What happens in heart units?
While the prospect of heart surgery, or even visiting an emergency unit with chest pain, could be one of the most terrifying things you’ve ever faced, for the medical staff you encounter this is simply another day at the office. Because the scenario is so familiar they may explain too quickly and they’re often under tremendous pressure. But stop them and ask – it’s your right – and you’ll find a caring ear ready to allay your fears.

It’s important that people know what treatment they should be getting. Anyone with chest pain should have an ECG, and strictly speaking you should have an angiogram within an hour and a half of arriving at a clinic if your condition demands it. Every minute counts, as most complications occur within an hour of a heart attack.

Never ignore chest pain
Heart patients typically describe chest pain as a tremendous pressure, as if an elephant were standing on their chests. Other symptoms may include shortness of breath, lameness or pain in the left arm, nausea and sweating, indigestion, or pain in the jaw or shoulder. Patients are also usually quite pale and concerned, as they know something is wrong. They may walk slowly, stopping to take a few breaths now and then.

Women, however, may experience slightly different symptoms, particularly if they are diabetic. These may include nausea, dizziness, stomach pain or even backache.

Chest pain caused by heart disease occurs when heart muscle does not get an adequate supply of blood, due to narrowing of the coronary arteries. A heart attack occurs when a coronary artery becomes completely blocked, cutting the blood supply to that part of the muscle which then begins to die. If more than 40% of the muscle dies the heart cannot be saved, so it’s vital to get chest pain seen to before any damage occurs.

Inform emergency staff immediately
On arriving at the emergency room, immediately tell the receptionist that you have chest pain, as all chest pain is potentially serious.
If you arrive at Panorama’s clinic complaining of chest pain, you’ll go straight through for an assessment before having to fill in numerous forms – their policy is to ascertain the risk first. That may not be the case at all emergency units, but it’s important to forget being self-conscious and ask firmly for attention. Even though chest pain may not look nearly as dramatic as fractured bones or open wounds, it can be far more life-threatening. Ask for an assessment and an electrocardiogram (ECG).

The initial assessment
You’ll first be asked to lie down – if there is any trauma happening in your heart it’s important to reduce exercise and strain. A sister will take your blood pressure and pulse, and begin attaching electrodes to your chest for the electrocardiogram. (Six electrodes are stuck to your chest, with additional ones on each shoulder and hip.) At the same time, a doctor or cardiologist will be examining you and getting your medical history. He or she will ask you to describe the pain, whether you’ve had heart trouble before, and whether you have any of these risk factors:

• High blood pressure
• High cholesterol
• High blood sugar (diabetes)
• Smoking
• Family history of heart disease
• Previous heart attack or disease

An electrocardiogram or ECG traces the electrical activity of your heart. As the heart is a threedimensional organ, the ECG measures the heart muscle along 12 vectors to get a comprehensive electronic profile. Irregularities in the ECG pattern reveal different things about the state of your heart, and the nature of the irregularity shows whether the problem concerns rhythm, the blood supply to the heart muscle or whether the heart is enlarged.

A blood sample may be necessary
The doctor or sister may take a small blood sample to make absolutely sure no heart event has taken place. When the heart muscle is damaged, specific enzymes leak into the blood stream. A blood test registers these enzymes, confirming that some damage to the muscle has already taken place. The doctor could then request an angiogram to assess the reason for the damage.

Being admitted
You’ll be admitted to the hospital if you require an angiogram or any treatment, or you may be admitted simply for observation over six hours or more to monitor your symptoms to make sure there’s no cause for concern.

On average, a little over half the patients who visit Panorama’s 24-hour Chest Pain Clinic are admitted for observation or treatment. March 2002 was typical: of the 71 who came in with chest pain, 36 (24 men and 12 women) were admitted. Of these, 14 had angiograms, two had stents inserted, two had bypasses, one had angioplasty, and the rest were treated with medication.

The Coronary Intensive Care Unit
The Coronary ICU is a hive of quiet activity. Several things will be happening at once and you may have two or even more sisters buzzing around your bed. An intravenous line or drip will be inserted (if not already in place), your blood pressure will be checked again and a second ECG will be taken to see if there have been changes in your heart pattern. (Those with hairier chests will be relieved to hear that once in the ward there’s generally time to shave the patches of skin where they stick the adhesive electrodes. You may look a bit odd, but they’ll be a lot less painful to remove!) You’ll be connected to a heart rate monitor which is linked to the central nursing station, where staff watch your vital signs, beat by beat. The monitor also has alarms that will alert nurses to any changes.

If you’re in for observation, more ECGs and blood tests will be taken at intervals of up to six hours, and you may be sent for a stress test – exercising on a treadmill while connected to an ECG to see how your heart copes under strain.

Based on the results, the cardiologist will decide whether you need an angiogram. The sisters will give you an anti-coagulant or blood thinner, and you can ask for a mild sedative. They should explain exactly what will happen during the procedure – if they don’t, ask them to. From here you’ll be moved to the Cath Lab.

The Cath Lab
This is the Coronary Catheterisation Laboratory, or Cath Lab, where angiograms are performed. Depending on the results of the angiogram, the team may immediately go on to insert a stent, a balloon pump or perform an angioplasty.

During a coronary angiogram, a contrast dye is injected into the main coronary artery while the heart is x-rayed from a variety of angles. The images are fed to a bank of television screens, and the dye very clearly shows the passage of the blood through the coronary vessels, revealing the exact location of any narrowing or blockage. (The cardiologist will give you copies of the images, showing diseased coronary blood vessels.)

It’s a fairly quick procedure, usually taking no more than 10 minutes. Here’s what happens:

You’ll be seen by a cardiologist, usually assisted by two sisters, who will insert a tiny catheter into the femoral artery in your groin. (A needle is used to insert the catheter – there is no cut.) The catheter, a thin tube about two millimetres thick and about a metre long, is slowly fed up through the artery all the way into your heart. While this may sound a bit uncomfortable, the process isn’t painful and doesn’t require an anaesthetic, although you may be given a local anaesthetic at the insertion point. You need to be awake as the doctor may ask you to breathe deeply or move during the x-rays.
Dye is then injected via the catheter while the camera starts x-raying the heart.

• If the angiogram is normal, you’ll be sent to a general cardiac ward for recuperation;
• If it shows that surgery is necessary, depending on the severity of the coronary lesion you’ll return to the ICU for preparation for the theatre, or the general cardiac ward for surgery at a later stage; or
• You may remain in the cath lab for one of several procedures.

Inserting a stent
A stent is a small tube made of latticed stainless steel wire which is used to support and hold open a blocked or narrowed artery. The doctor uses a balloon catheter to manoeuvre it into place – this is similar to the catheter used for the angiogram, except it has a small, deflated balloon inside the stent at its end. Once in place the balloon is inflated, which expands the lattice of the stent against the walls of the artery. The balloon is then deflated and removed while the stent remains to hold the blood vessel open and restore the blood flow.

Angioplasty
Angioplasty is now perhaps less common than a stent insert, but the principle is the same. A catheter with a balloon on the end is manoeuvred into the blocked coronary artery. Once in position across the blockage, the balloon is inflated to compress the fatty deposits (that are causing the blockage) against the wall of the artery, to widen the diameter of the vessel and improve the blood supply.

Other options
Other procedures that may take place in the cath lab after an angiogram may include:

• Inserting a balloon pump. This is a temporary measure that may be necessary prior to bypass surgery, to improve blood pressure and support the heart.
• Ablasion. If the AV node – the heart’s own pacemaker – is faulty, this procedure inhibits its function. A temporary pacemaker is inserted for the ablasion, followed by a permanent one that will remain in the heart.

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