Patient stories

YNHH patient stories:
Am I having a heart attack?

Yale-New Haven Chest Pain Center Meets Patient Needs
by Kenneth Best

Maybe you tried to chase down one too many fly balls on a warm summer night of softball. Perhaps you tried to clean the snow from the driveway a bit too fast. Or it could have been an unusually stressful day at work. It doesn't really matter. All you know is that you have this sharp pain in your chest and the only thought you have is: "Am I having a heart attack?" The idea of spending a couple of days in the hospital getting tested makes you feel even worse. It could even prevent you from going to the emergency room to find out the cause of the pain.

Yale-New Haven Hospital (YNHH) treats more heart attack cases than any other hospital in Connecticut, according to the Connecticut Hospital Association's annual heart attack survival report. Overall in Connecticut, 88.3 percent of all people who suffer a heart attack will survive. The key to surviving, or even preventing a heart attack, is quick treatment after the onset of symptoms. The best chances of survival without substantial damage to the heart are to get to a hospital within an hour of feeling the symptoms. Within two to four hours of a heart attack, there is a good to fair chance of reducing damage to the heart muscle. After four hours, the chances of surviving without damage to the heart are poor.

The Chest Pain Center in Yale-New Haven Hospital's emergency department (ED) helps ease the process of determining whether a patient is, in fact, experiencing heart failure, while also reducing the time a patient spends in the hospital.

In the past when patients had to be admitted for potential heart disease, it usually meant three days in the hospital. Now many are treated within 12 hours.

After its first six months of operation, the Chest Pain Center treated more than 350 patients, who spent about 15 hours in the unit. Patients who had been admitted to the hospital for similar evaluations, had an average length of stay of 2.4 days. Before the Chest Pain Center opened, about half of the patients who complained of chest pain were sent home. Of those patients who were treated in the center, all but about 50 were sent home.

Only a small percentage of patients who go to an emergency room with chest pain are actually suffering a major cardiac episode. But where the diagnosis is questionable, doctors take no chances: they admit the patient. Now through the extra diagnostic capabilities of the Chest Pain Center, doctors in the ED can understand what is causing chest pain before they make a decision to admit the patient. For many that means the question is settled in less than a day without being admitted to the hospital.

Patients experiencing chest pains still go the emergency department where evaluation and testing is done, including an electrocardiogram (EKG). If there is no "active ischemia" (a shortage of blood being pumped to the heart wall) which would immediately require being admitted for treatment of a heart attack, the patient then goes to the four-bed Chest Pain Center for further tests and monitoring.

If there is any active ischemia, doctors can admit them to the hospital immediately from the Chest Pain Center. If the evaluation is negative, doctors will refer them to their primary care physician.

The Chest Pain Center was created as part of the extensive renovation of the YNHH emergency department. In addition to making physical and technical improvements in the ED, the renovation allowed the creation of the Chest Pain Center as a separate patient care unit, so patients can be in a more relaxed environment similar to an inpatient room. Patients lie in a hospital bed instead of a gurney, separated by a wall instead of a curtain, as is normally found in emergency rooms. A technician can see each patient and monitor his or her vital signs and cardiac activity at three-hour intervals from an observation station. Part of the testing procedure includes checking key cardiac enzymes after a blood sample is drawn.

After nine hours of monitoring without incident, the patient undergoes a treadmill stress test supervised by a cardiologist.

Unlike most Chest Pain Centers, the YNHH Center has nuclear cardiac imaging technology on site, which allows doctors to obtain a three-dimensional image of the heart to see any blockages suggested by borderline or abnormal baseline EKG readings. The immediate availability of nuclear imaging helps to quickly determine any potential problems, since in about 40 percent of patients with chest pain, the EKG readings are unclear or the patient cannot take a treadmill test.

"You need the heart rate to go high enough on a stress test. In many older people there are all sorts of limitations in what they can do," said Dr. Frans Wackers, professor of diagnostic radiology and cardiology at the Yale School of Medicine and one of the pioneers in the field of nuclear cardiac imaging. "The idea is to do a quick work up and prevent an admission. Cardiac imaging is more reliable than other tests and ultimately is more cost effective if there is no need for admission to the hospital."The unique aspect of the Yale-New Haven Chest Pain Center is the ability to do the radionuclide imaging. We've already have some spectacular instances where an acute heart attack was detected by imaging but not by conventional techniques."

Dr. Wackers said a multi-center study of chest pain patients, including those at Yale-New Haven, found that 94 percent of the patients admitted to the hospital did not suffer heart attacks, which was the reason for their admission.

The benefits of the Chest Pain Center for patient care can already be seen by doctors. It helps in the emergency department because they take these patients out of the acute care area and free up nurses to take care of other patients. It also helps because doctors can monitor these lower-risk patients and let the cardiologists take care of other patients in the hospital. They have 24-hour coverage, with an emergency physician on the other side of the door if needed.

Louise DiRuccio, a retired teacher who is an active volunteer at Yale-New Haven Hospital, recently felt chest pains while arriving for her volunteer duty one morning. Several minutes later she found herself in the Chest Pain Center, where she spent the next 12 hours being monitored and evaluated. In her case, there were was no heart attack and she went home that evening.

"The doctors and nurses made things very comfortable for me. It was quiet and I had the feeling someone was assigned just to me," she recalled. "Everything was explained to me and the nurse told me how my sisters could call into the Chest Pain Center to see how I was doing."

Another patient, a 57-year-old man, said he appreciated the "kind treatment and professional manner" of the staff in the Chest Pain Center. "My feeling was that I was treated with concern and that certain things needed to be done to be sure I was all right," he said. "I had an EKG and then took the stress test. I was comfortable being there."

The Chest Pain Center represents a cooperative effort between several departments, including the ED, pharmacy, diagnostic imaging, coronary care unit and patient financial and admitting services. The ED provides personnel for medical direction, nursing care and other support functions, while cardiology provides staff coverage by a fellow and assigns a cardiologist to work with staff on protocols, policies, procedures and quality improvement.

Chest Pain Centers are becoming the standard of care nationally and that it is likely that in the near future such treatment protocols will be expected by patients, their doctors and health insurers as much as for patient satisfaction as for the fact that it helps to reduce costs.

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Last revised: May 22, 2007 (dh)

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