When the pudding becomes a pain in the chest

Over the next few months, I hope to cover those common symptoms, which we all know can mean something serious is going on and which, if missed, could represent a catastrophe.

This month the topic is chest pain.

You are just finishing your Christmas dinner and start to experience chest pain. You ring South Doc and the nurse recommends a visit to A&E by ambulance as this could be serious.

You and the nurse are worried about a heart attack.

This scenario represents 10 per cent of A&E workload and in 90 per cent of cases, after a short stay in hospital, you may be discharged. No system is infallible and there is a small failure rate in existing systems in missing a major cardiac event (MACE). In most studies, this equals about one per cent.

So, what is the system? Doctors use scoring systems to improve accuracy of diagnosis and the best ones are the simplest. They are easily accessed electronically and really do help to improve diagnostic accuracy, not only with chest pain, but also sore throats in children or the chance of having a blood clot in your leg or on the lung; then there is the FEVER PAIN score, THE WELLS SCORE, the ALVARADO score for appendicitis, the Blatchford Score for bleeding from the stomach and so on. It might be interesting to have a look at some of them online.

Back to the Christmas dinner. You have arrived in hospital or are speaking to your GP. The hospital doctor will use the HEART score. Now that is an easy one and very accurate. I will explain: 

H  stands for history. This is the information you give the doctors and is where intuition comes in. A really concerning story get the maximum two points and a lesser concerning story gets zero or one point.

E stands for ECG: No changes, zero points, and more concerning, one or two points.

A  stands for age: Over 65, two points; age 45 to 65, one point and, less than 45, zero.

R stands for risk factors: Things like smoking, high blood pressure, previous heart trouble. Three or more of these and you get two points. Less than three, two points. None, zero points 

T stands for a troponin test. Troponin is a chemical released by damaged heart muscle after a heart attack. A high level gets two points and a normal or slightly elevated level equals zero or one point. The level starts to rise three to four hours after a cardiac event and, the higher the rise, the greater the muscle damage.

For those of you of a mathematical bent, you will have worked out that the maximum number of points is 10, which means you will be seeing the cardiology team very soon!

Scores of four and higher again will be taken seriously and more tests ordered. Scores lower than four and you are safe to go home.

These scores are all well and good but your GP has other tricks up his or her sleeve, which I believe are even more accurate, and woe betide a hospital specialist who ignores GP intuition!

When GPs have gotten to know and examined and talked to thousands of patients, sixth sense becomes very honed. You might not have seen your GP for years and only consult when absolutely necessary. Your GP fixes you with a very careful scrutinising look that takes in so much. Your colour, presence of sweating, your breathing, level of pain and so on. If ‘he does not like the look of you’, after only seconds, a decision is made on what to do next. A full examination and ECG may be superfluous.

This is the Art of Medicine and, with GPs and hospital staff working together and communicating well, most chest pain is managed extremely well. Science and research combining well with good traditional GP skills and intuition.

Enjoy your Christmas dinner, go easy on the plum pudding, and Merry Christmas!

Dr Jeff Featherstone

Dr Jeff Featherstone is a West Cork GP and A&E doctor at Mercy University Hospital and Cork University Hospital.

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