks also have that wide range of severity. So, there are the heart attacks that cause someone to just kind of drop or require emergency procedures and there are really small heart attacks that are just enough to alert someone that someone has a problem but really doesn’t cause any lasting damage to the heart or change the quality of the person’s life.

Host:  So, what are some of the common risk factors?

Dr. Le:  Most commonly, well smoking is a huge one. Diabetes, high cholesterol, high blood pressure, and a family history. Those are the five classic ones and again, I’m just going to run through them. Smoking, diabetes, high cholesterol, high blood pressure and a family history. And that’s not just any family history. The family history of someone having heart disease at a young age. So, a male relative, a first degree male relative like a father or a brother having a heart attack or heart disease before the age of 55 or a female, a mother or a sister having heart problems before the age of 65. If your parents have heart disease in their 80s, that probably doesn’t raise your risk much. Those are the five traditional ones and then there are some kind of newer risk factors that people are starting to recognize now like air quality, so pollution turns out to be a risk factor for heart attacks. Lack of sleep turns out to be an important trigger for heart attacks.

Host:  And then Dr. Le for women, what are the more unique and common symptoms reported?

Dr. Le:  When you look at women who present with symptoms of a heart attack, and you sort out – it actually – women’s symptoms are much more similar to men’s than different. So, that’s not really the difference. But the difference that for women often they’ll present without symptoms of a heart attack. So women are less likely to report physical exertion as being the trigger and compared to men, are more likely to have symptoms while they are at rest or trigger by emotional stress. And it’s lack of the classical symptoms that leads often to a delay in women getting diagnosed. So, if you look at women who come into the emergency room with chest pain, the diagnosis of a heart attack will get missed more often than it will in men. And when it is made, it’s made later so, there’s a delay in the diagnosis.

Some of that has to do with women also not thinking about heart disease as much as men and although some people still don’t realize it, heart disease is the number one killer in women as well as in men. And heart disease in women in this country is very common. In fact, it’s estimated that for women over the age of 65, one in three will have some form of heart disease. So, it is really important for women to be aware that heart disease is an important issue so they can identify themselves and seek attention. And Eisenhower has been doing a lot of things like it’s called Go Red For Women and trying to raise awareness of heat disease in women. And that’s really part of a big international movement to raise awareness of heart disease in women.

Host:  And that is a good movement because we often think of men when we think of heart attack, but we should think about women as well. So, it’s good that we’re raising awareness about that. So how do you diagnose a heart attack? Earlier you said it could be indigestion or maybe it’s a muscle strain or it could be something else. How do you diagnose a heart attack?

Dr. Le:  Well first is to get in and talk to a doctor. So, for heart attacks, you need to call 9-1-1 and get to an emergency room right away if you think that there’s any chance at all that you’re having a heart attack. Because what we do when we evaluate a patient, first of all, the history is really important. What kind of symptoms they are having, and do they have risk factors. Are they someone who is a diabetic, smoker and there’s a likelihood of higher that they are having a heart problem. And what caused it and how they describe the discomfort. We’ll do a physical examination and that is not so much to help make the diagnosis as to ascertain how sick they are. Are they – is their heart racing? Is their blood pressure dangerously low or high? Are they having problems breathing.

There are two really important things you can’t do at home or in the doctor’s office or in most doctor’s office and first is an electrocardiogram. And the electrocardiogram will tell you if there’s an abrupt occlusion of an artery in the heart and if there is one, then that unleashes a whole cascade of medical events that have to happen right away. So, the electrocardiogram is critical. And then second are laboratory studies. And in particular, there’s a laboratory study called a troponin. A troponin Bill is a protein that is generally only stored in the cells of the heart muscle. So, if we draw some blood, if you come in with chest pain and we draw some blood from your arm; and we can detect troponin in the blood stream, that means that some of your heart cells have become damaged and they have spilled their contents into the blood stream. So, that establishes the diagnosis that something has gone on with the heart and depending on how much troponin we get in the bloodstream, we know how much of your heart has become endangered by this or damaged.

So, it’s not only diagnostic but it’s also proportional to the problem that’s going on. Now once you diagnose someone having a heart attack, most heart attacks in this country are caused by an occlusion or a blockage of flow through a coronary artery, one of these vessels that provide the heart muscle with oxygen and blood flow. If you go back 30-40 years ago, all we could do was to try to – if you had the so called supply and demand mismatch, all we could do is really try to reduce the demand. So, people were put on bedrest, then you gave them oxygen and you tried to have them in quiet environment to try to rest the heart. But then, starting about 30 years ago, there was a shift to affecting the supply to trying to target increasing the supply of blood and the first step was to give clot dissolving medications that would help to restore flow through a vessel that had just become blocked by a clot.

The medical term for that was a thrombolytic medication. So, our people in the lay parlance would call it clot busters. But then, about 20 years or 25 years ago, there was interest in using balloons and catheters to try to actually go into the vessel and mechanically open up the vessel. And now, that’s been proven to be the best way to treat these heart attacks and with these techniques now, we’ve lowered the mortality, the death rate from a heart attack from about 10 to 15% down to somewhere around 3% now in the Untied States.

So, now when a patient comes in, if they are identified as having a heart attack in the emergency room; the next step is to take them immediately to the cardiac cath lab and to do an emergency coronary angiogram to look at the blood vessels of the heart and if they – if we find a blocked vessel, to go ahead and open it up right there and then.

Host:  So, do you use clot busters at all when you say open it up, what is the treatment protocol? Is that a stent?

Dr. Le:  We don’t use clot busters anymore for the heart because we find that it’s much better to take people to the cath lab and open up the blocked vessel and when we do that, over 80 to 90% of the time, does involve putting a stent in as well.

Host:  And then lastly, Dr. Le, if you do feel like you’re experiencing these symptoms of a heart attack, you should never hesitate to call 9-1-1 or go to your nearest emergency department. Is that right?

Dr. Le:  I’d say done even go to the closest ED, just call 9-1-1. Because at the point the ambulance gets there, you’re essentially in an emergency room. And the ambulance can get to your home quicker than you can get to an ED. So, a lot of times, people factor in well I can get to the ED faster than the – than waiting for the ambulance to get here and so they’re thinking of the ED as the safe place and the ambulance as transport. But that’s not the case. The ambulance is the ED. Okay, because what we worry about with a heart attack is that your heart might develop an arrythmia and there are these rhythm disturbances that the heart can go into when it’s struggling when it’s not getting enough blood flow, when it’s under stress. And some of these arrythmias Bill, can be fatal. The paramedics, they can shock you out of it. They can treat those arrythmias right away and you can’t treat that in a car, in a private car heading to the emergency room.

So, you got to get the emergency room to you right away and 9-1-1 is the fastest way to do that.

Host:  Well Dr. Le, thank you so much for sharing that with us. Really important information. And our thanks to Dr. Kontaxis as well. And to learn more, please visit www.eisenhowerhealth.org. And if you found this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. This is Living Well With Eisenhower Health. I’m Bill Klaproth. Thanks for listening. Eisenhower Health – Healthcare as it Should be.