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When to go to the Emergency Department

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If there is chest pain, the emergency services (112) must be advised without delay, particularly if it is of new onset, intense and accompanied by shortness of breath, lasts more than a few minutes, and gets worse on walking, climbing stairs or doing any other type of physical activity. Very often there are delays in consulting, because people think that their symptoms are not serious and will disappear. These delays could mean that the heart is exposed to more damage or lead to complications.

It should be remembered that the fact of having chest pain does not mean that you are suffering from a myocardial infarction. In fact, the majority of people who consult for this reason do not have one, and in general, the pain is caused by less serious problems.

Chest pain at home

Call 112. If there is chest pain, the emergency services (112) must be advised without delay, particularly if it is of new onset, intense, accompanied by shortness of breath, lasts more than a few minutes, and gets worse on walking, climbing stairs or doing any other type of physical activity. Also, if there are doubts, or the pain is worrying or frightening, it is also advisable to call 112.

Nitroglycerin. If you have already had chest pain previously, or have a coronary artery disease, you will surely have been prescribed nitroglycerin. If this is the case, put a tablet under the tongue and let it dissolve; wait 5 minutes, and if the pain has not gone, repeat the dose and call 112.

Wait for the emergency services. You must be prudent and not drive and not ask anyone else to drive you to a health centre, but wait until the emergency services professionals arrive, who will evaluate and treat the chest pain when they arrive at your home. Furthermore, if there is a serious complication, they are capable of treating the problem immediately.

If there is loss of consciousness. It may be that the patient loses consciousness at home or you are in the street with an adult who has just lost consciousness. In this case, you should forcibly squeeze them and ask if they are alright. If the person does not respond, not breathing, or is breathing abnormally (gasping), 112 should be called immediately and indicate clearly where you are and what the situation is (for example; I am …., I am in ….street…..corner of…or number.., I am with a person who is not breathing and not responding). Ask for help from any other person nearby, and start cardiopulmonary resuscitation (CPR) manoeuvres. If you are near a pharmacy, shopping centre, etc., someone could look for an automatic external defibrillator (AED), while basic resuscitation manoeuvres are started and the Emergency services arrive.

Tests in the Emergency Department

The action taken in emergency departments is based on opening a medical record on the patient, perform a physical examination, and an electrocardiogram.

The electrocardiogram is a painless test that shows the progress of an electric wave through the different parts of the heart. In individuals with chest pain secondary to an acute coronary syndrome, there are usually changes in the electrocardiogram.

For this test, the patient does not have to do anything. Some adhesive patches are placed on the chest, arms and legs, which are connected through some cables to the electrocardiograph that records the electrical activity of the heart. At the end of the tests the results are printed out. This test is rapid and completely painless. It is possible that more than one electrocardiogram is performed during your visit in order to observe any changes in the recording that may help in the diagnosis.

On doing this test, you will be asked about the intensity of the pain at that moment in time using a pain assessment scale graduated from 0-10, where 0 indicates absence of pain and 10 implies an unbearable pain. In some cases, it is likely that the electrocardiogram may be the only test that is performed and you could be discharged quickly.

A blood analysis may then be requested, in which, among other parameters, certain enzymes that are found in the heart muscle will be measured (cardiac troponin). In the course of an infarction, these enzymes are released in the blood and can be measured. In general, it may be necessary to take several samples of blood in order to assess any changes over time. This could mean that your stay in the Emergency Department may be longer.

While awaiting the results of the different tests, the patients remain monitored (continuous electrocardiogram record) all the time in order to detect any complications.

If the electrocardiogram is normal and the blood results do not show any abnormalities, but the pain may be explained as being compatible with an angina, it is possible that a stress test may be indicated. This test consists of walking on a treadmill (similar to those in gymnasiums), while a continuous recording is made on an electrocardiogram, in order to look for any changes. It is advised to wear comfortable clothes and you do not take medications some hours before. Although you may eat, it is advised that it is something light, with no stimulating drinks such as coffee.

If you are unable to perform this exercise you may be given certain medications to simulate heart activity with exercise. In these cases, in general, it is also indicated not to drink coffee or drinks with caffeine before the test.

This test is generally performed with an echocardiogram (ultrasound of the heart), or a nuclear imaging test. This latter consists of an injection of a radioactive substance, called a tracer, through a venous catheter. The tracer travels through the blood to the heart. A camera situated outside the body follows the signals of the tracer, taking photographs and creating images that shows how the blood flows to the heart. This test uses a minimal amount of radiation that does not cause any long-term problem.

In some patients a catheterization is performed, which consists of inserting a catheter guided by x-rays, and generally through an artery in your wrist (radial artery), until the arteries of the heart. Once it reaches the coronary arteries, a contrast is injected through the catheter in order to be able to see whether they are obstructed or not. If they are obstructed, treatment can be established at that time. This consists in the widening of the artery with a balloon (angioplasty) and the inserting of a type of mesh coated with a drug to prevent the artery from becoming obstructed again.