CHEST PAIN When to Worry When Not to Worry

2. CHEST PAINWhen to Worry When Not to Worry Albert J. Miller, M.D. Professor of Clinical Medicine (Cardiology) Feinberg School of Medicine Northwestern University

4. 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.

5. 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.

6. TO BE AVOIDED…. R. Osborn 1956

7. The heart is important and is the center of things. It is the major aspect of this lecture. R. Osborn, 1956

8. 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

9. 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

10. 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

11. TYPES OF HEART DISEASE DEATHS IN 1999

12. 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

13. MASTADON WITH HEART

14. Henry Matisse 1869-1954

15. 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

16. Coronary anatomy categorized by number of diseased vessels THE CORONARY ARTERIES

17. THERE ARE NO EMPTY SPACES IN THE CHEST

18. CHEST VIEW FROM THE SIDE – NO EMPTY SPACES

19. 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

20. “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

21. “WHAT IS ANGINA PECTORIS?” PAIN THAT IS DUE TO SOME PORTION OF THE HEART MUSCLE NOT GETTING ENOUGH BLOOD AND OXYGEN

22. 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.”

23. 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…”

24. 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.”

25. HEBERDEN “Those who are afflicted with it, are seized, while they are walking, and more particularly when they walk soon after eating, with a painful and most disagreeable sensation in the breast, which seems as if it would take their life away, if it were to increase or to continue: the moment they stand still, all this uneasiness vanishes.”

26. WILLIAM HEBERDEN

27. 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

28. A CONCEPT OF THE NORMAL (SOMATIC) PERCEPTION OF PAIN… Mackenzie, M

29. 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

30. 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 Billings Chest Pain: An Integrated Diagnostic Approach Lea & Febiger, 1977

31. A CONCEPT OF REFERRED PAIN… Mackenzie, M

32. HEART, ESOPHAGUS AND UPPER LIMB SYMPATHETIC INNERVATION OVERLAP RELATIONSHIPS BETWEEN THE SPINAL LEVELS OF VARIOUS SYMPATHETIC NERVOUS SYSTEM CONNECTOR CELLS Last, RJ, Human Nervous System, 1984

33. SERIOUS PAIN MAY ARISE FROM ANY CHEST ORGAN • MYOCARDIAL INFARCTION • UNSTABLE ANGINA • DISSECTING AORTIC ANEURYSM • PERICARDITIS • PULMONARY EMBOLISM • PNEUMOTHORAX • PNEUMONIA • RUPTURED ESOPHAGUS

34. 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

35. SOME CAUSES OF ANTERIOR CHEST HEAVINESS • CONGESTIVE HEART FAILURE • PULMONARY EDEMA • PULMONARY HYPERTENSION • OBSTRUCTIVE PULMONARY DISEASE • DEPRESSION AND GRIEF • ANXIETY • HYPERVENTILATION • CORONARY ARTERY DISEASE

37. GESTURES MADE WHEN DESCRIBING SEVERE CHEST PAIN

38. ANGINA IS PRECIPITATED BY DIFFERENT STRESSORS IN DIFFERENT PERSONS THE PROSTITUTE COMPLAINED… “IT ISN’T THE WORK THAT BOTHERS ME, IT’S THE STAIRS.”

39. 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

40. 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

41. THE SEVERITY OF PAIN DOES NOT REFLECT THE EXTENT OF CORONARY ARTERY DISEASE… PAIN THRESHOLD VARIES FROM ONE PERSON TO NEXT

42. 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

43. 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

44. 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

45. SOME EXAMPLES OF PAIN SYNDROMES

46. 40 year old lady Increasing pain from back, radiating around to the front of the chest under the left breast. Present 2 days, burning in 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.

47. A 66 year old housewife Recurrent pain around left shoulder and upper left chest for 2 weeks. Pain quite bad when she was doing housework. Reaching up to get something off a shelf aggravated it. Aspirin and sleeping flat on her back eased the pain. She noted tenderness at the base of the neck on the left side. A few years ago she had a similar pain and x-rays of the neck showed rather severe arthritis.

48. 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.

49. 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 pneumonia above the diaphragm.

50. 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.