Author: noorali

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Diagnosis of Chest Pain

Dear Dr. B: Your last column discussed the symptoms of heart attack and immediate actions required to increase survival if one was having chest pain. What I would like to know is how often an ER physician would miss a diagnosis of a heart attack?

ER physicians are not infallible. The diagnosis of a heart attack can be missed. How often does this happen? This subject is well covered in an article published in the recent issue of the Canadian Medical Association Journal (CMAJ). Here is the summary of the article.

Approximately half a million people present to Canadian emergency department s with chest pain. About 62,000 Canadians are admitted to hospital with acute heart attack. Probably an equal number are admitted with unstable angina.

There are good assessment protocols for ER physicians to use in patients with chest pain but none helps clinicians determine which patients can safely be discharged from the emergency department after a brief assessment, says the CMAJ article.

U.S. studies have shown that approximately two percent of patients are discharged home where the diagnoses of a heart attack has been missed.

The authors of the CMAJ article studied 1819 patients at St. Paul’s and Vancouver General hospitals. The mean age of the patient was 58 years. Fifty eight percent of the patients were males. Thirty one percent of the patients arrived to the department by ambulance.

Twenty two percent (398 out of 1819) of patients had a diagnosis of acute heart attack or unstable angina on admission or confirmed within 30 days. Unfortunately, five percent of patients had been discharged from the emergency department because the diagnosis was missed.

The authors of the article indicate that the number of missed diagnoses in Canadian ER is higher than in U.S. where a study found the rate of missed diagnoses around two percent. The authors feel that the existing diagnostic pathways and guidelines do not include clear guidance for the early discharge of patients with chest pain.

The authors conclude that opportunities exist to improve both safety and efficiency by developing clinical tools to help clinicians identify patients who can safely be discharged after a short period of investigation. Ideally, the rate of missed diagnosis should not be more than two percent.

The study shows that if a patient presents with chest pain or discomfort to an emergency department in a Canadian hospital then 95 percent of the time you will have an appropriate diagnosis and treated accordingly. As better diagnostic tools become available the number of patients discharged with a missed diagnose will be much less.

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Heart Attack in Women

Dear Dr. B: I am a 60 years old woman. Few months ago, I felt nauseated and broke out in a sweat. My back went into spasm. After a few seconds, everything subsided. I just felt weak. I think I had a slight heart attack. Is it true that a woman’s symptoms of a heart attack are different from a man’s symptoms?

On an average, our heart beats 72 times a minute. That is 4320 times an hour. In 24 hours, our heart beats 103,680 times. That is lot of work. The work load increases as our activities increase.

Under normal circumstances and activities there is no chest pain, shortness of breath or discomfort when the heart is doing its work at a regular rate and rhythm.

But heart is very venerable to disease. Women are not immune to that. Newsweek reports that every year a quarter of a million women die of heart disease- more than the total number killed by breast cancer, diabetes and Alzheimer’s combined – making it Americas No. 1 killer of women , as well as men. Statistics in Canada are no different.

It is alright for women to worry about breast cancer and cervical cancer. But the risk of dying from heart disease is higher. And sometimes you don’t get a second chance. So if you have any symptoms suggestive of heart disease then talk to your doctor.

What are the typical symptoms of a heart attack?

If you are having a heart attack then you feel crushing chest pain – usually very severe. This may be associated with sweating, dizziness, shortness of breath and radiation of pain to the jaw, left shoulder and arm. There may be nausea and vomiting. There is fear of dying.

But not everybody has such classical symptoms. Twenty five percent of the people experience no chest pain during a heart attack. They may have other symptoms like shortness of breath, sweating and fainting. This is called “silent infarction”.

Some women fall in this category of “silent infarction”. They may feel tired, short of breath, nausea, indigestion, back pain or abdominal pain. Women tend to ignore these symptoms not realizing it could be a heart attack. And that is where the danger lies.

Heart disease in women is a real thing. After the age of 60, coronary heart disease is the main cause of death among women. In this age group, 25 percent of the women die of the disease – same as men.

What to do if you are having a chest pain or think you are having a heart attack?

Dial 911 and call an ambulance. Do not wait for self-diagnosis or drive in your own car. Chances of surviving a heart attack are better in an ambulance with paramedics at hand than in your own vehicle. If you are having a heart attack then the outcome of your illness may be dictated by:
-The speed and mode of transportation to emergency department.
-Your previous history of heart problems.
-Rapid evaluation of your condition by emergency physician.
-The use of “clot busting” drugs in a timely fashion.

How to prevent heart disease?

Make sure your cholesterol level and blood pressure is under control. Exercise regularly. Eat a healthy diet with lots of fruits and vegetables, fish and chicken. Take an aspirin a day – check with your doctor first to make sure it is safe for you to do so.

So, remember, if you think you are having a heart attack then dial 911 and call an ambulance. While waiting for it, have an aspirin. A telephone call and an aspirin may save your life.

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Sexually Transmitted Diseases

Dear Dr. B: What are the risks of sexually transmitted diseases (STD) for homosexual women and men?

If a person has sex with someone who has sexually transmitted infection then the risk of contracting the disease is extremely high. It does not matter whether a person is heterosexual or homosexual.

The infection is caused by bacteria or viruses.

Bacterial infections cause Chlamydia, gonorrhea, and syphilis. Viral infections cause hepatitis B, genital herpes, AIDS (human deficiency virus – HIV) and genital warts (human papillomavirus – HPV).

You are at risk of having STD if:

-you ever had sex
-you had many sex partners
-you had sex with someone who has had many sex partners
-you had sex without using condom

Long term consequences of STD can be serious and sometime life threatening. Chlamydia and gonorrhea can cause pelvic inflammatory disease in women and infection of testicular area in men. This may render a person sterile. Viral warts can cause cancer of the cervix or penis. Syphilis can cause infection of the nervous system, mental problems, blindness and death.

Dangers of hepatitis, genital herpes and AIDS are well known.

In most cases, STD can be diagnosed by your doctor with a history and physical examination, culture of the secretions from vagina or penis, a blood test or a urine test.

One can lower the risk of STD by having sex with someone
-who is not having sex with anyone else – a monogamous relationship
-who does not have STD
-by always using condom – no unprotected sex until your relationship has been established.

You may be interested to know that condoms have been around since 1640s. According to a report in the Medical Post (January 2nd, 2004), the world’s oldest condoms are part of a museum exhibition that will tour a number of European cities in 2004.

The exhibition titled “100,000 years of Sex”, was mounted by the curator of the Drents Museum in northern Holland who found the old condoms at a castle in England. They are made from fish bladders and have been dated back to the 1640s. The exhibition features European sexual artifacts up to 1900 and has been drawing record crowds – mostly women between 55 and 65, says the Medical Post report.

Can we treat STD?

Infection caused by bacteria can be treated with antibiotics. Infection caused by viruses are difficult to treat but some of the symptoms can be taken care of.

One of the risks of sexual contact is exposure to sexually transmitted diseases. Casual sex without a condom carries the most risk for STD because you may not know if your partner is infected. Practicing safe sex is the best way to stay out of trouble. Same rules apply to men and women, whether they are homosexual or heterosexual.

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Flesh-eating Disease

Dear Dr. B: What is flesh-eating disease?

Flesh-eating disease is a form of streptococcal infection that leads to death of tissues. It is a deep-seated infection under the skin. It progressively destroys fat, fascia and muscles. The condition is also known as necrotizing fasciitis.

Streptococci (invasive group A hemolytic streptococci) may act alone or in combination with other bacteria. The infection spreads rapidly. Shock and multiorgan failure are common. Mortality is high – up to 58 percent.

Fortunately, the disease is not that common. In Canada, it is estimated that 90 to 200 cases of necrotizing fasciitis occur each year. From time to time the disease hits the headlines. Then there is long silence before another case is reported. This leaves people wondering what is this all about.

The most famous case of flesh-eating disease was Loucien Bouchard, the former premier of Quebec. He luckily survived and had to have one leg amputated.

An editorial in British Medical Journal (BMJ) says that the condition was first described in a specific body region by Fournier in 1883 and as a more generalized condition by Meleney in 1924.

The most common sites of infection are perianal and groin areas and post surgical wounds. Infection around the umbilicus in a new born can be life-threatening. Among children the necrotizing fasciitis can be a serious complication of varicella infection.

Is it possible to make an early diagnosis before things get worse?

Unfortunately, no! The diagnosis is clinical. Initially, it is hard to differentiate from ordinary infection of the skin. But gradually patients get very sick. The pain is more severe than the clinical findings. There are only minor changes in the skin in early phases.

An article in the Canadian Medical Association Journal says the factors that help distinguish necrotizing fasciitis from ordinary skin infection include a generalized rash, toxic appearance, fever and low platelet count. Unfortunately, the current state of knowledge on diagnoses and management is limited. More research is required.

“The main diagnostic tool, however, is surgical exploration”, says the BMJ editorial. The characteristic finding is of grey, edematous fat, which strips off the underlying fascia with a sweep of the finger. Deeper changes are invariably more widespread than the skin changes.

Patient requires immediate hospitalization for medical and surgical management. Three specific treatments have been suggested:
-antibiotics,
-hyperbaric oxygen, and
-surgery.

The BMJ editorial says that no evidence exists that antibiotics halt the infection in necrotizing fasciitis and their use may tempt the surgeon to perform less mutilating but less effective surgery. Nevertheless, broad spectrum cover is routine and should specifically target anaerobes and streptococci.

Hyperbaric oxygen is strongly advocated by some. But there are no controlled studies to prove its usefulness. Using it would seem reasonable if it was readily available but not if the need for interhospital transfer delayed definitive surgery, says the editorial.

Surgery is the mainstay of management. Patient should be taken to the operating room as soon as flesh-eating disease is suspected. Massive removal of dead and dying tissue is undertaken. Sometimes amputation becomes necessary. Patient may require surgery more than once.

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