"How Can You Tell?"
He was taking his proton pump inhibitor as prescribed, and he watched his diet as reasonably as any of us living in Tex-Mex heaven could be expected to do. But from time to time, he would still get chest pains, and each time he agonized whether to return to the ER for another $10,000+ workup. When he does finally decide to come to the ER, here is our dilemma:
- A normal ECG does not rule out a heart attack
- The first set of normal cardiac enzymes does not rule out a heart attack
- A GI cocktail, even if successful in relieving his pain, does not rule out a heart attack
- Epigastric pain described as "indigestion" does not rule out a heart attack, and in fact is a relatively common presentation for MI
- Epigastric tenderness does not rule out a heart attack
- The absence of shortness of breath or diaphoresis does not rule out a heart attack
- Tall slender individuals might have Marfan's Syndrome or spontaneous pneumothoraces, and yet a normal chest X-ray does not rule out dissecting aneurysm or pneumothorax. So he gets a CT scan too.
Should he get a heart cath? If his arteries were totally normal perhaps that would save him some money over time, but if he had any subtle coronary disease at all, he would still probably be need to be admitted each time he presented to the ER. Maybe CT angiography would be a reasonable alternative, although patients with his risk profile would still give ME heartburn if I sent any of them home.
It's a tough question with no easy answers. Of course quitting smoking, avoiding spicy food, and maybe a fundoplication procedure might help. Then again, they might not.