Was a heart attack to blame for Albert?
In a previous episode: Albert was a 32 year old struggling salesman: his dog had died several weeks earlier; he and his girlfriend had just moved into a small rental apartment building; he could never rest because his downstairs neighbor was constantly playing the drums; and suddenly, while he was binge-watching Breaking Bad, eating a whole tray of a large pizza and finishing a six-pack of beer, came nausea, perfuse sweating, and intense pain.
In the emergency room, when the doctor asked where his pain was, Albert pointed to his xiphoid (the lowest part of his chest-bone). He told the doctor that the pain was 7 out of 10 in severity, and that it radiated nowhere. “It started about two hours ago and it is still going,” he said, “it is a crushing pain.” Albert told the doctor that his father had acute chest pain at a young age, and was later diagnosed with heart disease.
The doctor pressed his stethoscope to Albert’s chest and closed his eyes. The heart rate was normal and there were no murmurs, he noticed. An electrocardiogram showed only subtle changes in the electrical activity of Albert’s heart. This could be consistent with a heart attack, the doctor thought, or not. A lab technician took a blood sample, but there was no time to wait for the results. Listening to Albert’s story and to how he described his pain, the doctor thought that a heart attack is a likely diagnosis. And because heart attacks can kill, he gave Albert Aspirin, heparin, and nitroglycerin, and ordered some more tests.
Here is something I wanted to tell you about pain: People who believe that there is order in the universe, in the purpose of nature, would tell you that pain is a warning sign – like a red light flashing on your dashboard indicating that you are running out of gas, your oil is low, your engine needs service, or that you need to wear a seatbelt.
In Albert’s case, the blood test for cardiac enzymes which are often elevated in patients with a heart attack came back normal. And an emergency coronary angiography – an X-ray test that checks if the arteries supplying the heart are open – showed no blockage and good functioning heart. The red flashing light on Albert’s dashboard was signaling a heart attack, but heart attack it was not.
It was time to consider other causes of Albert’s chest pain. Doctors call it differential diagnosis. They consider all possible causes for pain. They narrow down the number of potential diagnoses by obtaining more information. They systematically rule out unlikely diagnoses. And they reach a final, correct diagnosis.
In the case of chest pain, the list of potential diagnoses is long and ominous. In Medicalease, it sounds like this: pericarditis, coronary ischemia, aortic dissection. In some patients, chest pain is a symptom of a disease that originates elsewhere: a gastric ulcer, biliary colic, herpes zoster.
After his angiography, Albert told his doctors that the pain in the chest has shifted to his right upper abdomen. Several hours later, his eyes color turned yellow and his urine turned dark. His blood test showed high bilirubin levels and an ultrasound examination confirmed that there was a stone in his gallbladder. These were all indications that he might have had acute cholecystitis (inflammation of the gallbladder) or that he might have passed a gallbladder stone.
To prevent future gallstones episodes, Albert’s doctors decided to surgically remove his gallbladder. During laparoscopic surgery, they found a very distended, severely inflamed gallbladder, with gangrenous wall that was threatening to burst. The pathologist told them later that within the gallbladder, he found a large number of irregular, roughly spherical, yellow and yellowish-green gallbladder stones.
About the true nature of pain, I would tell you this: Don’t buy a car whose dashboard flashing red lights are as good as the human alarm system we call pain! Why? Because our pain mechanism suffers from the following:
Poor reliability – the red light might start flashing for no good reason (an intense headache may feel like you are going to die, but it is only rarely caused by a brain tumor).
Poor correlation between the intensity of signal and the severity of the condition that underlies it – the red light might be flashing hysterically when the windshield fluid is half full, but it flashes only occasionally and faintly when the brakes are failing (a kidney stone which is a benign, highly treatable condition could give you the most severe pain; cancer would usually be painless until it is too late to eradicate).
And poor specificity – the red light might start flashing for the wrong reason (you didn’t wear your seatbelt, but it tells you that your oil runs low), as in Albert’s case where a chest pain indicated a gallbladder disease, not a heart attack.
Pain isn’t the ideal alarm system, but it is the best we have. It should not be ignored, for in many cases, pain is a symptom of a significant medical problem, sometimes urgent, that should be addressed.
As for Albert, three weeks after his surgery, his chest pain was gone. He was doing just fine.
Dr. Shahar Madjar is a urologist working at Aspirus Keweenaw Hospital. He sees patients in Laurium, Houghton and L’Anse. Contact him at firstname.lastname@example.org.