CHEST PAINWhen to Worry
When Not to Worry
Albert J. Miller, M.D.Professor of Clinical Medicine
(Cardiology)Feinberg School of Medicine
Northwestern 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, 1956
The 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 discomfort Pain or discomfort in arms,
back, jaw, neck or stomach Shortness of breath Sweating or lightheadedness Indigestion or nausea Tiredness
CHEST PAIN – SUBJECTS TO BE COVERED IN THIS LECTURE…
History of ischemic heart pain Anatomy of the heart in the chest Nervous connections of the heart Language of chest pain Pains not from the heart Pains that suggest heart origin D/d of heart and esophageal pains Case presentations
SOME FACTS ABOUT CHEST PAIN…
APPROXIMATELY 6 MILLION PATIENTS VISIT EMERGENCY DEPARTMENTS WITH CHEST PAIN ANNUALLY IN THE UNITED STATES
APPROXIMATELY 1.5 MILLION PATIENTS EXPERIENCE HEART ATTACKS AND MORE THAN 500,000 DIE ANNUALLY
Kahn, SE Arch Path Lab Med, Oct 2000
TYPES OF HEART DISEASE DEATHSIN 1999
MOST PERSONS HAVE CHEST PAIN AT SOME TIME OR OTHER…THE CHEST ANATOMY INCLUDES:
Chest wall skin, nerves, arteries, veins, muscle, ribs, lymphatics
Pleura - inner lining of chest wall Trachea, bronchi, pulmonary
arteries and veins, lungs, diaphragm Heart, pericardium, aorta Mediastinal fat, nerves, vessels Esophagus
MASTADON WITH HEART
Henry Matisse1869-1954
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 vessels
THE 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 PAIN
TAKING 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 father’s illness: “He was seized by so sharp a pain in the left arm…that 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 1710-1801
“There 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
WILLIAM HEBERDEN
SOMATIC PAIN Somatic pain generally arises
from the surface of the body Somatic pain is accurately
localized Examples: (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 PAIN…
Mackenzie, M
VISCERAL PAIN
Diffuse, difficult to localize Geography is ill-defined Borders of pain are vague Pain tends to feel deep The patient is troubled by the
inability to adequately define the pain
CONCERNING REFERRED PAIN
It 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 PAIN…
Mackenzie, M
RELATIONSHIPS BETWEEN THE SPINALLEVELS OF VARIOUSSYMPATHETIC NERVOUSSYSTEM CONNECTORCELLS
Last, RJ, Human Nervous System, 1984
HEART, ESOPHAGUS AND UPPER LIMB SYMPATHETIC INNERVATION OVERLAP
SERIOUS PAIN MAY ARISE FROM ANY CHEST ORGAN
MYOCARDIAL INFARCTION UNSTABLE ANGINA DISSECTING AORTIC ANEURYSM PERICARDITIS PULMONARY EMBOLISM PNEUMOTHORAX PNEUMONIA RUPTURED ESOPHAGUS
THE LANGUAGE OF WORRISOME CHEST PAIN
Tightness, Squeezing, Compressing Heaviness, Crushing Pressure, Constriction, Like a band
around the chest Elephants on my chest Heavy weight on chest Deep aching Burning
SOME CAUSES OF ANTERIOR CHEST HEAVINESS
CONGESTIVE HEART FAILURE PULMONARY EDEMA PULMONARY HYPERTENSION OBSTRUCTIVE PULMONARY DISEASE DEPRESSION AND GRIEF ANXIETY HYPERVENTILATION CORONARY ARTERY DISEASE
GESTURES MADEWHEN DESCRIBINGSEVERE CHEST PAIN
ANGINA IS PRECIPITATED BY DIFFERENT STRESSORS IN
DIFFERENT PERSONS
THE PROSTITUTE COMPLAINED…
“IT ISN’T THE WORK THAT BOTHERS ME, IT’S THE STAIRS.”
Pains rarely arising from the heart
Sharp, Sticking, Piercing Pinching, Like a knife, Stabbing Cutting, Catching Persistent aching Pains in right arm or right chest Sharp pains under left breast Pains brought on by position
IT HELPS TO KNOW WHAT COMPANY A PAIN KEEPS
Coffee, alcohol, food indiscretions Heartburn, acid reflux, hiatal hernia Brought on by exertion, worse in cold
weather and wind Brought on by eating; worse with
exertion after eating Chills, fever, cough, hemoptysis,
palpitations
THE SEVERITY OF PAIN DOES NOTREFLECT THE EXTENT OF CORONARYARTERY DISEASE…
PAINTHRESHOLDVARIES FROM ONEPERSON TONEXT
CHARACTERISTICS CARDIAC AND ESOPHAGEAL PAIN HAVE IN COMMON
Mid or lower retrosternal pain: heaviness, squeezing, tightness, burning
May present as epigastric, with radiation upwards
Pain radiates upward towards throat May radiate to neck, left shoulder, or
arm May be precipitated or aggravated by
exertion
CHARACTERISTICS CARDIAC AND ESOPHAGEAL PAIN HAVE IN COMMON
May be relieved by sublingual nitroglycerine
May be eased or relieved by standing Pain more likely to occur after eating May be accompanied with
considerable anxiety A feeling of weakness and
sweatiness may accompany the pain
WHEN STABLE ANGINA BECOMES UNSTABLE Pain is longer in duration Pain is more frequent Pain occurs at rest or with less
physical or emotional stress Pain is more severe Pain radiates in different pattern Recent 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 housewife
Recurrent 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 ANGINA
Aching pain in left wrist with exertion
Aching in left elbow with stress Vague tightness left side of neck
with exertion Pain on left side of throat with
effort Pain in left thumb with stress
Some notes about the diagnosis of chest pain
SL ntg does not differentiate cardiac from esophageal pain
Relief of pain with antacid does not rule out cardiac origin
Esophageal pain can be precipitated by exercise
Emotional stress is a major cause of anginal pain
CONCLUSIONS
Any prolonged pain merits investigation
Pains related to exertion merit investigation
Pains brought on by eating, with or without exertion, merit attention
Recurrent mid-chest, left neck, jaw, and arm pains merit attention
WE CLOSE WITH POETRY
BIRDIE WITH A YELLOW BILL
HOPPED UPON MY WINDOWSILL,COCKED HIS BEADY EYES, AND SAID,“AIN’T YOU SHAMED YOU SLEEPY HEAD?”
DRUG TREATMENTS TO TREAT & PREVENT RECURRENT
ANGINA Beta blocking agents
Metoprolol Calcium channel blocking agents
Amlodipine, nifedipine, verapamil Nitrates: sublingual, oral, topical
Isosorbide dinitrate, nitroglycerine Angiotensin converting enzymes Angiotensin receptor blockers
