IN August 2021 we published the first version of this article to sensitise the population about chest pain and the need for rapid evaluation and treatment. Our article, at that time, was prompted by the high level of ignorance and misinformation about the significance of chest pain and the need for immediate attention.

Nearly one year after the publication of that article, we have not seen significant change in the way individuals, providers, and payers respond to chest pain. Chest pain and related symptoms may often be the first manifestation of a heart attack or other potentially catastrophic cardiovascular and non-cardiovascular conditions and so must be adequately evaluated. When a heart attack occurs, the risk of death is high in the absence of appropriate medical intervention.

While every episode of chest pain may not be life threatening, it is impossible to know without comprehensive evaluation by trained professionals. Until such comprehensive evaluation is performed, every chest pain must be treated as an emergency. Any recommendation to the contrary is inconsistent with best medical practice. Many individuals with chest pain delay seeking care that could save their lives. In many instances, when patients have sought medical attention for chest pain, the response of the medical system has been slow, resulting in delays in diagnosis and treatment, often with dire consequences. In many cases, insurance providers have delayed responding to pre-authorisation requests for diagnostic or therapeutic interventions, often resulting in severe complications and adverse outcomes. We want to sound the alarm again. It is time to put an end to the unnecessary deaths and disability that result from delayed and inappropriate response to chest pain and its complications.

Nearly one year after we sounded our alarm on this matter, chest pain remains one of the most mismanaged medical complaints in Jamaica. Just to be clear, while medical jargon often colloquially refers to chest pain, many patients present with a mixture of symptoms that may include chest discomfort. Classical chest pain from obstruction of blood flow to the heart, or heart attack, may be associated with profound sweating, movement of the pain to the arms or neck, nausea, and vomiting. In many individuals, however, this classical presentation may not occur, and presentation may be less dramatic. Some individuals may experience abdominal discomfort or gastrointestinal complaints. In addition to chest pain, other prominent symptoms that should alert one to a possible heart attack or major blockage of heart vessels include shortness of breath, with or without exertion, fainting or collapse, fatigue, inability to perform normal activities or signs of heart failure, including swelling of the legs. While there is a tendency to emphasize risk factors for heart attack, like smoking, prior heart attack, diabetes, hypertension, and high cholesterol, it is instructive that many individuals experiencing a first heart attack would have no prior documented risk factors or history of heart attack prior to the first event. This underscores the rational for treating every chest pain as an emergency until proven otherwise.

As we stated in our earlier piece on this subject, it bears repeating that denial is not therapeutic, and ignorance is not curative. It is critically important that diagnosis is rapid and therapeutic intervention deployed consistent with international standards of care and best practices.

Case Report

A 41-year-old, otherwise healthy male, was seen at a public hospital emergency room with a history of chest pain and collapse while playing football. He was evaluated in the ER and an X-ray was performed. He was told that his heart was enlarged and discharged home with a recommendation to obtain an echocardiogram and lab tests as an outpatient. His employer, concerned about his well-being, contacted us for guidance.

Intervention

The case above is illustrative of the lack of appropriate responsiveness to chest pain and associated complaints. A 41-year-old active male presenting with chest pain and collapse must be thoroughly evaluated by competent personnel. Discharging such a patient without proper diagnostic testing is inappropriate and could portend significant danger. We were concerned that this patient may have suffered a heart attack, serious abnormality of the heart rhythm, or may have underlying structural heart disease that could be potentially fatal if unaddressed. We strongly recommended that the patient, who was in the country, be transferred to the Heart Institute of the Caribbean (HIC) as a matter of urgency so that we could evaluate and treat. Thankfully, his employer complied and mobilised resources to get the patient to HIC. On arrival at HIC, an electrocardiogram (ECG) revealed an evolving anterior wall heart attack involving one of the major coronary arteries, the left anterior descending coronary artery. An echocardiogram was done which also showed the pumping function of the heart was reduced consistent with a heart attack. Our team performed an angiogram, which confirmed critical narrowing of the left anterior descending coronary artery that required immediate intervention. An angioplasty and stent placement was successfully performed to restore flow to the blood vessels. The patient was subsequently admitted to our cardiac intensive care unit and medical treatment optimised. He recovered fully and was discharged home. A potentially catastrophic outcome was averted.

The choices we make can kill or cure — ignorance is not a solution and could be deadly

Door-to-balloon time (D2B) refers to the time it takes for a heart attack victim to receive a treatment called balloon angioplasty from the moment they walk through the hospital doors. This time should be as short as possible, preferably under 90 minutes, unless there are contraindications or the patient needs further stabilisation. As a community we should strive to improve health literacy around heart disease and remove all obstacles in the heart care value chain to ensure that patients with chest pain and/or heart attack receive urgent attention. To provide best-in-class acute heart care the institutions involved in the care of these patients must work collaboratively to resolve the asymmetry in-care delivery and to facilitate referrals to appropriate locations when the desired level of care is not available in one location. Discharging patients home in lieu of appropriate care referral is not an acceptable solution.

Despite resource limitations and suboptimal health literacy, cardiovascular care delivery must be based on the best medical evidence, and quality must be measured in terms of outcomes. The deficiencies in the health-care services value chain that lead to inappropriate care can be remedied by leveraging resources within the private and public sectors in a cooperative and collaborative way to improve care of patients and outcomes. Despite structural deficits as previously outlined, it is still possible to consistently provide rapid intervention and treatment in all cases of chest pain or heart attack.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107.