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What do different types of chest pain indicate? Dr. Russell Silverman, cardiologist, explains the differences between atrial fibrillation, congestive heart failure, and other types of chest pain.
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Learn more about Russell Silverman, MD
Russell Silverman, MD
Dr. Russell S Silverman, MD has 41 years of experience. His specialties include Internal Medicine, Cardiovascular Disease and Nuclear Cardiology.Learn more about Russell Silverman, MD
Transcription:
Bill Klaproth (Host): So, when you feel your heartbeat in your chest, fluttering, skipping, pounding and uncomfortable feeling; that’s usually a sign of atrial fibrillation or AFib. And then we hear the term congestive heart failure. So, what is that? What are the signs and symptoms of congestive heart failure and how is that different from AFib? Well, we’re going to find out with Dr. Russell Silverman, a cardiologist at St. Joseph’s Healthcare, who is going to help explain both of these to us. Dr. Silverman, thanks so much for your time. So, let’s start with AFib. What exactly is that?
Russell Silverman, MD (Guest): Yes, atrial fibrillation is an irregular heart rhythm that occurs as a result of the top chamber of the heart going out of rhythm and resulting in a potentially very fast response in the lower chambers. Normally, the heartbeat initiates in let’s say the upper right part of the heart, the right atrium and travels through both top chambers, the right and left atrium and then filters down into the bottom chambers, the ventricles. And it’s a very organized heart rhythm but in atrial fibrillation, the sinus node where the heartbeat initiates is no longer taking charge and you may have many different areas in the heart firing independently causing a very chaotic irregular heart rhythm. And that might be no problem for a patient but more often than not, it does have implications and it also has a number of precipitating factors that we are aware of.
Host: Right. So, a lot of different areas of the heart firing at once. So, that is that fluttering that people feel in their chests during AFib.
Dr. Silverman: It may be a fluttering. It could sometimes might feel like pressure in the chest. It could feel uncomfortable to the patient and it also can make them feel short of breath and more than just fluttering or an unusual sensation in the chest gives them a discomfort. We usually don’t feel our heartbeat because we are accustomed to the heart beating regularly and unless the heart is pounding hard like we’ve just exercised; we don’t pay much attention to it. But it’s when you have those extra beats, something out of the ordinary that the body is not accustomed to then we start having symptoms.
Host: Right. I could see where that would be very alarming to someone. So, who is at risk for AFib?
Dr. Silverman: So, we look at atrial fibrillation from a number of different perspectives and there’s a lot of risk factors for atrial fibrillation. There’s a small percent of the population that have atrial fibrillation without any precipitating cause. And we don’t understand that very well. It can happen in 18, 19, 20 year olds. But usually we see atrial fibrillation as an older age group, somewhere not old at 40, but 40 and up I would say would be a more common time that atrial fibrillation might occur.
And the precipitating factors might be alcohol, for instance and in this country, around holiday time or probably around the world, around Christmas holiday time, New Years; alcohol intake is probably at a higher than normal rate and people go into atrial fibrillation as a result of excessive alcohol and we call that actually holiday heart syndrome. Since it does occur during the holiday months and we’re slowly reaching that time of year again. So, that’s something to keep in mind is to moderate alcohol consumption.
But more commonly, throughout the rest of the year, reasons people might go into atrial fibrillation might be a thyroid problem, might be longstanding high blood pressure, might be heart valve problems such as a leaky mitral valve or a mitral valve that is narrowed and doesn’t open as well as it should. So, there are a number of diseases that cause atrial fibrillation.
Host: So, how do you diagnose this Dr. Silverman? Is there a test you give someone? Do they wear a heart monitor? How do you figure out that oh this is AFib?
Dr. Silverman: Usually a simple EKG if they are having the symptoms at that moment will diagnose the rhythm disturbance. If it’s an intermittent problem, something we call paroxysmal atrial fibrillation or something that happens at intervals; we can give patients monitors to wear either surface monitors on the skin or even implantable monitors that measure the heart rhythm and report out on a monthly basis, weekly basis, whenever the patient has symptoms and these little devices last about three years and can pick up intermittent episodes of atrial fibrillation that might not otherwise become apparent because they are so infrequent.
But the problem is, that it’s the infrequent atrial fibrillation that can result in patients having strokes. Which is one of the major complications of atrial fibrillation.
Host: So, if someone does have AFib, what are the treatment options?
Dr. Silverman: We usually measure their risk to having an embolic or event. Embolic means a blot clot leaving the heart because of the AFib. Now when blood travels through the heart; it is pumped through the heart. So, the heart actually cleans itself with every beat because blood is ejected. But in atrial fibrillation, blood travels rather stagnantly through the top chambers and there are structures in the top chambers, the appendages we call them which we don’t know what the function of those are or were. They certainly don’t have much of a function now. But blood gets caught in the left atrial appendage and can become stagnant and actually form a clot.
And when it forms a clot, that clot can break off. And we measure risk of patients having a propensity to form that clot and break off by something called a Chads Vasc Score and what that represents; it’s a measure of certain risk factors that we know lead to embolic events or stroke in patients. And the Chads Vasc Score includes age, blood pressure, gender, things like that so that we can actually come up with a score that says yes, you are at risk or no you are not at risk.
If you have a low Chads Vasc Score one or zero for instance; you may just as well be as safe to take aspirin daily. But if your Chads Vasc Score is greater than one; your risk of stroke goes up with every increase in that Chads Vasc Score. And at that time, then a full dose anticoagulation would be recommended. And then you need to weigh the risk of giving somebody a blood thinner against their risk of them bleeding from being on that blood thinner and decide if the patient would do best with full dose anticoagulation or just with aspirin. And that full dose anticoagulation may be warfarin or Coumadin which is probably more commonly known or if anybody watches football on television on the weekend of course; you will see a lot of commercials for other agents that we now use for treatment of atrial fibrillation as blood thinners. Just to name a few by their brand name Eliquis, Xarelto, Pradaxa so those agents may also be used if you meet the criteria for being anticoagulated with those agents.
Host: Got you. All right, well thanks for the great information about AFib. That’s really useful. So, let’s turn to congestive heart failure. If we can just quickly talk about that for a minute. So, what’s the difference between congestive heart failure and AFib?
Dr. Silverman: Well, interesting atrial fibrillation can lead to congestive heart failure and congestive heart failure can lead to atrial fibrillation. Sometimes we don’t know which came first the chicken or the egg, but the fact is, that patients who go into atrial fibrillation with a rapid response can develop heart failure. And those patients who go into heart failure by virtue of the fact that the pressure in their hearts are increased because of the inability of the heart to clear itself of blood; can also lead to atrial fibrillation.
Atrial fibrillation is a result of for instance high blood pressure is a problem because that also is a risk for congestive heart failure, the so called ejection fraction preserved group. So, they have normal heart function but yet they go into heart failure. And people didn’t understand that until fairly recently and it’s because the heart muscle in the hypertensive or high blood pressure patient does not relax properly so blood does not fill the chamber properly, it does not stretch properly and the pressure builds up in the left atrium that leads to the left ventricle, then into the lungs leading to congestion, fluid congestion and congestive heart failure.
Atrial fibrillation makes that worse because the atria is not being emptied properly and the ventricle is not being filled properly and it’s a series of bad events that lead to heart failure.
Host: Right. So, when it comes to symptoms or feeling things when we were talking about AFib, you talked about the fluttering and that uncomfortable feeling like gosh, I’m actually feeling my heart, what is going on. What are the symptoms of AFib? Is there a feeling in our chest we should be watching out for or are the symptoms different?
Dr. Silverman: Well the symptoms of congestive heart failure would be predominantly shortness of breath, decreased exercise tolerance, inability to lie flat because you get more short of breath as blood returns to the heart because of your prone or supine position and the development of intolerable shortness of breath, almost a feeling of drowning. So, those symptoms are symptoms to watch for. Other symptoms might be decreased exercise tolerance, inability to do today what you could do two months ago, weight gain, swelling in the legs, things along those lines. So, the symptoms become apparent to the individual, but the shortness of breath is probably the most predominant rhythm that people need to recognize.
Host: So shortness of breath is the telltale sign when it comes to congestive heart failure. When it comes to diagnosis, what is most important to know?
Dr. Silverman: We have a number of modalities available to us to diagnose congestive heart failure. First one is certainly a physical exam and a history which are critical in making the diagnosis. The proper questions to be asked, the weight gain, the swelling in the legs, shortness of breath, can’t lay down, things like that and physical exam, listening for certain heart sounds that change with heart failure and listening for evidence of fluid in the lungs. And those are the most important things.
Host: Right. And then treatment for someone with congestive heart failure is what?
Dr. Silverman: Well treatment varies depending upon the type of heart failure. But in general, diuretics or pills that medications that make you produce urine, treating the blood pressure, lowering the heart rate, and we have a number of other newer modalities that we use to treat heart failure but in general, chronic management would include diuretic therapy and a number of medications to keep the heart rate down and of course dietary management of salt intake is a great help to reduce the recurrence of heart failure.
Host: Really good information Dr. Silverman. We appreciate that. That’s Dr. Russell Silverman, a cardiologist at St. Joseph’s Healthcare. For more information please visit www.sjhsyr.org, that’s www.sjhsyr.org. And if you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is St. Joseph’s Health MedCast from St. Joseph’s Health. I’m Bill Klaproth. Thanks for listening.
Bill Klaproth (Host): So, when you feel your heartbeat in your chest, fluttering, skipping, pounding and uncomfortable feeling; that’s usually a sign of atrial fibrillation or AFib. And then we hear the term congestive heart failure. So, what is that? What are the signs and symptoms of congestive heart failure and how is that different from AFib? Well, we’re going to find out with Dr. Russell Silverman, a cardiologist at St. Joseph’s Healthcare, who is going to help explain both of these to us. Dr. Silverman, thanks so much for your time. So, let’s start with AFib. What exactly is that?
Russell Silverman, MD (Guest): Yes, atrial fibrillation is an irregular heart rhythm that occurs as a result of the top chamber of the heart going out of rhythm and resulting in a potentially very fast response in the lower chambers. Normally, the heartbeat initiates in let’s say the upper right part of the heart, the right atrium and travels through both top chambers, the right and left atrium and then filters down into the bottom chambers, the ventricles. And it’s a very organized heart rhythm but in atrial fibrillation, the sinus node where the heartbeat initiates is no longer taking charge and you may have many different areas in the heart firing independently causing a very chaotic irregular heart rhythm. And that might be no problem for a patient but more often than not, it does have implications and it also has a number of precipitating factors that we are aware of.
Host: Right. So, a lot of different areas of the heart firing at once. So, that is that fluttering that people feel in their chests during AFib.
Dr. Silverman: It may be a fluttering. It could sometimes might feel like pressure in the chest. It could feel uncomfortable to the patient and it also can make them feel short of breath and more than just fluttering or an unusual sensation in the chest gives them a discomfort. We usually don’t feel our heartbeat because we are accustomed to the heart beating regularly and unless the heart is pounding hard like we’ve just exercised; we don’t pay much attention to it. But it’s when you have those extra beats, something out of the ordinary that the body is not accustomed to then we start having symptoms.
Host: Right. I could see where that would be very alarming to someone. So, who is at risk for AFib?
Dr. Silverman: So, we look at atrial fibrillation from a number of different perspectives and there’s a lot of risk factors for atrial fibrillation. There’s a small percent of the population that have atrial fibrillation without any precipitating cause. And we don’t understand that very well. It can happen in 18, 19, 20 year olds. But usually we see atrial fibrillation as an older age group, somewhere not old at 40, but 40 and up I would say would be a more common time that atrial fibrillation might occur.
And the precipitating factors might be alcohol, for instance and in this country, around holiday time or probably around the world, around Christmas holiday time, New Years; alcohol intake is probably at a higher than normal rate and people go into atrial fibrillation as a result of excessive alcohol and we call that actually holiday heart syndrome. Since it does occur during the holiday months and we’re slowly reaching that time of year again. So, that’s something to keep in mind is to moderate alcohol consumption.
But more commonly, throughout the rest of the year, reasons people might go into atrial fibrillation might be a thyroid problem, might be longstanding high blood pressure, might be heart valve problems such as a leaky mitral valve or a mitral valve that is narrowed and doesn’t open as well as it should. So, there are a number of diseases that cause atrial fibrillation.
Host: So, how do you diagnose this Dr. Silverman? Is there a test you give someone? Do they wear a heart monitor? How do you figure out that oh this is AFib?
Dr. Silverman: Usually a simple EKG if they are having the symptoms at that moment will diagnose the rhythm disturbance. If it’s an intermittent problem, something we call paroxysmal atrial fibrillation or something that happens at intervals; we can give patients monitors to wear either surface monitors on the skin or even implantable monitors that measure the heart rhythm and report out on a monthly basis, weekly basis, whenever the patient has symptoms and these little devices last about three years and can pick up intermittent episodes of atrial fibrillation that might not otherwise become apparent because they are so infrequent.
But the problem is, that it’s the infrequent atrial fibrillation that can result in patients having strokes. Which is one of the major complications of atrial fibrillation.
Host: So, if someone does have AFib, what are the treatment options?
Dr. Silverman: We usually measure their risk to having an embolic or event. Embolic means a blot clot leaving the heart because of the AFib. Now when blood travels through the heart; it is pumped through the heart. So, the heart actually cleans itself with every beat because blood is ejected. But in atrial fibrillation, blood travels rather stagnantly through the top chambers and there are structures in the top chambers, the appendages we call them which we don’t know what the function of those are or were. They certainly don’t have much of a function now. But blood gets caught in the left atrial appendage and can become stagnant and actually form a clot.
And when it forms a clot, that clot can break off. And we measure risk of patients having a propensity to form that clot and break off by something called a Chads Vasc Score and what that represents; it’s a measure of certain risk factors that we know lead to embolic events or stroke in patients. And the Chads Vasc Score includes age, blood pressure, gender, things like that so that we can actually come up with a score that says yes, you are at risk or no you are not at risk.
If you have a low Chads Vasc Score one or zero for instance; you may just as well be as safe to take aspirin daily. But if your Chads Vasc Score is greater than one; your risk of stroke goes up with every increase in that Chads Vasc Score. And at that time, then a full dose anticoagulation would be recommended. And then you need to weigh the risk of giving somebody a blood thinner against their risk of them bleeding from being on that blood thinner and decide if the patient would do best with full dose anticoagulation or just with aspirin. And that full dose anticoagulation may be warfarin or Coumadin which is probably more commonly known or if anybody watches football on television on the weekend of course; you will see a lot of commercials for other agents that we now use for treatment of atrial fibrillation as blood thinners. Just to name a few by their brand name Eliquis, Xarelto, Pradaxa so those agents may also be used if you meet the criteria for being anticoagulated with those agents.
Host: Got you. All right, well thanks for the great information about AFib. That’s really useful. So, let’s turn to congestive heart failure. If we can just quickly talk about that for a minute. So, what’s the difference between congestive heart failure and AFib?
Dr. Silverman: Well, interesting atrial fibrillation can lead to congestive heart failure and congestive heart failure can lead to atrial fibrillation. Sometimes we don’t know which came first the chicken or the egg, but the fact is, that patients who go into atrial fibrillation with a rapid response can develop heart failure. And those patients who go into heart failure by virtue of the fact that the pressure in their hearts are increased because of the inability of the heart to clear itself of blood; can also lead to atrial fibrillation.
Atrial fibrillation is a result of for instance high blood pressure is a problem because that also is a risk for congestive heart failure, the so called ejection fraction preserved group. So, they have normal heart function but yet they go into heart failure. And people didn’t understand that until fairly recently and it’s because the heart muscle in the hypertensive or high blood pressure patient does not relax properly so blood does not fill the chamber properly, it does not stretch properly and the pressure builds up in the left atrium that leads to the left ventricle, then into the lungs leading to congestion, fluid congestion and congestive heart failure.
Atrial fibrillation makes that worse because the atria is not being emptied properly and the ventricle is not being filled properly and it’s a series of bad events that lead to heart failure.
Host: Right. So, when it comes to symptoms or feeling things when we were talking about AFib, you talked about the fluttering and that uncomfortable feeling like gosh, I’m actually feeling my heart, what is going on. What are the symptoms of AFib? Is there a feeling in our chest we should be watching out for or are the symptoms different?
Dr. Silverman: Well the symptoms of congestive heart failure would be predominantly shortness of breath, decreased exercise tolerance, inability to lie flat because you get more short of breath as blood returns to the heart because of your prone or supine position and the development of intolerable shortness of breath, almost a feeling of drowning. So, those symptoms are symptoms to watch for. Other symptoms might be decreased exercise tolerance, inability to do today what you could do two months ago, weight gain, swelling in the legs, things along those lines. So, the symptoms become apparent to the individual, but the shortness of breath is probably the most predominant rhythm that people need to recognize.
Host: So shortness of breath is the telltale sign when it comes to congestive heart failure. When it comes to diagnosis, what is most important to know?
Dr. Silverman: We have a number of modalities available to us to diagnose congestive heart failure. First one is certainly a physical exam and a history which are critical in making the diagnosis. The proper questions to be asked, the weight gain, the swelling in the legs, shortness of breath, can’t lay down, things like that and physical exam, listening for certain heart sounds that change with heart failure and listening for evidence of fluid in the lungs. And those are the most important things.
Host: Right. And then treatment for someone with congestive heart failure is what?
Dr. Silverman: Well treatment varies depending upon the type of heart failure. But in general, diuretics or pills that medications that make you produce urine, treating the blood pressure, lowering the heart rate, and we have a number of other newer modalities that we use to treat heart failure but in general, chronic management would include diuretic therapy and a number of medications to keep the heart rate down and of course dietary management of salt intake is a great help to reduce the recurrence of heart failure.
Host: Really good information Dr. Silverman. We appreciate that. That’s Dr. Russell Silverman, a cardiologist at St. Joseph’s Healthcare. For more information please visit www.sjhsyr.org, that’s www.sjhsyr.org. And if you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is St. Joseph’s Health MedCast from St. Joseph’s Health. I’m Bill Klaproth. Thanks for listening.