At the Forefront Live: Chest Pain Q&A
February 27, 2020
And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's get right into the program. Dr. Nathan, Dr. Blair, thanks for being with us today. We appreciate you being on the program. If you could start us off and just tell us a little bit about yourselves and what you do here at your U Chicago Medicine. And Dr. Nathan, we'll start with you.
Well, thanks so much for having me. It's a pleasure to be here. I'm an associate professor of medicine. I'm a general and interventional cardiologist. In my administrative roles, I serve as a medical director of the cardiac intensive care unit and co-director of the cath lab. I work in the cath lab, the cardiac intensive care unit. And I see patients in the clinic as well.
Great Dr. Blair?
Yeah, again, thanks for having me. It's great to be here. I'm an assistant professor of medicine here at University Chicago. And I'm, just like Dr. Nathan, a general cardiologist and an interventional cardiologist, which means I see patients in the office. I also see patients in the hospital. And I have designated days where I'm in the cardiac catheterization lab doing procedures to help patients with chest pain, among other things.
Great. So this is clearly a topic today that has really touched a nerve with a lot of our viewers because we've already received several questions before we even started the program. People have been writing them into our Facebook page. So that's great. And we want to encourage people to go ahead and continue to send questions. And we'll try to get to as many as we can over the next half hour.
I'm going to start with kind of a basic, though. When people experience chest pain, I think the initial reaction probably will be to ignore it, or say it's indigestion, or something like that. What do people need to know? And how do they know the difference?
Yeah, so, you know, the way I sort of speak to patients and sort of frame it in my own mind is you have to think about the context of the chest pain, the severity, and the progression of the chest pain, and what are some of the reproducibility factors?
And so things that get our attention as cardiologists are chest pain that is sort of taking out an ominous tone, that's progressive, perhaps coming on with exertion and worsening, relieved with rest, and chest pain that takes your breath away, makes you nauseous, or otherwise unwell, and certainly chest pain that results in passing out and other symptoms like that are certainly more concerning. But in broad strokes, I think any chest pain requires some degree of medical vigilance.
Yeah. You know, it's something we tell people on the program all the time. If you really have concerns, it's better to be safe than sorry. See a physician and get it checked out. Dr. Blair, one of the things that we always talk about too or we hear about are the pains radiating down your arm. Is that a good indicator or not?
Yes, actually it's a great indicator of something you should really be concerned about. Also, it may not necessarily be pain. It may be something like pressure or discomfort.
But definitely if the pain, pressure. Or discomfort travels down your left arm with numbness or travels down to your neck, and definitely if it's worse when you walk around, those are some very severe warning signs that should seek medical attention. And if it comes on suddenly, that medical attention should be sought immediately.
Well, we're going to get the launch right into viewer questions because I do want to hit as many of these as we possibly can. And one of the first ones we got is, what kind of tests can be done to see if you actually have coronary heart disease? So if you suspect that this is an issue, what kind of things can be done?
So I think just a few facts about coronary artery disease-- heart disease as a whole is the number one killer in the Western world, certainly in the United States where somebody dies of a heart-related event every 40 seconds. So the prevalence of heart disease is extremely high. And so I think screening should be sort of commensurate with that.
Before everyone rushes off to get invasive or very involved medical testing, I think start with the basics, right? Start with an assessment of your cardiovascular risk profile, which can very easily be done in the office, bloodwork, blood pressure. Perhaps an ECG and some laboratory tests would give you an initial sense of how high risk you are. And then based on that, that can sort of inform your decision to get more elaborate or in-depth tests.
I had the opportunity to go to the Go Red for Women luncheon earlier, this was last week. And one of the things that kind of struck me is women and men experience different symptoms. I mean, obviously there are differences. But we feel things a little differently. And I think oftentimes, particularly with women, they don't seek treatment because they may not think it's what it actually is. So what do women need to be aware of?
I can take that.
So women present with chest pain and with coronary disease just as much as men. They happen to do so kind of almost a decade behind men. But the predominance of coronary disease in women is about the same.
And when you talk about the types of symptoms that women have versus men, by and large, both women and men are going to have those characteristic symptoms of chest pain, pressure, fullness, or discomfort. However, there is a slightly higher prevalence of women who present just kind of a little bit atypically. Maybe it could be presenting with heartburn, or discomfort, or pain in the abdomen, or just overall fatigue, or malaise, or shortness of breath.
But by and large, men and women will present very similarly. And but any sort of symptom around the chest area, and especially worse with exertion, should be something to be concerned with, men or women.
I'd just like to amplify--
--just some of John's comments. I agree completely. I think we have to be circumspect when we take in a history and try to understand what these symptoms are. So any sort of reproducible or exertional chest anything, I think, is cause for some concern or at least for some medical attention. I was at the Go Red event as well, which was a wonderful event.
You know, women have a very high risk of cardiovascular disease. And I think you couple that with the lower rates of detection and you've got a real problem that we need to sort of take head-on. You know, one of the axioms in our world is atypical is the new typical. So start thinking about atypical symptoms as perhaps a manifestation of ischemic heart disease.
Right. We are getting all kinds of questions coming in. So I, again, want to get through as many as possible. And there are a few of these that are specific to women that were written in. This one, in women, how do you tell the difference between chest pain that's GERD and chest pain that signals heart issues? And is there a difference by sex with that?
Yeah, that's a good question. That gets to the heart of the issue that Sandeep was talking about, where a lot of people can go undiagnosed or kind of been told that they're there heartburn is just that, just heartburn. It kind of boils down to what types of risk factors that your patient or you may have and whether the symptoms get worse or get worse with exertion.
So the risk factors that we're talking about, we're talking about smoking, high blood pressure, diabetes, a strong family history of heart disease, and a personal history of high cholesterol. If you have any or a combination of those, the index of suspicion, that we call it, goes up if you have symptoms in the chest area, whether it be typical or atypical symptoms like these GERD-like symptoms.
The other thing is, like I said, if the GERD gets worse, or if the reflux or heartburn gets worse when you walk around, it probably is not heartburn and is more likely to be related to your heart. Because your heart needs energy to perform. It demands more energy when you exercise. So if whatever chest pain syndrome you're having gets worse when you walk around, it probably is due to the lack of blood flow to your heart when you're walking around.
Now, the question from a viewer-- if I have high cholesterol, would you suggest a statin and/or would you suggest fish oil?
Yeah, so I think that's a great question. I think that question is applicable to millions and millions of Americans. You know, again back to fundamentals, just because you have a history of high cholesterol doesn't mean you necessarily have it right. Now chances are you do, but we don't draw this picture in black and white.
First and foremost, I think getting a fasting lipid profile and just seeing how high the different lipid fractions are, and then making some decisions. There are some modifiable lifestyle factors, dietary factors, and so on that can be very impactful from the standpoint of cholesterol, as well as blood pressure, as well as glycemic control in diabetics.
And so I think that that sort of forms the base of the pyramid. And then as you get further up the pyramid in terms of therapies, you start thinking about statins, fish oil, and so forth. Specific to fish oil, there's some really recent data that suggests that concentrated fish oil supplements may improve outcomes in patients with cardiovascular disease.
But in terms of primary prevention, I think diet, exercise, and monitoring your lipids and then phasing in some of these other pharmacotherapies is appropriate.
Really fantastic questions for viewers so far. Here's another one. Do you recommend the calcium CT scan to assess heart attack risk?
So, I can field that. So, the calcium CT scan is a very inexpensive way of adding onto what's already known about a patient to further add on to figure out their cardiovascular risk. The basic things are just a simple thing like a blood pressure cuff and also a fasting lipid panel once you get to a certain age.
But beyond that, if you have other kind of intangible risk factors like if you have kind of borderline cholesterol and you're just worried, or if you have people in your family who have had heart disease but didn't necessarily have it when they were really young, then you can get a CAT scan to look at the amount of calcium you might have in your coronary arteries.
And that can kind of, one way or another, kind of put you on one end of the risk-- or one side of the risk spectrum versus the other. So it can help kind of clarify your risk, especially if you're on the borderline combination of factors that might put you on or off of a statin for prevention.
And, you know, for the viewers, I also sort of liken the issue of coronary calcium to the issue of smoke versus fire, right? So the presence of smoke usually indicates that there's a fire. There's a rough proportionality. The more smoke you have, probably the larger fire it is.
But it doesn't necessarily predict some of the outcomes or functional components that we're also interested in when we try to look for coronary artery disease. And so what that means is that if you have a lot of calcium, you have coronary disease for sure, right? The calcium doesn't belong in the vascular bed. However, the functional implications of that coronary artery disease is going to vary greatly from person to person. And that's where we get additional testing.
The one other thing I would say is that in patients who have known coronary lesions, a known history of cardiovascular disease, and certainly if you've had angioplasty stent or bypass surgery, risk scoring with calcium with a CT scan doesn't really add a whole lot. So this is for first time detection and screening in a primary prevention capacity.
Very interesting. That's an excellent point. So here's another one-- I have to tachycardia and high cholesterol. Should I be concerned when painful shocks move from my left breast to upper right breast for several days?
I think this might be a more specific thing that would that we can talk to you about in consultation. It's very hard without getting a full history and a full physical to tell you whether this is something to worry about. But I do want to re-emphasize some of things that we've been talking about. If these types of symptoms predictably get worse when you walk around or when you're exercising, then it's something that may be a little bit more concerning than if it happens just for seconds, and it's random, and doesn't seem to be related at all with exertion.
Really, really interesting questions coming in. Here's another one. What If you feel a sharp pain, as if something is pinching your heart? We're getting very specific in the pains, I guess.
I think a lot of this, again, goes back to something that John said. A thorough history and physical examination gets to the heart of the matter, pun intended. You know, we do get a lot of information just looking at you and sort of gauging what types of symptoms you have, and what reproduces them, and what's the periodicity of it.
Generally speaking, sharp pains that are transient or fleeting, feels like electric shocks or pinpricks, things that you can reproduce by palpation, by pressing down on the chest wall are less likely to be related to ischemic heart disease. But that's a very broad statement and really has to be refined with some face to face time.
Again, better safe than sorry. So what does a stress test tell you about your heart health?
So, a stress test is a test that we get at a particular point in time. And it's really designed to determine why you may be having chest pain. I want to emphasize that the stress test is mostly for symptomatic people, people who have a symptom, like the ones that you mentioned earlier, and want to know whether it's their heart.
It doesn't really do much in terms of determining whether you have-- whether you're at risk for developing coronary disease or whether you have coronary disease that hasn't met the-- hasn't gotten bad enough to cause symptoms. So it's really an assessment of symptoms.
That being said, if you do have symptoms and you do a stress test, a normal stress test generally reassures you that, at least in that point in time, that your symptoms are very unlikely to be due to your heart.
Whereas a positive stress test, especially one where you're exercising on the stress treadmill and you have those reproduction of chest symptoms, a positive one of those may indicate that you have a blockage in one or more of your heart arteries that may need further evaluation beyond that. But it doesn't overall tell you what the wellness of your heart is, necessarily, or the risk of developing a heart attack or stroke in the future.
So one of our viewers is wanting to take this back to the basics. And I think this is a good question and something you can maybe expound on a little bit. And basically, if you can talk to us a little bit about a heart healthy diet, what that means. You know, we're hit with so many different fad diets. And it seems like every time you get online, there's a new diet out there. What's a good diet that somebody could follow that would be something that's actually good for them in their heart?
It's a great question. I know however I answer this, I'm going to get some hate mail for this because I didn't say exactly the diet that they're on. You know, I think the American Heart Association endorses a lot of the common elements of a diet that's appropriate for patients who want to prevent cardiovascular disease and certainly want to prevent the progression of cardiovascular disease.
Focusing on a diet that is rich in fruits and vegetables, low amounts of saturated fat and cholesterol, and perhaps enhanced with olive oil, perhaps enhanced with olives, with almonds, and so forth, as components of the Mediterranean diet may be appropriate. But really it's about balance. It's about lean sources of protein and minimizing the content of saturated fats and cholesterol. John, would you would you agree with that?
Yeah, absolutely. The American Heart Association recommends a Mediterranean-style diet, which is exactly what Sandeet outlined. When I'm talking to patients, I usually try to boil it down to the basic components. Try to cut out sugary beverages. You should actually completely cut out sugary beverages and switch to non-sweetened beverages.
Cut back drastically on baked goods and things like breads and rices, which don't necessarily give you that much nutrients. And instead, switch over to plenty of fruits and vegetables. And by plenty, I mean five to seven servings, if you can, per day, and lean meats. And what I usually say is anything that comes in a box, can, or a bag, you should probably cut out of your diet. If you're a smoker, also quit smoking as soon as you can.
So, another question from one of our viewers. What's your stance on pre and probiotics? This one may get you an email or two afterwards.
I can field that. Pre and probiotics, those are very popular in the media. And, you know, perhaps if you want to get into more of that type of discussion, I'd be happy to talk about that in the clinic. But I would say do the first steps that Dr. Nathan and I outlined before it with the macro nutrients before getting into the pre and probiotics.
So for example, if you're eating a diet very rich in an foods that are in a can, box, or bag and you eat probiotics, those probiotics probably aren't doing all that much for you. So first start with the big basics. And then after that, you can really fine-tune that with these pre and probiotics as needed.
Although overall though, they're not harmful. And they may possibly have a beneficial effect in addition to the overall healthy general diet, heart healthy general diet.
You know, everybody's is always in a hurry. And everybody's always rushing. And a lot of families will turn to fast food because it's easy. And then that starts that whole habit. And then everything's fried and not good for you. And it's difficult to break those habits.
But, you know, to your point, I think there are some things that can be done that could be fairly simple that would make a pretty significant difference. And people just need to be aware of that and continue to think about that.
One of your patients, by the way, just wrote in and said, thanks, Dr. Blair.
So that was nice.
So talk to us a little bit about angiography What exactly is that? And what does it do?
So Angiography is an invasive diagnostic test that involves passing a thin, flexible plastic catheter through the artery, either in your leg or preferentially in your wrist, threading that up under the guidance of live X-ray camera to the heart, injecting some contrast dye, and then taking pictures of the inside of the blood vessels of the heart.
It also allows to do a variety of more sophisticated tests, such as physiologic testing of blockages, to see whether blockages are truly significant or not, as well as to pass tiny little ultrasound probes inside the heart and take pictures from the inside. Angiography is also the platform for some of the catheter-based procedures that Dr. Blair and I perform, including angioplasty and stent.
We use a variety of different tools to get rid of plaque from within the arteries of the heart. And those tests and maneuvers can be applied in a broader scale to almost any arterial bed in the body.
And let's do talk a little bit about the treatment options that are available. Because I think, again, when people hear that they have coronary heart disease, they have coronary artery disease, they get they get very upset, nervous, and rightfully so. But there are things that can be done.
Absolutely. The treatment for coronary disease, for all patients with coronary disease, has to do with making sure that their blood is thinned-- and sometimes just a baby aspirin is enough-- a cholesterol-lowering medication with a statin medication, and control of other risk factors like high blood pressure, diabetes, and quitting smoking.
So that's the basic background of therapy for all patients with coronary artery disease. For patients who have symptoms, the symptoms that we're talking about with exertion, and chest with chest pressure or pain, or even shortness of breath with exertion, for those patients who remain symptomatic after good blood pressure control and after all the things that we talked about, a coronary stent or coronary artery bypass is oftentimes the next step to relieve those symptoms.
That is to say, that's for patients who have kind of stable symptoms. There are a subset of patients who have coronary plaques that become unstable and they present to the emergency department with what people call a heart attack or a myocardial infarction.
With those patients, immediate attention to the emergency department so that Dr. Nathan, or myself, or one of my partners can do an angiogram and then identify the artery that is undergoing the heart attack and opening that up with a stent is could potentially be lifesaving.
So there's-- as I mentioned, there's a variety of things to treat coronary artery disease. And it really depends on how symptomatic you are and how sudden you present with your symptoms.
And angiography, angiograms, stents, those have been around for quite a few years now. But the technology has changed pretty significantly over the past few years, I'm not mistaken.
Yeah, you're absolutely right. The technology has changed in a couple of different ways-- miniaturization of devices, improved efficacy or improved outcomes, and big improvements in the safety of these procedures. I think we used to historically think of bypass surgery, as John mentioned, or angioplasty and stenting in their own silos. And I think it's important for our viewers to recognize that there are hybrid options as well. With minimally invasive or endoscopic bypass surgery being applied to a couple of the vessels and the remaining vessels being taken care of with stents-- we refer to that as TCAB hybrid. That's an acronym, total endoscopic coronary artery bypass, as a hybrid strategy for fixing these vessels.
So even in patients who have very complex coronary artery disease, there may be minimally invasive options that they take care of the totality of the |
And it's fascinating. These minimally-invasive options, the patients oftentimes are out of the hospital just in a matter of a couple of days.
Yep, absolutely. The turnaround for these procedures have also shortened, along with the other safety profile. You know, keep in mind that historically, patients with heart attacks in the 50s through the 70s remained in hospital for up to two weeks on strict bed rest. And now, many of these patients, if they come in early enough, we're able to take care of the problem, they're home in two or three days.
That's incredible. And, you know, it's funny. I ran into actually a patient just the other day for another project we're working on. And he had some work done on his heart. And he said that the relief that he felt, or the way he felt afterwards, was immediate almost. And he just felt so much better. And he had more breath, and energy, and that sort of thing. So it can be pretty dramatic.
Absolutely. And one of the things that has really helped the recovery from these procedures and the safety of these procedures is how we perform them. And traditionally, when people think of an angiogram, they think of going in through an artery in the groin, and having their procedure, than laying flat for six hours with a sandbag on their groin.
Over the last decade or so, there have been a lot of advances. Instead of going through the groin, we actually go through the wrist. And that provides a much less invasive strategy to do this with much quicker healing times, where you can actually get up, and walk around, and eat, and walk around your room following the procedure because we went through a small artery in your wrist.
And most techniques can do basically all of the very complex work that may or may not need to be done with stents all through the wrist. So that's been a very significant breakthrough that we've really adopted a long time ago when-- almost a decade ago. Is that, right?
Yeah, 12 years ago.
Dr .Nathan really pushed for that technique here. And now it's pretty much mainstay therapy here at University of Chicago.
Yeah, John raised a great point. Trans-radial angiography and intervention, which is the technical term for going through the wrist and performing catheter-based procedures, has a solid body of data behind it. This is not just sort of a preference thing anymore. When it can be applied-- and it can't always be applied-- but when it can be applied, there's perhaps a significant improvement in outcomes, patient well-being, the likelihood of bleeding after the procedure, and, as John mentioned, being able to get up immediately walk around with a Band-Aid on your wrist is really huge.
Yeah, it's fantastic. Well, we are out of time. You two were fantastic. That was really, really interesting. And really happy that our viewers were so engaged. So that's great.
And one of the things that I do want to note, that's kind of exciting, we are rebroadcasting our Facebook Live now are at the Forefront Lives on WGNTV on Saturday mornings at 10:30 now. So you'll be able to catch this program here in a couple of weeks there. So that's great.
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Chest pain is a key symptom of coronary heart disease, the most common type of heart disease that kills 370,000 people annually.
Coming up on At the Forefront Live, we'll speak with interventional cardiologists Dr. Sandeep Nathan and Dr. John Blair about the causes of chest pain and some of the possible treatments. We'll also discuss when chest pain indicates a serious coronary artery problem. And the best part, we'll take your questions live coming up right now.
John Blair, MD
John Blair, MD, FACC, is a cardiologist who specializes in the care of complex coronary artery disease, mitral and aortic valve disease and congestive heart failure.Learn more about Dr. Blair