Heartache

Among the pains in the heart, the greatest practical importance is the pain in IHD. In order to understand the mechanism of pain sensations, the peculiarities of their localization and irradiation, it is necessary to briefly discuss the anatomical and physiological features of the blood supply and innervation of the heart.

As you know, the blood supply to the heart is carried out at the expense of the right and left coronary arteries. The right one, starting from the aorta, goes further posteriorly through the coronary sulcus and, after reaching the posterior longitudinal sulcus, descends downward. The left coronary artery also starts from the aorta, divides into two branches - the descending and envelope. The first goes to the anterior longitudinal groove, the second lies under the left ear, and then passes to the posterior surface of the heart. The main trunks of both branches pass superficially and only branches of the second order penetrate into the depth of the myocardium, the latter extending perpendicularly from the surface. The right coronary artery supplies most of the right heart, the posterior part of the septum, part of the posterior wall of the left ventricle, and the medial papillary muscle. The left coronary artery supplies the rest of the left ventricle, the anterior part of the septum and a small portion of the anterior surface of the right ventricle along the septum.

The innervation of the heart is carried out with the help of 6 plexuses - two anterior, two posterior, one for the anterior surface of the atria and a plexus of the sinus Galler. All this complex network consists of branches that extend to the heart from the upper, rarely - middle and lower cervical nodes of the border sympathetic trunk. In addition, the heart receives the nerve fibers of five to six thoracic nodes of the vertebral nerve. Irradiation of pain in the back, chest, left arm is due to the conduct of sensitive impulses through the stellate node to the spinal nerves of the cervical (CVI) and thoracic (ThI-ThIV) segments. Irradiation of pain in the shoulder, the side surface of the neck and the external surface of the hands is carried out along sensitive fibers passing through the star node, then along the neck sympathetic trunk, the vertebral nerve and along the connecting branches of the spinal nerves of segments CV-CVIII to the corresponding cervical nerves. When the pain radiates to the lower jaw, there is a superficial pain corresponding to the innervation zone of the III spinal nerve, and a deeper pain in the teeth along the course of the mandibular nerve.

Thus, the features of innervation of the heart - the wealth of sympathetic fibers, the wide level of segmental innervation (from CVI to TIV) - cause a number of clinical features of "cardiac" pains, which allow them to differentiate from pains of a different origin, but create the prerequisites for errors.

The patient's complaints of chest pain, "heart area", "heart" in a modern doctor, are primarily associated with the possibility of IHD, although in reality non-cardiac causes of these pains, especially in individuals younger than 40-45 years old, are much more common. Equally undesirable is both hypo- and overdiagnosis of IHD. The latter can lead to unnecessary and wrong treatment, endless intake of various antianginal drugs; frequent hospitalizations, mental traumatization, disability and, as a result, deterioration of the patient's quality of life. One of the reasons for overdiagnosis of IHD is the inadequate use of the usual diagnostic capabilities available to each doctor. The main significance in the diagnosis of IHD still belongs to clarifying the characteristics of chest pain, identifying and assessing the risk factors of this disease and ECG at rest and under physical exertion. The data of the physical examination of the patient are important mainly for the exclusion of another pathology, because even with severe and undeniable angina, uncomplicated myocardial infarction, the size of the heart, the auscultation data can be normal. The diagnostic value of the combination of typical angina pains and risk factors is very high - no lower than using veloergometry, coronary angiography or myocardial scintigraphy. However, often the characteristic of pain in the heart is not enough certain, and the presence of risk factors in itself does not always lead to coronary artery disease. The ECG at rest is often unchanged or not specific enough, and the results of exercise tests can be falsely positive or false-negative for various reasons. Coronary angiography also does not always solve the diagnostic problem, since typical angina can be with unchanged coronary arteries and absent in the presence of severe stenosis.

[1]

Causes of the heart hurts

Causes of pain in the heart

There are 2 types of pain in the heart, caused by heart disease:

• anginal pain associated with myocardial ischemia resulting from coronary artery insufficiency;
• non-angiogenic pain, or cardialgia, which are based on other mechanisms than those that cause myocardial ischemia.

[2], [3], [4], [5], [6], [7], [8], [9]

Diagnostics of the heart hurts

Diagnosis of pain in the heart

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 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.

[10], [11], [12], [13], [14], [15], [16], [17]