Dear Dr. Roach: My sister recently had chest pain during exercise and now she is on metoprolol, but the cardiologist hasn’t explained to her the reason for the medication. What could she be on the medicine for?
M.D.
There are many reasons for chest pain. It happens both within the heart and in other parts of the chest, such as the lining of the lungs (the lungs themselves don’t have nerve fibres) and the chest wall, including the ribs, muscles, cartilage and connective tissue.
Metoprolol is a beta blocker. These medicines work by slowing down the heart, reducing how forcefully it squeezes, and by blocking the circulating hormones epinephrine and norepinephrine, also called adrenaline and noradrenaline. Beta blockers are always used, whenever possible, in people with chest discomfort due to blockages in the arteries to the heart.
If the heart needs more blood than it can get due to the blockages, chest discomfort is the main symptom, but there are others. Indigestion, arm pain and back or stomach pain may occur, or people may have shortness of breath, or no symptoms at all. This type of heart disease is called coronary artery disease, and is the reason people get heart attacks in almost every case. People with coronary artery disease should also be taking aspirin and a statin drug, unless there are very good reasons not to give them.
There are other possibilities. Hypertrophic obstructive cardiomyopathy is a different type of heart condition, relating to structural changes in the muscle of the heart itself, not the blood vessels supplying the heart. This condition may also cause chest pain or discomfort especially on exercise, and metoprolol is the most common treatment. Other types of heart failure are often treated with beta blockers as well.
The best source of information is your sister’s cardiologist. If possible, it’s ideal to have a family member come to an appointment. A person gets so much information from their doctor that oftentimes they get a bit overwhelmed and have a hard time remembering or explaining what the doctor said. The doctor might also give some written information for her to take home.
Dear Dr. Roach: Your recent answer to someone’s complaint about no eating after midnight before a surgery brings to mind my upcoming colonoscopy. In addition to not eating, I am required to take medication that amounts to totally emptying my bowels for a 24-hour period, plus no food prior to my 3:00 p.m. appointment the next day. This seems to be excessive also, especially to a newly diagnosed diabetic as myself.
M.R.
Most preparation regimens for colonoscopy allow a person to take clear liquids during most of the preparation phase, so you can take in enough calories that diabetes does not become a problem. Although, you certainly need to talk to the doctor taking care of your diabetes to discuss what to do with any medications you might be taking. The colon needs to be completely empty in order for the gastroenterologist to get a thorough look inside.
Several people wrote in about the “no food after midnight” rule in surgery, mostly commenting that it is necessary to have everyone fasting, even if their procedure is later in the afternoon, in case of the need for emergency rescheduling. While there is some truth there, I think that for elective procedures, prolonged fasting has more harms than benefits, and a well-organized operating room should not need every patient to be fasting since midnight.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
