A 'normal' ECG doesn't exclude a pending heart attack

IN this article Consultant Cardiologist and HealthWatch Medical Advisory Panellist Dr. D. P. Atukorale, warns people who get chest pain, and find their ECG normal yet to be cautious, because even a normal ECG doesn't always exclude the possibility of a pending heart attack.

Dr. Atukorale has written this article in reply to a question by Mercia Perera of Wattala, whether there could be instances of a pending heart attack being not shown even in an ECG report.

Is coronary angiography indicated in every case of acute chest pain?

When a middle aged or elderly person presents with acute chest pain to the family physician (GP) it is the duty of the GP to exclude unstable angina (severe angina) by taking a careful history and doing a good clinical examination and arranging for an urgent ECG if facilities are available.

If the acute chest pain is due to unstable angina or myocardial infarction the patient should be urgently admitted to a hospital (preferably to a general hospital or base hospital or to a private hospital having intensive care facilities) even if the ECG is normal.

Other causes of chest pain

There are other causes of acute chest pain such as: (a) pleurisy (inflammation of the pleura), (b) pneumothorax (c) pulmonary embolism, (d) oesophageal reflux, (e) gall bladder disease, (f) pericarditis (inflammation of the pericardium), mitral valve prolapse (MVP), (h) pain arising from bones and muscles of the chest wall, (i) aortic dissection, (j) pain referred from the cervical spine or thoracic spine and (k) skin disorders such as shingles (herpes zoster) which can give rise to severe unilateral chest pain which precedes the zoster rash.

Myocardial infarction (heart attack) pain is similar in location and character to angina; however the infarction pain is usually more severe and occurring at rest without provocation and usually lasts for more than 15 minutes and may last for hours.

Patients who present with acute chest pain and ischemic ECG changes require admission and appropriate treatment. Even if the ECG is normal, a good history of an unstable pattern of ischemic chest pain (particularly if the pain lasts for more than 15 minutes) indicates that urgent admission is required for further evaluation and treatment.

However, in a proportion of patients with chest pain the history will be non-specific, clinical examination unremarkable, ECG will be normal or non-diagnostic and it will be impossible to exclude unstable angina or myocardial infarction (heart attack) on clinical grounds alone.

In these patients cardiac enzymes and troponin (troponin T or troponin I) tests should be done if there are facilities for cardiac enzymes and troponin tests.

If these tests are negative, the tests should be repeated after 12 hours and 12-20 per cent of these patients will have detectable troponin elevation.

If these tests are negative, these patients can be transferred to a medical ward or sent home after giving instructions for further investigations such as exercise ECG.

Indications for coronary angiography

Majority of cardiologists in Sri Lanka subject patients with chest pain and strongly positive exercise ECGs for coronary angiography.

There are some cardiologists who subject all heart attack patients to coronary angiography without arranging for exercise ECG, with a view to PTCA or CABG if there are no contra-indications.

I personally arrange all heart attack patients, a few days after the heart attack (if there are no contra-indications such as heart failure or poor left ventricular functions) for an exercise ECG and arrange for coronary angiography if the exercise ECG is strongly positive (a) if the patients can afford to bear the cost of angiography (about Rs. 28,500) and if these patients can afford to undergo coronary artery surgery (CABG) (about Rs. 350,000) or PTCA (Rs. 400,000 to Rs. 600,000).

Those patients who cannot afford coronary angiography and surgery or PTCA in the private sector are referred to the Institute of Cardiology National Hospital Colombo.

Risks of coronary angiography

There is a very small risk involved with the procedure of coronary angiography (CA). The mortality rate of the procedure is experienced in developed countries is less than 0.1 per cent.

As a rule the cardiologist or one of his assistants get the patient or one of his or her guardians to sign a consent form after explaining the risks of the procedure to the patient or guardian.

Rarely in serious cases of CHD, the patient can develop very serious rhythm disturbances during CA ending in cardiac arrest and death. As mentioned earlier in the hands of experienced cardiologists the mortality and morbidity due to the procedure of CA is very low.

In Sri Lanka there are few cardiologists in the private sector who subject all chest pain cases to angiography even if the ECG is normal, without subjecting the patients to exercise ECG. Doing coronary angiograms in cases of non-cardiac chest pain is not so uncommon in Sri Lanka.

I have come across some of these innocent patients who have been taken for a ride in the private sector by doing highly unnecessary coronary angiograms.

In conclusion coronary angiography is not a risk free procedure. I know of number of deaths due to the procedure of angiography both in government sector and private sector.

The patients should be selected very carefully and the risks of the procedure should be explained to the patient or the guardian, before getting the consent for the angiogram.

It would be very interesting for a Sri Lankan to do research regarding true mortality and morbidity due to the procedure of coronary angiography and I am sure our mortality rates will be quite different from those of the developed countries.

Coronary angiography

Coronary angiography (coronary arteriography) is the study of the anatomy of the coronary arteries which are visualised by x'ray by injecting a contrast material (radio-opaque dye) into the coronary arteries which supply oxygen and other nutrients to myocardium (heart muscle).

Sending a catheter to coronary arteries is one of the most skilled jobs in medicine and is now done routinely and with little risk in most of the cardiology units of the world.

At present in Sri Lanka this test can be performed in the Institute of cardiology, National Hospital, Colombo, Teaching Hospital, Galle and some of our private hospitals in Colombo.

The coronary catheter is passed either through the femoral artery of the lower limb or brachial artery of the upper limb by percutaneous approach under local anaesthesia and radio-opaque dye is injected into each of the coronary arteries and multiple views in different projections are taken.

Occlusions of coronary arteries are nearly always caused by atherosclerosis and these occlusions are shown clearly in the angiogram.

Coronary angiogram is the only way of telling how great the coronary problem is at present and establishes whether the patient will be best helped by medical management or by angioplasty (PTCA) or by coronary artery surgery (CABG).

In patients with unstable angina, 30-35 per cent of patients have one vessel disease, 10-20 per cent of patients has no significant lesion, 5-10 per cent of patients have significant left main stem stenosis (which needs urgent PTCA or CABG) and 40-50 per cent have multi-vessel disease.

Combatting trauma with an eye movement based drugless psychotherapy treatment - EMDR

THREE Sri Lankan doctors who have been trained in the states in EMDR are now back in the country.

In this article Dr. Ruwan M. Jayatunga MD trained in EMDR (HAP) explains how this treatment originated, how it works and its benefits:

EMDR-An effective mode of psychotherapy

Eye Movement Desensitization and Reprocessing (EMDR) is a non-drug, psychotherapy procedure. It was discovered and developed by Francine Shapiro PhD in 1987.

In 1987, Francine Shapiro was walking in the park when she realized that eye movements appeared to decrease the negative emotion associated with her own distressing memories.

She assumed that eye movements had a desensitizing effect, and when she experimented with this she found that others also had the same response to eye movements.

It became apparent however that eye movements by themselves did not create comprehensive therapeutic effects and so Shapiro added other treatment clements, including a cognitive component, and developed a standard procedure that she called Eye Movement Desensitization and Reprocessing.

EMDR is one of the most researched method of psychotherapy used in the treatment of trauma. EMDR has a broad base of published case reports and controlled research which supports it as an empirically validated treatment of trauma.

The Department of Veterans Affairs Practice Guidelines has placed EMDR in the highest category, recommended for all trauma populations at all times.

In addition, the International Society for Traumatic Stress Studies current treatment guidelines have designated EMDR as an effective treatment for PTSD (Chemtob, Tolin, van der Kolk and Pitman, 2000).

EMDR is a complex treatment approach that combines salient elements of the major therapeutic schools such as cognitive, behaviourial, psychodynamic and inter-actional. It is a specific treatment approach which helps a person quickly resolve the emotional aftermath of traumatic experiences.

EMDR is an information processing therapy and uses an eight phase approach. EMDR is helpful in treatment of PTSD (Post traumatic Stress Disorder), unresolved grief, phobias, sexual abuse, combat trauma, depression, eating disorders and in substance abuse. It can also be used to enhance emotional resources such as confidence and self-esteem.

As Dr. Shapiro explains all humans are understood to have a physiologically-based information processing system. This can be compared to other body systems, such as digestion in which the body extracts nutrients for health and survival.

The information processing system processes the multiple elements of our experiences and stores memories in an accessible and useful form. Memories are linked in networks that contain related thoughts, images, emotions and sensations.

Learning occurs when new associations are forged with material already stored in memory. When a traumatic or very negative event occur, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing.

This prevents the forging of connections with more adaptive information that is held in other memory networks. For example, a rape survivor may 'know' that rapists are responsible for their crimes, but this information does not connect with her feeling that she is to blame for the attack.

The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed.

When the individual thinks about the trauma, or when the memory is triggered by similar situations, the person may feel like she is reliving it, or may experience strong emotions and physical sensations.

A prime example is the intrusive thoughts, emotional disturbance, and the negative self-referencing beliefs of PTSD.

Shapiro proposes that EMDR can assist to successfully alleviate clinical complaints by processing the components of the contributing distressing memories.

Information processing is thought to occur when the targeted memory is linked with other more adaptive information. Learning then takes place, and the experience is stored with appropriate emotions, able to appropriately guide the person in the future.