Diagnosis of pain in the heart area

From a practical point of view, first of all, it is important to carefully characterize the pain in the heart area, 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 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 diagnostics of pain in the heart region 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 pain within 1-1.5 minutes after taking it has diagnostic value.

Determining the specifics of pain in the heart area 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 pain in the heart area 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 pain in the heart area based on clinical data.

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