Pain is not the only feature of heart attack

Editor—Ruston et al conclude that if we are to minimise the time between the onset of myocardial ischaemia and the administration of thrombolysis “the myth that a heart attack is a dramatic event needs to be dispelled.”¹ Perhaps medical advice that includes the word “pain” is the single biggest problem. The article is based on descriptions from patients, yet the word pain is used only once, and then in the final paragraph, when the authors cite advice from health professionals. Pain is evidently the word used by doctors and nurses, not untutored patients without prior experience of ischaemia.

When we stand on something sharp or touch something hot we have enough shared experience to identify and localise the experience and communicate it to others. But nature has not equipped us with sufficient consistency of sensation to ascribe correctly any distressing sensations originating in the heart, aorta, oesophagus, gall bladder, cystic duct, or duodenum. In listening to many people who have experienced myocardial ischaemia I too have noted that pain is rarely volunteered; instead the patient uses a range of words, always augmented by a gesture (usually to the chest, neck, and arm) and often accompanied by grimacing. It is this body language that is most consistent and transcends cultural expectations, level of education, and linguistic limitations. Some patients even say, “I call it a pain because that was what the nurses always asked me about in the ward.”

Heberden used the word “angina” (from angere: to constrict, to choke). People taking a clinical history will know that a range of descriptions is used, including tightening, a lump in the throat, pressure, indigestion, wind, and a need to keep swallowing. Often a series of phrases such as “I mean” or “you know” is used as the patient struggles to find words for a sensation for which no shared language exists. Other forms of angina (Ludwig’s and Vincent’s) have now effectively disappeared so the qualification “pectoris” is largely redundant. The sensation of infarction is similar but unrelieved by rest or vasodilators.

The authors note the power of television drama in conveying the wrong image of a heart attack, which is of a fat, red faced man suddenly gasping and clutching at his tie. Surely the answer must be to provide the media with better descriptions. Real depictions of the onset and evolution of myocardial infarction in EastEnders and The Archers would be much more useful than pamphlets that wrongly, it seems, instruct the public to look out for 15 minutes of central chest pain as the hallmark of heart attack.