CHEST PAINWhen to Worry When Not to WorryAlbert J. Miller, M.D.Professor of Clinical Medicine (Cardiology)Feinberg School of MedicineNorthwestern University
A TRUE STORY OF J.R., A 51 YEAR OLD LAWYER HE WAS DRIVING HOME FROM WORK WHEN HE DEVELOPED A SEVERE PAIN IN THE MIDDLE OF THE CHEST. HE FELT WEAK AND SWEATY. HE DECIDED TO DRIVE HOME, AND WAS RELIEVED WHEN ABOUT 1 HOUR LATER THE PAIN WAS GONE. FOUR DAYS LATER HE MENTIONED THE EPISODE TO HIS FATHER.
FOLLOWUP ON 51 YEAR OLD LAWYER THE FATHER CALLED THE SON AN IDIOT AND TOLD HIM TO CONTACT HIS DOCTOR RIGHT AWAY. AT CORONARY ANGIO- GRAPHY A CLOSED ANTERIOR DESCENDING CORONARY ARTERY WAS OPENED, BUT THE PATIENT HAD SUSTAINED A LARGE INFARCT.
TO BE AVOIDED.R. Osborn1956
R. Osborn, 1956The heart is important and isthe center ofthings. It is the major aspect ofthis lecture.
SIGNS OF A HEART ATTACK: FROM THE AMERICAN COLLEGE OF CARDIOLOGY Chest pain or discomfortPain or discomfort in arms, back, jaw, neck or stomachShortness of breathSweating or lightheadednessIndigestion or nauseaTiredness
CHEST PAIN SUBJECTS TO BE COVERED IN THIS LECTUREHistory of ischemic heart painAnatomy of the heart in the chestNervous connections of the heartLanguage of chest painPains not from the heartPains that suggest heart originD/d of heart and esophageal painsCase presentations
SOME FACTS ABOUT CHEST PAINAPPROXIMATELY 6 MILLION PATIENTS VISIT EMERGENCY DEPARTMENTS WITH CHEST PAIN ANNUALLY IN THE UNITED STATESAPPROXIMATELY 1.5 MILLION PATIENTS EXPERIENCE HEART ATTACKS AND MORE THAN 500,000 DIE ANNUALLYKahn, SE Arch Path Lab Med, Oct 2000
TYPES OF HEART DISEASE DEATHSIN 1999
MOST PERSONS HAVE CHEST PAIN AT SOME TIME OR OTHERTHE CHEST ANATOMY INCLUDES:Chest wall skin, nerves, arteries, veins, muscle, ribs, lymphaticsPleura - inner lining of chest wallTrachea, bronchi, pulmonary arteries and veins, lungs, diaphragmHeart, pericardium, aortaMediastinal fat, nerves, vesselsEsophagus
MASTADON WITH HEART
THE CORONARY ARTERIES THEY ARE APPROPRIATELY SELFISH AND ARE THE FIRST ARTERIES THAT ARISE FROM THE AORTA TO SUPPLY BLOOD AND OXYGEN TO THE HEART MUSCLE ITSELF
Coronary anatomy categorized by number of diseased vesselsTHE CORONARY ARTERIES
THERE ARE NO EMPTY SPACES IN THE CHEST
CHEST VIEW FROM THE SIDE NO EMPTY SPACES
A CAREFUL HISTORY IS IMPORTANT TO THE PROPER EVALUATION OF CHEST PAINTAKING A CAREFUL AND COMPLETE HISTORY IS THE CRITICAL PATHWAY TO MAKING THE CORRECT DIAGNOSIS OF CHEST PAIN
WHAT IS A HEART ATTACK? A HEART ATTACK (MYOCARDIAL INFARCTION) OCCURS WHEN THE BLOOD SUPPLY TO A PART OF THE HEART MUSCLE IS CUT OFF
WHAT IS ANGINA PECTORIS? PAIN THAT IS DUE TO SOME PORTION OF THE HEART MUSCLE NOT GETTING ENOUGH BLOOD AND OXYGEN
BENIVEINI, 1500s Described a woman who was sometimes troubled with pain at her heart. At last the pain began to attack her more frequently and at length she was carried off.
EDWARD, EARL OF CLARENDON (1609-74) Described his fathers illness: He was seized by so sharp a pain in the left armthat the torment made him pale as if he were dead; and he used to say that he had passed the pangs of death and that he should die in one of those fits
WILLIAM HEBERDEN 1710-1801There is a disorder of the breast, marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, of which I do not recollect any mention among medical authors.
Those who are afflicted with it, are seized, while they are walking, and more particularly when they walk soonafter eating, with a painful and mostdisagreeable sensation in the breast,which seems as if it would take theirlife away, if it were to increase or tocontinue: the moment they stand still,all this uneasiness vanishes.HEBERDEN
SOMATIC PAINSomatic pain generally arises from the surface of the bodySomatic pain is accurately localizedExamples: (a) a cut on the arm, (b) a bruised elbow, (c) a fractured ankle, (d) a needle stick in the arm
A CONCEPT OF THE NORMAL (SOMATIC) PERCEPTION OF PAINMackenzie, M
VISCERAL PAINDiffuse, difficult to localizeGeography is ill-definedBorders of pain are vaguePain tends to feel deepThe patient is troubled by the inability to adequately define the pain
CONCERNING REFERRED PAINIt is a pain referred to a somatic location.Impulses from the thoracic viscera are strangers to the consciousness. The patient with pain from the heart or esophagus can do no better than localize it to the central chest region.Modified from Edmeads and BillingsChest Pain: An Integrated Diagnostic ApproachLea & Febiger, 1977
A CONCEPT OF REFERRED PAINMackenzie, M
RELATIONSHIPS BETWEEN THE SPINALLEVELS OF VARIOUSSYMPATHETIC NERVOUSSYSTEM CONNECTORCELLSLast, RJ, Human Nervous System, 1984HEART, ESOPHAGUS AND UPPER LIMB SYMPATHETIC INNERVATION OVERLAP
SERIOUS PAIN MAY ARISE FROM ANY CHEST ORGANMYOCARDIAL INFARCTIONUNSTABLE ANGINADISSECTING AORTIC ANEURYSMPERICARDITISPULMONARY EMBOLISMPNEUMOTHORAXPNEUMONIARUPTURED ESOPHAGUS
THE LANGUAGE OF WORRISOME CHEST PAINTightness, Squeezing, CompressingHeaviness, CrushingPressure, Constriction, Like a band around the chestElephants on my chestHeavy weight on chestDeep achingBurning
SOME CAUSES OF ANTERIOR CHEST HEAVINESSCONGESTIVE HEART FAILUREPULMONARY EDEMAPULMONARY HYPERTENSIONOBSTRUCTIVE PULMONARY DISEASEDEPRESSION AND GRIEFANXIETYHYPERVENTILATIONCORONARY ARTERY DISEASE
GESTURES MADEWHEN DESCRIBINGSEVERE CHEST PAIN
ANGINA IS PRECIPITATED BY DIFFERENT STRESSORS IN DIFFERENT PERSONSTHE PROSTITUTE COMPLAINEDIT ISNT THE WORK THAT BOTHERS ME, ITS THE STAIRS.
Pains rarely arising from the heartSharp, Sticking, PiercingPinching, Like a knife, StabbingCutting, CatchingPersistent achingPains in right arm or right chestSharp pains under left breastPains brought on by position
IT HELPS TO KNOW WHAT COMPANY A PAIN KEEPSCoffee, alcohol, food indiscretionsHeartburn, acid reflux, hiatal herniaBrought on by exertion, worse in cold weather and windBrought on by eating; worse with exertion after eatingChills, fever, cough, hemoptysis, palpitations
THE SEVERITY OF PAIN DOES NOTREFLECT THE EXTENT OF CORONARYARTERY DISEASEPAINTHRESHOLDVARIES FROM ONEPERSON TONEXT
CHARACTERISTICS CARDIAC AND ESOPHAGEAL PAIN HAVE IN COMMONMid or lower retrosternal pain: heaviness, squeezing, tightness, burningMay present as epigastric, with radiation upwardsPain radiates upward towards throatMay radiate to neck, left shoulder, or armMay be precipitated or aggravated by exertion
CHARACTERISTICS CARDIAC AND ESOPHAGEAL PAIN HAVE IN COMMONMay be relieved by sublingual nitroglycerineMay be eased or relieved by standingPain more likely to occur after eatingMay be accompanied with considerable anxietyA feeling of weakness and sweatiness may accompany the pain
WHEN STABLE ANGINA BECOMES UNSTABLEPain is longer in durationPain is more frequentPain occurs at rest or with less physical or emotional stressPain is more severePain radiates in different patternRecent onset angina is considered to be unstable
SOME EXAMPLES OF PAIN SYNDROMES
40 year old lady
Increasing pain from back, radiating around to the front of the chest underthe left breast. Present 2 days, burningin nature, and skin is tender to touch.Even light clothing brushing against area is uncomfortable. The doctor predicts that a rash will develop in the painful area, and it does. The pain eases after the rash appears.
A 66 year old housewifeRecurrent pain around left shoulder andupper left chest for 2 weeks. Pain quitebad when she was doing housework.Reaching up to get something off a shelfaggravated it. Aspirin and sleeping flaton her back eased the pain. She notedtenderness at the base of the neck on theleft side.A few years ago she had a similar painand x-rays of the neck showed rather severe arthritis.
A 20 YEAR OLD GIRL
Ms J was anxious about a pain she had experienced 3 times in the last few days. The pain was sharp, quite severe, sudden in onset, under the left breast, occurred at rest and was made worse by a deep breath. She was forced to take shallow breaths. At times it feels like something got caught. The pain, gone after a few minutes, leaves a a vague aching.
A 24 YEAR OLD MAN
He was in excellent health when he joined the Army. While in basic training he developed fever of 101 degrees and chills and had a bad pain on the top of his left shoulder. The pain was worse on taking a deep breath. Chest x-rays showed a left lower lung pneumoniaabove the diaphragm.
SEVERE BURNING PAIN IN THE MIDDLE OF THE CHEST Mr B, 48 years old, had chronic heartburn, made worse with coffee and alcohol and spicy foods. Sometimes he would get regurgitation of sour stuff into his mouth. This night he awoke with a terrible burning pain in the middle of the chest.
52 YEAR OLD MAN Mr J had known angina pectoris. While driving home a mild angina became more severe and radiated to his left jaw.
LADY AGE 41 YEARS Mrs J developed a tightness in the mid-chest when rushing for the bus. It kept recurring when she was rushed, but disappeared promptly when she rested.
35 YEAR OLD LADY Mrs T had a history of episodes of her heart racing. But this time it was associated with rather severe pain in the left upper arm. The pain persisted for one hour.
A 40 YEAR OLD MAN
Mr J, worked out 3 times a week. For 2 weeks elevating the treadmill and walking fast caused him to have a peculiar tightness in the middle of the chest.
MAN AGE 44 YEARS Mr E, was awakened during the night with a rather severe pain in the middle of the chest and left shoulder. The pain eased after taking an antacid pill.
72 YEAR OLD LADY
Mrs. A had a peculiar jaw pain for 2 weeks that would come and go while doing housework and when walking up the stairs, particularly when she was rushed. Her dentist found no dental problems.
SOME ATYPICAL PAIN MANIFESTATIONS OF ISCHEMIC HEART DISEASE
ATYPICAL ANGINAAching pain in left wrist with exertionAching in left elbow with stressVague tightness left side of neck with exertionPain on left side of throat with effortPain in left thumb with stress
Some notes about the diagnosis of chest painSL ntg does not differentiate cardiac from esophageal painRelief of pain with antacid does not rule out cardiac originEsophageal pain can be precipitated by exerciseEmotional stress is a major cause of anginal pain
CONCLUSIONSAny prolonged pain merits investigationPains related to exertion merit investigationPains brought on by eating, with or without exertion, merit attentionRecurrent mid-chest, left neck, jaw, and arm pains merit attention
WE CLOSE WITH POETRYBIRDIE WITH A YELLOW BILLHOPPED UPON MY WINDOWSILL,COCKED HIS BEADY EYES, AND SAID,AINT YOU SHAMED YOU SLEEPY HEAD?
DRUG TREATMENTS TO TREAT & PREVENT RECURRENT ANGINABeta blocking agentsMetoprololCalcium channel blocking agentsAmlodipine, nifedipine, verapamilNitrates: sublingual, oral, topicalIsosorbide dinitrate, nitroglycerineAngiotensin converting enzymesAngiotensin receptor blockers
*****Osborns wonderful book On Leisure had this illustration. Death is to be avoided.*Note the face in the heart.**We will discuss these topics in this order.***There is a multitude of places in the chest from which pain can occur.*The ancients of some millions of years ago knew of the heart and placed it quite well.***Figure 1-24. Diagrammatic representation of coronary anatomy categorized by one-, two-, and three-vessel disease in the Coronary Artery Surgery Study (CASS). Significant disease was defined as stenosis of 70% or greater in a vessel or major branch. For left main coronary arteries, significant disease was defined by stenosis of 50% or greater. With a left-dominant circulation, the circumflex coronary artery and its major branches are counted as one vessel and the posterior descending coronary artery is considered a different vessel. In a right-dominant circulation, the right coronary artery with the posterior descending artery is considered as one vessel and the circumflex coronary artery and its marginal branches are considered as another vessel. The distribution of the posterior descending coronary artery from either the right coronary or the circumflex artery depends on the dominance of the vessel.
*This drawing by a famous artist shows the heart surrounded by lung and mediastinal tissues, sitting on the diaphragm and leaning on the esophagus behind it.*The lung is in front, and directly behind the heart is the esophagus. We used to define certain heart chamber enlargement by pressure on the barium-filled esophagus.****One of the earliest recorded descriptions of pain arising from the heart.*A classic description of angina pectoris by a layman.*A superb description of angina pectoris in a paper that would not be accepted for publication in the modern era.*****Describing visceral pain is even difficult for physicians.**Pain arising from a viscus (e.g. the heart at V) is referred felt as if coming from the somatic site A.*Note the overlap sympathetic innervation of the heart, esophagus and upper limb.******************************
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