Diagnosing heart pain

Differential diagnosis of pain in the heart area

Atypical variant of angina

It should be immediately emphasized that pain in the heart area initially requires cardiological clinical and paraclinical analysis. At some stage of neurological observation, the patient may experience pain associated with heart damage. A number of manifestations require special attention as indicating a possible coronary nature of pain. Thus, short attacks (in some cases protracted - up to an hour) behind the sternum or parasternal pressing, squeezing, burning pain (sometimes other localizations), associated with physical exertion, emotions (sometimes without a clear reason), requiring the patient to stop walking, relieved by nitroglycerin, with irradiation to the left arm, shoulder blade, jaw (other localizations are also possible or without irradiation at all), require assessment to exclude a possible angina pectoris nature.

Osteochondrosis of the spine

In some cases, osteochondrosis of the spine (cervical, thoracic) along with typical neurological disorders can also cause pain in the heart area. This fact has led in recent years to hyperdiagnosis of osteochondrosis as a possible cause of pain in the heart area, which causes frequent errors in the diagnosis of both organic cardiac and vegetative-diagnostic diseases. The relationship of pain with movements of the spine (flexion, extension, turns of the neck and trunk), increased pain when coughing, sneezing, straining, the presence of sensory (subjective pain and detected during objective examination) disorders in the corresponding zones, reflex changes, local pain during percussion of the spinous processes and palpation of paravertebral points, changes in the spondylogram - these and other signs allow us to state the presence of signs of osteochondrosis of one or another localization in the patient.

It should be emphasized that the detection of the above signs is not yet a sufficient argument for the connection between the pain in the heart area and the presence of degenerative changes in the spine. A detailed anamnesis, with the help of which the time sequence of the appearance of symptoms, the characteristic features of the pain phenomenon and the close connection with the dynamics of other clinical manifestations, the reduction of symptoms during the treatment of osteochondrosis allow us to assume the spondylogenic nature of pain in the heart area.

Myofascial syndromes

Myofascial syndromes can be one of the manifestations of spinal osteochondrosis, but they can also have a different genesis. In recent years, they have come to be considered within the framework of a concept clinically expressed in manifestations of local muscle hypertonus. Pain is often associated with myofascial changes in the pectoralis major and minor muscles. Reflex pain phenomena in this area have received the name pectalgic syndrome or anterior chest wall syndrome in the literature. Pain in muscles upon palpation, a significant reduction in pain when using blockades, manual therapy, and post-isometric relaxation techniques are of diagnostic value.

Syndrome of impaired autonomic regulation of cardiac rhythm

The most common manifestations of cardiac arrhythmia within the framework of autonomic disorders are tachycardia, bradycardia and extrasystole.

Tachycardia

Sinus tachycardia (usually from 90 to 130-140 per 1 min) can be observed both in permanent and paroxysmal vegetative disorders. Subjective sensations are expressed in the presence of complaints of increased heart rate, the feeling that "the heart is hitting the chest hard", etc. As a rule, the coincidence of subjective sensations of accelerated heart function with objective ECG studies occurs in only half of patients. In addition to the above complaints, patients experience other unpleasant sensations - general weakness, shortness of breath, dizziness, and fear of death in the case of a vegetative crisis. An important feature of tachycardia is its lability and fluctuation, depending on the presence of a number of provoking factors (anxiety, physical exertion, food intake, drinking coffee, tea, alcohol, etc.). In some patients, a hyperventilation test is a powerful provoker of tachycardia. It should be added that in some patients tachycardia may be quite persistent, not responding to digitalis and novocainamide, but it may respond to beta-blockers. In such cases, in addition to excluding organic heart disease, differential diagnosis should include thyrotoxicosis.

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

Bradycardia

Slowing of the heart rate (less than 60 per 1 min) within the framework of the vegetative dystonia syndrome occurs much less frequently than tachycardia. The most frequent complaint is the sensation of palpitations, the feeling that the pulse is weakening or disappearing. Such unpleasant, painful sensations are especially sharply intensified during the development of a vegetative crisis of a vagus-insular nature or during a crisis with pronounced hyperventilation, when the patient breathes rarely, deeply and tensely.

Persistent bradycardia requires a thorough cardiological analysis to exclude “sick sinus syndrome”, which is also accompanied by other cardiac disorders.

Extrasystolic arrhythmia

The appearance of extrasystoles is the most common pathophysiological basis for the occurrence of most unpleasant sensations from the heart: interruptions, jolts, palpitations, "freezing", shortness of breath, dizziness, hot flashes to the head, etc.

The frequency of extrasystoles in patients with autonomic dysfunction reaches 30%. This is due to the fact that subclinical extrasystoles are also quite common in the population, reaching (with round-the-clock monitoring) 31% at rest, and 33.8% during physical exertion.

Just like other rhythm disorders, extrasystolic arrhythmia is within the framework of the syndrome of autonomic disorders and is closely associated with psychovegetative manifestations, depends on their dynamics and is reduced under the influence of psychotropic drugs, psychotherapy and breathing exercises.

Syndrome of impaired autonomic regulation of arterial pressure

Fluctuations in blood pressure as a manifestation of dysdynamic syndrome (along with cardiac and dysrhythmic) in vegetative dystonia occur in 36% of patients.

Arterial hypertension syndrome

Arterial hypertension syndrome with autonomic dysfunction (transient, labile, unstable, psychogenic hypertension) is found in 16% of patients. Most often, complaints are expressed in the presence of headache (pressing, squeezing, pulsating, burning, bursting), heaviness, confusion in the head, general weakness and other manifestations of psychovegetative syndrome. A feature of mental changes is the pronounced affective tension of patients within the framework of most often various neurotic syndromes (hypochondriacal, anxious, depressive, asthenic). Some patients have pronounced phobic disorders, patients actively seek the cause of the disease and ways to treat it. Vegetative symptoms are diverse and reflect the presence of permanent and paroxysmal manifestations of psychovegetative syndrome in the patient. Blood pressure figures are usually moderate - 150-160 / 90-95 mm Hg. Increases in arterial pressure are most pronounced during vegetative paroxysm; outside of paroxysm, high lability of arterial pressure is observed, often depending on the emotional state of patients. In the structure of psychovegetative syndrome, algic phenomena are quite common: headaches, pain in the heart, in the spine.

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

For the purpose of differential diagnostics, it is necessary to distinguish dystonic hypertension from hypertension as an early manifestation of hypertension. The latter is characterized by more stable figures of increased blood pressure, changes in the fundus, and on the ECG. Hypertensive crises, unlike vegetative paroxysms, are shorter (vegetative paroxysms can last from 30 minutes to several hours). Blood pressure most often 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 vegetative) in one patient, one should focus on the criteria identified in the non-paroxysmal period, taking into account the specified signs in dynamics.

Arterial hypotension syndrome

This syndrome (105-90/60-50 mm Hg) is most often found 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 the psychovegetative syndrome in a "chronic", or rather permanent, form, is observed in combination with persistent asthenic disorders.

Patients complain of headaches of various nature, but most often cephalgias of the vascular-migraine type predominate. Pulsating headache in some cases increases and reaches an almost migraine level of intensity (hypotension and migraine are a fairly common situation). An acute decrease in arterial pressure can lead to the occurrence of syncopal states. Patients often have orthostatic manifestations, expressed by dizziness or lipothymic state.

Headache is often combined with dizziness, unsteadiness when walking, pain in the heart area, palpitations, and a feeling of shortness of breath.

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

Arterial pressure lability syndrome

The most characteristic manifestation of vegetative dystonia is precisely the lability of arterial pressure. The transient episodes of its increase or decrease, described above, are essentially various manifestations of the syndrome of arterial pressure lability, which, along with the lability of heart rhythm regulation, constitute 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 mechanisms of neuroendocrine regulation. At the same time, the factors causing fluctuations in arterial pressure can be extremely polymorphic: psychogenic effects, meteorological fluctuations, endocrine dysfunctions, etc.

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

Electrocardiographic abnormality syndrome

A special study of ECG in patients with autonomic disorders revealed the following types of changes in ECG:

1. An increase in the amplitude of the positive T wave is usually recorded in the right chest leads and is combined with an increase in the S- T segment in these same leads.
2. Disorders of rhythm and automatism are expressed in the registration of arrhythmias of various nature, extrasystoles, sinus tachycardia and bradycardia on the ECG.
3. Changes in the ST segment and T wave are most often found in patients with autonomic dysfunction. There is a temporary decrease, fluctuation of the ST segment and inversion of the positive T wave. There is also a pseudocoronary rise of the ST segment above the isoline - a syndrome of early or premature repolarization. Researchers associate the genesis of this syndrome with the imperfection of the neurovegetative control of electrical activation of the heart with a predominance of parasympathetic influences.

Problems of pathogenesis and symptom formation of cardiovascular tonic manifestations

In recent years, cardiovascular dystonic manifestations have served as the subject of targeted research by the domestic school of vegetologists.

In fact, the analysis of cardiovascular disorders was the source of the basic concepts of a broader problem - autonomic dystonia in general. In the monograph by A. M. Vein et al. (1981), which summarized 20 years of research on the problem of autonomic pathology, and in subsequent publications by the team of the Russian Autonomic Center, modern ideas about the pathogenesis of autonomic (including cardiovascular) disorders, the vast majority of which are psychogenic in nature, are described in detail. The multidimensionality of the structure of the pathogenetic mechanisms of the autonomic dystonia syndrome is shown. The use of a functional neurological approach made it possible to identify the basic mechanisms of pathogenesis, which are expressed in the disruption of cerebral activation homeostasis, disruption of the integrative function of non-specific brain systems (disintegration syndrome), and to establish the role of ergotropic and trophotropic systems in the mechanisms of autonomic disorders. The presence of disorders of the circadian organization of autonomic functions and disruption of interhemispheric interactions in patients with autonomic disorders are shown.

In recent years, an important role of respiratory dysfunction - an obligate manifestation of psychovegetative disorders - in some mechanisms of symptom formation in vegetative, including cardiovascular, disorders has been revealed. Taking into account the contribution of respiratory dysfunction, or more precisely, hyperventilation manifestations, to the symptomatogenesis of various clinical phenomena under consideration, the following should be highlighted:

1. change (distortion) of the breathing pattern, consisting of a reduction in the mobility of the diaphragm (inertia, diaphragmatic block), which occurs in 80% of patients with autonomic dysfunction (during X-ray examination). This leads to a violation of the cardiodiaphragmatic ratios;
2. the shutdown of the diaphragmatic portion of breathing leads to compensatory hyperfunction of the intercostal, scalene, pectoral muscles, as well as the muscles of the shoulders, which causes myalgic pain and local hypertonicity - the basis of pain in the chest area, in the region of the heart;
3. hypocapnic (respiratory) alkalosis, according to a number of authors, can affect the myocardial oxygen supply by spasm of the coronary arteries and an increase in the affinity of hemoglobin for oxygen, which is naturally encountered in hypocapnia and alkalosis (the 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 the new approach to the analysis of pathogenesis and symptom formation of cardiovascular disorders are presented by studies of peripheral autonomic insufficiency. At the same time, the analysis of cardiovascular reflexes in patients with autonomic paroxysms allowed to identify indirect signs of autonomic insufficiency mainly of the parasympathetic division, which may indicate its functional nature.

From a practical point of view, first of all, it is important to carefully characterize the chest pain, which will immediately allow the patient to be classified into one of the following categories: with attacks of angina pectoris that are typical in all respects; with pain in the heart that is clearly atypical and uncharacteristic of angina pectoris.

In order to obtain these characteristics, it is necessary to ask the doctor active clarifying questions about all the circumstances of the onset, cessation and all the features of the pain, i.e. the doctor should never be satisfied with only the patient's story. To establish the exact localization of pain, the patient should be asked to point with his finger where it hurts and where the pain radiates. The patient should always be rechecked and asked again whether there is pain in other places and where exactly. It is also important to find out the actual connection between pain and physical activity: whether pain appears during its performance and whether it forces the patient to stop it, or the patient notes the appearance of pain some time after the performance of the load. In the second case, the probability of angina pectoris is significantly reduced. It is also important whether pain always occurs with approximately the same load or the range of the latter varies greatly in different cases. It is important to find out whether we are talking about physical activity that requires certain energy expenditure, or only about a change in body position, arm movements, etc. It is important to identify a certain stereotype of the conditions for the onset and cessation of pain and their clinical characteristics. The absence of this stereotype, changing conditions of the onset and cessation of pain, different localization, irradiation and nature of pain always make one doubt the diagnosis.

Differential diagnosis of chest pain based on interview data

Pain diagnostic parameters	Typical for angina pectoris	Not typical for angina
Character	Squeezing, squeezing	Stabbing, aching, piercing, burning
Localization	Lower third of the sternum, anterior surface of the chest	Top, under the left collarbone, axillary region, only under the shoulder blade, in the left shoulder, in different places
Irradiation	In the left shoulder, arm, IV and V fingers, neck, lower jaw	In the I and II fingers of the left hand, rarely in the neck and jaw
Conditions of appearance	During physical exertion, hypertensive crises, attacks of tachycardia	When turning, bending, moving arms, deep breathing, coughing, eating large meals, in a lying position
Duration	Up to 10-15 min.	Short-term (seconds) or long-term (hours, days) or of varying duration
Patient's behavior during pain	Desire for rest, inability to continue the load	Prolonged restlessness, searching for a comfortable position
Conditions for stopping pain	Stop exercising, rest, take nitroglycerin (for 1-1.5 minutes)	Moving to a sitting or standing position, walking, any other comfortable position, taking analgesics, antacids
Associated symptoms	Difficulty breathing, heart palpitations, interruptions

It is also necessary to clarify the actual effect of nitroglycerin and never be satisfied with the patient's words that it helps. A certain cessation of heart pain within 1-1.5 minutes after taking it has diagnostic value.

Determining the specifics of heart pain requires, of course, time and patience from the doctor, but these efforts will undoubtedly be justified during subsequent observation of the patient, creating a solid diagnostic base.

If the pain is atypical, complete or incomplete, especially in the absence or low severity of risk factors (for example, in middle-aged women), other possible causes of the origin of heart pain should be analyzed.

It should be borne in mind that the most common in clinical practice are 3 types of extracardiac pain that can simulate ischemic heart disease: pain in diseases of the esophagus, spine and neurotic pain. Difficulties in identifying the actual cause of chest pain are associated with the fact that visceral structures (lungs, heart, diaphragm, esophagus) inside the chest have overlapping innervation with the inclusion of the autonomic nervous system. In the pathology of these structures, pain sensations of completely different origins can have a certain similarity in localization and other characteristics. As a rule, it is difficult for a patient to localize pain from internal, deep-seated organs and much easier - from superficial formations (ribs, muscles, spine). These features determine the possibility of differential diagnosis of heart pain based on clinical data.

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