Diagnosis of pain in the heart

Differential diagnosis of pain in the region of the heart

Atypical variant of angina pectoris

It should immediately be emphasized that pain in the heart initially requires a cardiological clinical and paraclinical analysis. At some stage of neurological observation, the patient may have pain associated with heart damage. A number of manifestations require special attention as indicating a possible coronarogenic nature of the pain. So, short attacks (in some cases, prolonged - up to an hour) behind the breastbone or parasternal pressing, compressive, burning pains (sometimes other localization) associated with physical activity, emotions (sometimes without a clear reason), requiring the patient to stop walking, nitroglycerin, with irradiation in the left arm, scapula, in the jaw (other localizations are possible, or completely without irradiation), require evaluation in order to exclude possible angina pectoris.

Osteocondritis of the spine

Osteochondrosis of the spine (cervical, thoracic) in a number of cases, along with characteristic neurological disorders, can also cause pain in the region of the heart. This fact led in recent years to overdiagnosis of osteochondrosis as a possible cause of pain in the heart, which causes frequent errors in the diagnosis of both organic cardiac and vegetative-diagnostic diseases. Relation of pain to spinal motion (flexion, extension, turns of the neck and trunk), increased pain during coughing, sneezing, straining, the presence of sensitive (subjective painful and detected by objective examination) disorders in the corresponding zones, reflex changes, local soreness with percussion of spinous processes and palpation of the paravertebral points, changes in the spondylogram - these and other signs allow us to ascertain the presence of signs of osteochondrosis in a patient of one or another localization.

It should be emphasized that the detection of these signs is not yet sufficient argument for the connection of the pains that arise in the region of the heart with the presence of degenerative changes in the spine. The detailed anamnesis, by means of which the temporal sequence of the appearance of symptoms is established, the characteristic features of the phenomenon of pain and close connection with the dynamics of other clinical manifestations, the reduction of symptoms in the treatment of osteochondrosis suggest the spondylogenic nature of the pains in the region of the heart.

Myofascial syndromes

Myofascial syndromes can be one of the manifestations of osteochondrosis of the spine, but may have a different genesis. In recent years, they began to be considered within the concept, clinically expressed in the manifestations of local muscle hypertonia. Often pains are associated with myofascial changes in the large and small pectoral muscles. Reflex pain phenomena in this area were referred to in the literature as pectalgic syndrome, or a syndrome of the anterior chest wall. Diagnostic value is the pain of the muscles during palpation, a significant reduction in pain when using blockades, manual therapy, methods of post-isometric relaxation.

The syndrome of disturbance of vegetative regulation of a rhythm of heart

The most common manifestations of cardiac rhythm disturbance in the framework of vegetative disorders are tachycardia, bradycardia and extrasystole.

Tachycardia

Sinus tachycardia (as a rule, from 90 to 130-140 per 1 min) can be observed in both permanent and paroxysmal vegetative disorders. Subjective feelings are expressed in the presence of complaints of heart palpitations, the feeling that "the heart strikes hard on the chest," etc. As a rule, the coincidence of subjective sensations of the accelerated work of the heart with objective studies on the ECG occurs only in half of the patients. In addition to these complaints, patients experience other unpleasant feelings - general weakness, lack of air, dizziness, and fear of death in case of vegetative crisis. An important feature of tachycardia is its lability and fluctuation, depending on the presence of a number of provoking factors (excitement, exercise, eating, drinking coffee, tea, alcohol, etc.). In some patients, the hyperventilation test is a powerful provocateur of tachycardia. It should be added that in some patients tachycardia can be quite persistent, not responding to digitalis and novocainamide drugs, but it can respond to the appointment of beta-blockers. In such cases, in addition to excluding organic heart disease, a differential diagnosis should be made with thyrotoxicosis.

Tachycardia, which occurs paroxysmally in the structure of a vegetative crisis, requires differentiation from an attack of paroxysmal tachycardia. The latter is characterized by the suddenness of onset and disappearance, the greater severity of tachycardia (130-180 in 1 min with ventricular and 160-220 in 1 min with atrial tachycardias), ECG changes (deformation or perversion of the P wave, conduction disturbance, etc.).

Bradycardia

Slowing heart rate (less than 60 per 1 min) within the autonomic dystonia syndrome is much less common than tachycardia. The most frequent complaint is a feeling of palpitations, a feeling that the pulse is weakening or disappearing. Such unpleasant, painful sensations are especially dramatically intensified when a vegetative crisis of the vagoinsular character is unfolded, or in a crisis with severe hyperventilation, when the patient seldom, deeply and strenuously breathes.

Persistent bradycardia requires a deep cardiac analysis to exclude "syndrome of weakness of the sinus node", which is accompanied by other cardiac disorders.

Extrasystolic arrhythmia

The appearance of extrasystoles is the most frequent pathophysiological basis for the appearance of most unpleasant sensations from the heart: interruptions, tremors, palpitations, "fading", lack of air, dizziness, hot flashes to the head,

The frequency of extrasystoles in patients with autonomic dysfunction reaches 30%. This is due to the fact that subclinical extrasystoles occur in the population quite widely, reaching (at 24-hour monitoring) at rest 31%, and with an exercise load of 33.8%.

As well as other disorders of the rhythm, extrasystolic arrhythmia is located within the framework of the syndrome of vegetative disorders and is closely related to psychovegetative manifestations, depends on their dynamics and is reduced under the influence of psychotropic drugs, psychotherapy and respiratory gymnastics.

Syndrome of disturbance of vegetative regulation of arterial pressure

Variations in blood pressure as manifestations of the dysdinamic syndrome (along with cardial and dysrhythmic syndrome) in autonomic dystonia occur in 36% of patients.

Syndrome of arterial hypertension

Syndrome of arterial hypertension in autonomic dysfunction (transitory, labile, unstable, psychogenic hypertension) is found in 16% of patients. Most often, complaints are expressed in the presence of a headache (pressing, constricting, pulsating, burning, bursting), severity, ambiguity in the head, general weakness and other manifestations of psychovegetative syndrome. The peculiarity of mental changes is the expressed affective tension of patients within the framework of most often various neurotic syndromes (hypochondriacal, anxious, depressive, asthenic). Some patients expressed violations of the phobic plan, the patients are actively looking for the cause of the disease and the ways of its treatment. Vegetative symptoms are diverse and reflect the patient's permanent and paroxysmal manifestations of psychovegetative syndrome. The figures of blood pressure, as a rule, are moderate - 150-160 / 90-95 mm Hg. Art. The upsurge of blood pressure is most pronounced during autonomic paroxysm; beyond paroxysm, high lability of arterial pressure, often depending on the emotional state of patients, is established. In the structure of psycho-vegetative syndrome, algic phenomena are quite often encountered: headaches, pains in the region of the heart, in the spine.

To determine the lability of blood pressure, repeated blood pressure measurement can be used - at the very beginning of the conversation with the patient and three more times at the end of the conversation.

For the purpose of differential diagnosis, it is necessary to distinguish between dystonic hypertension and hypertension as an early manifestation of hypertensive disease. The latter is characterized by more stable figures for increasing blood pressure, the presence of changes on the fundus, on the ECG. Hypertonic crises, in contrast to autonomic paroxysms, are shorter (vegetative paroxysms can last from 30 minutes to several hours). Arterial blood pressure usually reaches higher figures, there may be severe headaches with vomiting; affective manifestations are less pronounced. In connection with the possible combination of two types of paroxysms (hypertonic and autonomic) in one patient, one should be guided by the criteria that are revealed in the non-paroxysmal period, taking into account the indicated characteristics in dynamics.

Syndrome of arterial hypotension

This syndrome (105-90 / 60-50 mm Hg) occurs most often in people with an asthenic constitution and with a predominance of the parasympathetic tone of the autonomic nervous system. Arterial hypotension, being an expression of psycho-vegetative syndrome in the "chronic", or rather permanent, form, is observed in combination with persistent asthenic disorders.

Patients complain of a headache of a different nature, but most often the cephalgia of the vascular-migraine type prevail. The pulsating headache in some cases increases and reaches an almost migraine level of intensity (hypotension and migraine are a fairly common situation). Acute lowering of blood pressure can lead to the appearance of syncopal conditions. Patients often have orthostatic manifestations, which are expressed by dizziness or lipotypic condition.

Headache is often combined with dizziness, unstable walking, pain in the heart, palpitation, a sense of lack of air.

A persistent reduction in blood pressure requires the exclusion of latent chronic adrenal insufficiency in patients.

The syndrome of lability of blood pressure

The most characteristic manifestation of autonomic dystonia is the lability of blood pressure. Transient episodes of its increase or decrease, described above, are essentially different manifestations of the syndrome of lability of arterial pressure, which along with the lability of regulation of the heart rhythm form the true content of the concept of cardiovascular dystonia.

It is important to note that dystonic instability is a reflection of the same lability of the emotional sphere and the mechanisms of neuroendocrine regulation. In this case, the factors that cause fluctuations in blood pressure can be extremely polymorphic: psychogenic effects, meteorological fluctuations, endocrine dysfunctions, etc.

As a rule, patients have a combination of various disorders in both cardiovascular and other visceral systems.

The syndrome of electrocardiographic disorders

A special ECG study in patients with vegetative disorders made it possible to identify the following variants of ECG changes:

1. An increase in the amplitude of the positive T wave is usually recorded in the right thoracic leads and is combined with an increase in the S- T segment in the same leads.
2. Disorders of rhythm and automatism are expressed in the registration of ECG arrhythmias of various types, extrasystoles, sinus tachy and bradycardia.
3. The change in the ST segment and T wave is most common in patients with autonomic dysfunction. There is a temporary decrease, ST segment fluctuation and a positive T wave inversion . There is also a pseudo-coronary rise of the S- T segment above the isoline, a syndrome of early or premature repolarization. The researchers associate this syndrome with the imperfection of neurovegetative control of the electrical activation of the heart with a predominance of parasympathetic influences.

Problems of pathogenesis and symptom formation of cardiovascular tonic manifestations

Cardiovascular dystonic manifestations have served for recent years the subject of targeted studies of the Russian school of vegetology.

Essentially, when analyzing cardiovascular disorders, the basic concepts of a broader problem - vegetative dystonia in general - have been formed. In the monograph of AM Vein et al. (1981), summarizing 20 years of research on the problem of vegetative pathology, and in subsequent publications of the Russian Vegetative Center staff, modern views on the pathogenesis of vegetative (including cardiovascular) disorders, the vast majority of which are of a psychogenic nature, are presented in detail. Multidimensionality of the structure of pathogenetic mechanisms of vegetative dystonia syndrome is shown. The use of the functional neurological approach has made it possible to reveal the basic mechanisms of pathogenesis, which are expressed in the violation of cerebral activation homeostasis, the violation of the integrative function of nonspecific brain systems (disintegration syndrome), and also establish the role of ergotropic and trophotropic systems in the mechanisms of vegetative disorders. The presence of disorders of circadian organization of vegetative functions, violation of interhemispheric interactions in patients with vegetative disorders are shown.

In recent years, an important role of respiratory dysfunction - an obligate manifestation of psycho-vegetative disorders - has been revealed in some mechanisms of symptom formation in vegetative, including cardiovascular, disorders. Given the contribution of respiratory dysfunction, more precisely, hyperventilation manifestations, the symptomogenesis of the various clinical phenomena under consideration should be distinguished:

1. change (distortion) of the pattern of breathing, consisting in reduction of the diaphragm mobility (inertia, diaphragm blockade), which occurs in 80% of patients with autonomic dysfunction (with fluoroscopic examination). This leads to a violation of cardio-diaphragmatic relationships;
2. shutting off the diaphragmatic portion of breathing leads to compensatory hyperfunction of the intercostal, staircase, pectoral muscles, as well as the muscles of the shoulder, which causes myalgic pain and local hypertonia - the basis of pain in the chest region, in the heart;
3. hypocapnic (respiratory) alkalosis, according to a number of authors, can affect the blood supply of the myocardium with oxygen by spasm of the coronary arteries and the increase in the affinity of hemoglobin to oxygen, which naturally occurs with hypocapnia and alkalosis (Bohr effect). The role of hypocapnia in the broad and multidimensional mechanisms of symptom formation is considered in the work of L. Freeman, P. Nixon (1985).

Interesting possibilities of a new approach to the analysis of pathogenesis and the symptom formation of cardiovascular disorders are the studies of peripheral vegetative insufficiency. At the same time, the analysis of cardiovascular reflexes in patients with autonomic paroxysms revealed indirect signs of vegetative insufficiency of the predominantly parasympathetic division, which may indicate its functional nature.

From a practical point of view, first of all, the careful characterization of chest pains, which immediately allows the patient to be assigned to one of the following categories, is important: with typical angina attacks in all parameters; with clearly atypical and uncharacteristic angina pectoris in the heart.

In order to obtain these characteristics, the doctor's active clarifying questions are needed about all the circumstances of the onset, cessation and all the features of the pain, i.e., the doctor should never be satisfied only with the patient's story. To establish the exact location of pain, you should ask the patient to show a finger where it hurts, and where the pain is given. You should always recheck the patient and ask again if there are pains in other places and where exactly. It is also important to find out the actual relationship of pain to physical activity: are there any pains in the process of its implementation and whether they cause it to stop, or the patient notices the appearance of pains some time after the exercise. In the second case, the probability of angina is significantly reduced. It also means whether pain always occurs at approximately the same load, or the range of the latter varies greatly in different cases. It is important to find out whether it really is about physical activity that requires certain energy costs, or only about changing the position of the body, hand movements, etc. It is important to identify certain stereotyped conditions for the appearance and cessation of pain and their clinical characteristics. The absence of this stereotype, the changing conditions for the appearance and cessation of pain, different localization, irradiation and the nature of pain always make one doubt the diagnosis.

Differential diagnosis of chest pain according to interrogations

Pain Management Options	Characteristic of angina pectoris	Uncharacteristic of angina
Character	Compressive, compressive	Stitching, aching, piercing, burning
Localization	Lower third of sternum, anterior surface of thorax	Top, under the left collarbone, underarm area, only under the scapula, in the left shoulder, in different places
Irradiation	In the left shoulder, arm, IV and V finger, neck, lower jaw	In I and II the finger of the left hand, rarely in the neck and jaw
The conditions of appearance	During physical exertion, with hypertensive crises, attacks of tachycardia	When bending, bending, moving hands, deep breathing, coughing, plentiful food, lying down
Duration	Up to 10-15 minutes	Short-term (seconds) or long (hours, days) or different duration
Behavior of the patient during pain	The desire for peace, the inability to continue the load	Long-term anxiety, finding a comfortable position
Conditions for cessation of pain	Stopping the load, resting, taking nitroglycerin (for 1-1.5 minutes)	Going to a sitting or standing position, walking, any other convenient position, taking analgesics, antacids
Concomitant symptoms	Difficulty in breathing, palpitations, interruptions

It should also clarify the actual effect of nitroglycerin and never be satisfied with the patient's words that he is helping. Diagnostic value has a certain cessation of pain in the heart for 1-1,5 minutes after it is taken.

The clarification of the peculiarities of pain in the heart requires, of course, a doctor's time and patience, but these efforts will certainly be justified in the subsequent observation of the patient, creating a solid diagnostic base.

If the pain is incomplete, complete or incomplete, especially if there are no or low risk factors (for example, in middle-aged women), other possible causes of the origin of pain in the heart should be analyzed.

It should be borne in mind that most often in clinical practice there are 3 types of extracardiac pain, able to simulate CHD: pain in diseases of the esophagus, spine and neurotic pain. Difficulties with finding out the real cause of chest pains are due to the fact that visceral structures (lungs, heart, diaphragm, esophagus) inside the chest have an overlapping innervation with the inclusion of the autonomic nervous system. With the pathology of these structures, pain sensations of completely different origin may have some similarities in localization and other characteristics. The patient, as a rule, finds it difficult to localize pain from internal, deep-lying organs and much easier - from superficial formations (ribs, muscles, spine). These features and determine the possibility of differential diagnosis of pain in the heart from clinical data.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]