chest pain when to worry when not to worry

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