Ask Us Anything About… Chest Pain

Barbara Schindo – Thank you for joining us. You are watching Ask Us Anything about Chest Pain. I’m Barbara Schindo. Today, we will have an expert joining us from Penn State Health St. Joseph Medical Center to talk about chest pain and chest discomfort, the differences you need to know and when you should see medical a opinion or medical help. Joining us this afternoon to talk about chest pain is Dr. Guy Piegari. Interventional cardiologist and the Cath Lab Director at Penn State Health St. Joseph. If you have questions for Dr. Piergari, whether you’re watching this live or on playback, please feel free to put your questions in the comment field below this post, and we will get an answer for you. Dr. Piegari, thank you so much for joining us this afternoon. Let’s start with kind of the basics. Can you talk a little bit about what is chest pain and chest discomfort?

Dr. Guy Piegari – Okay, so, I prefer to say chest discomfort, because each individual has a different way of describing what might be pain related to their heart. So, I prefer to say to the patient, “Are you having any chest discomfort?” Then I ask them to describe what they are exactly feeling so I can kind of assess whether it’s related to the heart are not. Chest discomfort associated with heart disease is because, at that particular time, when you’re having chest discomfort, a portion of the heart muscle isn’t getting enough blood to do its job, and that will cause chest discomfort. It can happen at rest, but usually, when it begins, it’s something that you notice when you try to exert yourself. Exertion could be something as simple as going up one half flight stairs of walking out to the mailbox, or playing sports of any type, and of course, if you get anxious and stressed, that can also cause chest discomfort, because it doesn’t really matter what the activity is, it just means that at that particular time, your heart is not being supplied with enough blood to do its job. The most common reason for that to happen is a blockage in one or more of the heart arteries, which restricts blood flow to the heart, that’s the most common cause. That can occur acutely, which just means right away or it can occur slowly over the course of minutes to hours. Typical chest discomfort from the heart is called angina. It is usually described as a pressure sensation that begins in the center of the chest. It gradually increases in intensity. It can go up to the neck, the jaw, the shoulders down one or both arms, and it really takes a minute or two to gradually come on. It does not come on instantaneously, and it doesn’t go away instantaneously. So, if it comes on while you’re exerting yourself, then it’ll reach a maximum intensity, and you will stop. You won’t want to go any further, and as you stop and your activity level declines, so will your chest discomfort. It’ll gradually subside. This is how I would describe the discomfort to people/patients who do not have a diagnosis of coronary artery disease if you already have a diagnosis of coronary artery disease you probably will know what discomfort feels like, and who are probably carrying sublingual nitroglycerin. So, you’ll take up to three sublingual nitroglycerin tablets, five minutes apart, until the discomfort usually goes away. What we tell our patients with heart disease, if you take three sublingual nitroglycerin tablets and the pain hasn’t gone away, then you need to go to the nearest emergency room. If it does go away, then all you really need to do is notify your cardiologist at some point in time to say, hey, I’m starting to have more angina. It’s happening more frequent with less exertion, and it’s taking more nitroglycerin tablets to take it away. So, that’s what most people experience. There is a subset of patients who don’t have typical symptoms. Their symptoms may strictly be exertional shortness of breath that kind of comes on slowly as we spoke and then gradually goes away when they rest. And could be back pain. It can be in between the shoulder pain. It could be abdominal discomfort. Now we do know that women are more likely to have these atypical symptoms, but men can have it too. So, you just have to be alert to it. Pain that comes on instantaneously and only lasts for a few seconds, that’s not likely to be cardiac related.

Barbara Schindo – So, you mentioned that some patients with chest discomfort are already, you know, being seen by a cardiologist and they have these nitroglycerin tablets that they can take to help them when they are going through a discomfort episode. What about folks who don’t have any, you know, preexisting condition or aren’t already being treated? You know, when somebody who has never had this happen in them before, at what point of discomfort or any specific symptoms that you would recommend that they call a doctor or maybe go to the emergency room?

Dr. Guy Piegari – Yeah, so, the symptoms that I just describe, if you start to have those sort of symptoms on a repetitive basis, it is important to contact your primary care physician and at least start asking them the question, do I need to see a cardiologist? Now if you have the discomfort that I described that does not go away and it lingers for more than five or 10 minutes, that’s something different. That could be related to a heart attack. The difference between a heart attack and angina is that the artery is now probably totally blocked, and that discomfort is not going to go away unless someone opens up the artery, or ultimately, as the heart muscle dies, the pain will go away. That could take several hours. So, the faster you get to the emergency room, the better.

Barbara Schindo – I’m glad that you mentioned earlier about chest discomfort being related to stress and anxiety because I think a lot of people think about that. They think, you know, if they have stress at work or they’re feeling very anxious, they might immediately think, oh, no, something is very wrong. So, it’s not necessarily a myth that that could cause chest discomfort.

Dr. Guy Piegari – It’s definitely not a myth. It’s pure physiology. When we get stressed or anxious, our blood pressure tends to rise and the heart rate tends to go up. If your heart has to pump against the higher blood pressure or has to pump more quickly than it’s supposed to, it wants more blood, and if it can’t get more blood you’re going to have discomfort. There are occasions when patients don’t have any heart arteries, but the heart muscle isn’t getting enough blood for a variety of other reasons, which can include a problem with the lungs. It can be a problem with very low blood count, because we do need certain red blood cells to carry oxygen, and if you’re anemic because you’ve been bleeding, then you can have chest discomfort. That does not necessarily mean you have a blocked heart artery. It just means that the heart muscle isn’t getting enough blood. There’s a lot of other things that can cause it. One of the more common things that we see is kind of infection. Any kind of infection is going to demand more blood flow, and it’s going to dilate your blood vessels. And so, the heart’s going to have to pump faster and stronger, and that can cause chest discomfort. That is, angina, but not because of blocked heart arteries.

Barbara Schindo – Thank you. Thank you for that response there, and you are watching Ask Us Anything About Chest Discomfort with Dr. Guy Piegari, Interventional Cardiologist and Cath Lab Director at Penn State Health St. Joseph. Again, if you have any questions for Dr. Piegari, whether you’re watching this now with this live or you’re watching on playback, please feel free to put your question in the comment field, and we will get a response for you. Dr. Piegari, you had mentioned heart attacks earlier. So, I know that probably a big concern of anybody who’s experiencing chest discomfort is am I having a heart attack? Can you talk a little bit about any symptoms specific to heart attack and are those different for men and women?

Dr. Guy Piegari – So, the symptoms of a heart attack are really what we talked about, the chest discomfort, which is usually described as a pressure sensation in the center of the chest, which can go up to the neck, jaw, shoulders, arms, etc. And if it’s a heart attack, it usually does not go away until you seek medical care or you complete the heart attack. That’s the typical symptoms. The other more common symptom that we see is people will have epigastric discomfort, which they’ll describe it as heartburn, and actually, heartburn, can actually be discomfort from the heart, but not because you ate a spicy meal. It’s just the way you present. Sometimes the abdominal discomfort from a heart attack can be confused with the symptoms of someone having a gallbladder attack, and that is pretty common in women, actually. And then women have other atypical symptoms, especially back pain applied between the scapula. That can be another atypical form of chest discomfort related to the heart. And sometimes it’s just purely shortness of breath, and there is a segment of the population who does not have any discomfort that you can readily attribute to cardiac disease, and most of those patients will be diabetic, and up to 25% of diabetics will not have typical chest discomfort when they’re having a problem with the heart. And of course, that’s very difficult to interpret and diagnose.

Barbara Schindo – That is interesting that there are some people that may not experience that typical symptom or reaction. Dr. Piegari, one thing I want to ask you about. So, Penn State Health St. Joseph was recently awarded a pretty exciting award, Myocardial Infarction Registry Platinum Performance Award from the American College of Cardiology. Can you talk a little bit about, you know, what is that award and how does it can awarded, and what does it mean for the patient you serve?

Dr. Guy Piegari – Sure. As I said, the longer the chest discomfort goes on, the more heart damage is occurring. So, the goal is to try to interrupt the heart attack as quickly as possible. And this has been — we’ve known about this a good 20 years, and over the course of time, with the advent of angioplasty and stenting, we’ve recognized that besides giving medication to dissolve clots, doing angioplasty or putting a stent in, and doing it in a timely fashion saves heart muscle and save lives. So, a certain set of criteria were developed that we should follow to try to get the artery opened up in a timely fashion, and those guidelines include getting the patient to the cardiac catheterization laboratory and opening up the vessel within 90 minutes. And over the last couple of years, they have come up with a set of criteria to evaluate individual centers that do this procedure to see how well they’re doing compared to peers in their own state and nationally. And the Golden Awards are the Silver, Gold, and Platinum Award. Platinum is the highest award you can achieve. It measures a number of criteria like how quickly does the patient get to the Cath Lab? How quickly does the artery get opened? It also looks at how the patient is treated before, during, and on discharge? Are they going home on the proper medication at the proper dosages? Are we controlling their blood pressure? Are they on antiplatelet agents to keep the stent from closing? Are you treating their cholesterol appropriately and with the right drugs? So, pretty much every institution in Pennsylvania that does angioplasty and stenting reports this criteria to the American College of Cardiology, and on a yearly basis, they look at the criteria that you submit, in its verified, and then they award you either silver, gold, or platinum. Platinum is the highest, and when we receive that award two months ago at that time, we were only one of six hospitals in the State of Pennsylvania that achieved that award, and regionally, we were the only hospital, and that includes Philadelphia.

Barbara Schindo – That’s truly excellent news, both for the facility and for the patients that get their treatment there, because I think it shows they’re receiving some top-notch, excellent treatment.

Dr. Guy Piegari – One of the reasons I think we can do such a good job is since we are somewhat of a smaller institution compared to any Philadelphia hospital or Harrisburg hospital, we are smaller, so we can control the patient population much better. We control the ancillary staff, and we can respond much quicker than they can at some of the larger institutions, and that played out in the statistics, in the data, and that is why we received that award.

Barbara Schindo – You are watching Ask Us Anything About Chest Discomfort with Dr. Guy Piegari, an interventional cardiologist and cath lab director at Penn State Health St. Joseph. Dr. Piegari, I have just a few more questions for you. Another exciting development at Penn State Health St. Joseph is that next month, a new electrophysiology lab will be opening. Can you talk a little bit about that and what that will mean for patients?

Dr. Guy Piegari – Sure. Just to give you a quick background, electrophysiology has to do with the electrical system of the heart and the conduction system of the heart. I joined Berks Cardiology 35 years ago, having served 12 years in the military. When I first got here 35 years ago Berks Cardiology already had an electrophysiologist who was practicing with us. We were the only hospital in the area that did electrophysiology. If we needed to do — the only other place you can go that was close by was Philadelphia or or Lancaster. Over the last 35 years, what we offer in the Department of Electrophysiology has steadily climbed. We have always had a dedicated EP laboratory, and now we are building a brand-new state-of-the-art EP laboratory that will be able to do 95% of all the electrophysiological procedures that are available in the nation. So, we’re very excited about that, and it’s going to open up in late, I think, I believe, mid December.

Barbara Schindo – That is very exciting, and it is great to be offering that really advanced type of treatment and that range of treatment to patients, you know, right at home, so they don’t have to travel far to be getting that caliber care.

Dr. Guy Piegari – Yeah, let me just to find electrophysiology, fancy word, but it deals with the heartbeat. So, it includes people who have very slow heartbeats, who might need a pacemaker. It deals with people who have very fast heart rates, who may need treatment to slow down the heart. We do with patients with atrial fibrillation, which is the most common rhythm disturbance that cardiologists, in general, see, and there are some very exciting treatments now available for atrial fibrillation. It isn’t just taking medication. There are procedures that can be done to interrupt atrial fibrillation, so that you don’t have to worry about that rapid, irregular heartbeat in the past. The only way to prevent blood clots, which was highly associated with atrial fibrillation our blood thinners called coumadin. And coumadin is still around. It’s really been a very useful drug for many, many years. But now there is four other anticoagulants that we do use. They are more effective in preventing strokes and less likely to cause bleeding. So, we have that option available through the EP, and then we have the Watchmen device. They’re a subset of patients who require anticoagulation who cannot take a blood thinner because they have anemic issues for a variety of different reasons. The most common is bleeding, and those patients, we can put a Watchman device in, which is a device that can be inserted in a the particular chamber of the heart where most of the blood clots form, and if successful, then they don’t need to take anticoagulation.

Barbara Schindo – Wow, that is a lot of exciting, exciting treatment developments and really good news for patients. Dr. Piegari, I have one more question for you. Can you talk a little bit about, you know, we can dealing with the COVID-19 pandemic for the past year and a half, which is a respiratory disease. Has it had a, you know, whether they had COVID or not, has it had an effect on people that have regular chest discomfort?

Dr. Guy Piegari – So, COVID does not cause coronary artery disease. So, it has not been demonstrated to cause buildup of plaque in the arteries. That happens slowly over the course of many years and is related to high blood pressure, diabetes, cholesterol, family history, tobacco. Those are the big risk factors. However, COVID can put a stress on the heart. So, that you can develop chest discomfort, even if you have normal coronary arteries. And if you do have coronary artery disease, the COVID infection can cause a tremendous amount of stress on the heart, because remember, the heart is dependent on oxygen. Oxygen is dependent on oxygen traveling from the air through the lungs to the blood, and COVID affects the lungs dramatically. So, COVID can cause angina in normal people. It can cause angina in people with blocked heart arteries. It can also cause inflammation of the heart muscle, which is myocarditis, and it can cause rhythm disturbances, very commonly atrial fibrillation.

Barbara Schindo – Okay, Dr. Piegari, thank you so much for joining us this afternoon and for all this really helpful and useful information for our listeners. For those of you watching this, you may be watching on playback, if there’s any questions that you have about chest discomfort that Dr. Piegari did not talk about, please feel free to still put a comment in the comment field under this post, and we will get an answer for you. Again, Dr. Piegari, thank so much for joining us, and thank you for watching.

Dr. Guy Piegari – Thank you, have a good day.