Diagnosis of pain in the region of the heart

From a practical point of view, first of all, the careful characterization of pain in the heart area, which immediately allows the patient to be referred to one of the following categories, is important: with typical attacks of angina 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. 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 pain in the region of the heart according to the data

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 within 1 -1.5 minutes after its administration.

Clarifying the characteristics 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 basis.

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 area 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 according to clinical data.

[1], [2], [3], [4], [5], [6], [7], [8]