Ischaemic heart
disease
Angina is the pain that
comes from the heart muscle when it is not getting enough oxygen. This is
usually due to coronary artery disease. The name is derived from the Greek 'agkone'
which means strangling. The mechanism of pain sensation is uncertain: the
metabolic products of 'oxygen lack' stimulate pain nerve fibres which run
together with nerve fibres supplying body parts from the neck to the upper
chest. The pain is thus usually felt across the middle of the chest (and not on
the left side).
Causes
Angina pain is usually
caused by narrowing of the arteries supplying heart muscle with blood that
carries oxygen to enable the muscle to burn sugar for energy. Narrowing of these
arteries is called coronary artery disease.
Other causes include,
problems with heart valves (the heart has to work harder, so needs more oxygen),
anaemia (the blood can carry less oxygen so the heart muscle needs a higher flow
rate), problems with heart muscle (cardiomyopathy) where there may be excess
heart muscle causing higher demands of oxygen, an overactive thyroid gland
driving the heart faster, and sometimes spasm of the muscle in the coronary
arteries which temporarily narrows them.
The incidence of angina is
is approximately 5 new patients per 1000 people per year in males over the age
of 40 years in the UK.
History
Angina pain is usually
situated across an area of the central chest. It is very unlikely that the
patient will be able to point to the precise area of the pain and the
description may be not of pain, but rather of discomfort. This may spread to the
neck, jaw, the arms (either, but more commonly the left, and usually the inside
of the arms) or the top of the stomach area. It is possible for the pain to
spread to the back. The hallmark of angina is that the discomfort occurs when
the heart is stressed. For example, increasing cardiac work load during
exercise, after emotional upset or after meals. Of these by far the most common
presentation is of exercise induced chest discomfort. Bear in mind that in
Indo-Asian patients the presentation may be atypical (and indeed these patients
are particularly prone to ischaemic heart disease. Heavy, crushing, tight,
band-like or like a clenched fist are descriptions that would be consistent with
angina. It is not uncommon for the discomfort to have been attributed to
indigestion by the patient (and sometimes the doctor!). Angina pain stops when
the patient rests, usually after a few minutes only. The exception may be angina
that was precipitated by emotional upset since the patient may brood or reflect
on the cause of the upset for a considerable period of time. Pain commencing or
persisting at rest may well be a heart attack where the blood supply is
interrupted sufficiently long and severely enough for some heart muscle fibres
to start dying. This is an indication for urgent assessment. The pain of a heart
attack is similar to that of angina but may be more severe and may be
accompanied by other feelings of unwellness such as sweating or anxiety. It will
typically last longer and will not respond to nitrate tablets or spray (e.g. GTN
under the tongue).
Clinical findings
There are no diagnostic
clues for angina per se in the examination although clues pertaining to the
cause may be found. For example, high blood pressure, signs of high cholesterol
such as xanthelasma (chalky deposits of cholesterol in the skin around the
eyes), tobacco stains on fingers (although let’s face it you will already know
that smoking causes heart disease—won’t you?), murmurs of heart valve
disease heard with the stethoscope, and abnormalities in heart rate and rhythm
may provide clues for the doctor. Clearly, if the patient is unwell, has a low
blood pressure and has persistent pain we will be referring up to the hospital
physician to rule out/in either a heart attack or unstable angina.
Investigations
The resting heart tracing (ECG)
is great for diagnosing acute or recent heart attacks but usually not relevant
for angina per se when it may perfectly normal or show some non-specific
changes. That is not to say that useful information cannot be had. If the ECG is
abnormal the information may be highly useful. Is the rhythm normal, is there
evidence that the heart has been under strain or is more muscular than
expected?. If there is doubt regarding the diagnosis of angina then the exercise
ECG will help. Here the patient walks on a treadmill gradually increasing speed
and gradient whilst a continuous ECG monitors the tracing looking for tell tale
signs of lack of oxygen in the heart muscle. A negative treadmill test when the
patient has reached maximum effort and predicted heart rate makes angina
unlikely (although there is always syndrome X—ischaemic heart disease in the
absence of evidence on treadmill testing—a small proportion of these patients
will have a heart attack in the following 2 years). Exercise ECG testing or
exercise radionucleotide scanning using thallium may reveal that the heart
muscle has an inadequate supply of oxygen. The exercise ECG is abnormal in 85%
of patients with angina.
If ischaemic heart disease
is confirmed it would be necessary to check for risk factors including
cholesterol, blood sugar, blood pressure, body mass index for obesity, smoking,
alcohol and lifestyle (e.g. exercise).
Initial
management
Four main classes of anti-anginal
drugs are in common use: nitrates; calcium antagonists; potassium channel
blockers (that tend to work by dilating blood vessels making it easier for the
heart to pump blood around), and beta-blockers that act principally by
slowing heart rate and making the heart work less hard. Low dose, daily aspirin
has been shown to be of benefit and concomitant treatment of high blood pressure
and cholesterol lowering will be necessary. Various drugs may be more suitable
than others for individual patients. Nitrates may cause headaches initially,
verapamil (a calcium antagonist) may cause constipation, other calcium
antagonists (especially nifedipine) may cause ankle swelling and facial
flushing, beta blockers may cause tiredness and impotence and should not be used
in patients with obstructive airways disease (e.g. asthma) or poor circulation
in the legs since they may make it worse.
Angina will usually require
assessment by a cardiologist, principally to identify those patients who will
benefit from dilatation of coronary artery narrowing or who require surgery to
bypass the narrowing in the coronary arteries.
Follow up
management
Heart disease is a killer.
This is dependent on the number of affected vessels, the severity of the
narrowing and the possibility of correcting the problem with surgery or
angioplasty (opening up the narrowing using a tiny balloon temporarily pumped up
inside the blood vessel).
Patients and relatives may
be frightened when they discover that they have ischaemic heart disease and for
the first time may be confronted with thoughts about their mortality. The
presence of heart disease may have significant effects on their ability to
continue with their present employment. Successful rehabilitation will take
these worries and concerns into account.
Musculo-skeletal
pain
Pain coming from the
muscles, ribs or cartilage of the rib cage is common. Musculo-skeletal pain
presents as atypical chest pain that is reproducible by springing the chest,
movement of the chest wall during deep respirations, movement of the limbs or by
direct pressure. The causes are many but consider trauma, injury due to coughing
and Tietze’s syndrome. Tietze's syndrome is an inflammation of the cartilage
that joins the ribs to the breast bone. The patient has pain that is often well
localized just next to the breast bone. The syndrome usually affects the second
rib from the top. The pain is made worse by motion, coughing, or sneezing. There
is localized tenderness. Treatment is with pain relief e.g. ibuprofen or
paracetamol and usuall clears up in a week or so.
Oesophageal pain
Your oesophagus (the gullet)
is the tube that joins the mouth to the stomach. It runs straight down the
middle of the chest behind the heart. Reflux oesophagitis is common condition,
occurring at any age, caused by acid splashing up into the oesophagus from the
stomach. Reflux oesophagitis causes a burning sensation behind the breast bone,
often described as heartburn although it can be difficult to distinguish from
heart pain particularly if it spreads to neck, shoulders or arms. If the
oesophagus becomes very inflamed there may be difficulty with swallowing and
long term reflux may lead to narrowing of the gullet. Bending, stooping, heavy
lifting and tight clothes all force acid up into the oesophagus and cause
heartburn. With reflux oesophagitis the relation to lying flat or bending, with
relief on belching or swallowing antacid, helps to differentiate it from heart
pain.
X-ray examination or a look
into the oesophagus with a flexible fibreoptic scope may help to determine the
cause, although it is often possible to pin this down on the story alone and the
good response to acid suppression using drugs. Simple antacid preparations can
be bought from the pharmacist without prescription, more potent acid suppressive
drugs (such as the proton-pump inhibitors) require a prescription from your
doctor. Patients with reflux oesophagitis can make a big difference to their
symptoms by maintaining an ideal weight, avoiding alcohol, stopping smoking and
avoiding large meals, particularly last thing in the evening. Since reflux
symptoms often come and go over a prolonged period of time, it is well worth
investing in these lifestyle changes.
Pain coming from
the lungs
Many problems affecting the
lungs can cause pain when the lining of the lung becomes inflamed. The pain is
often worse on breathing and coughing and may be accompanied by shortness of
breath as well as other symptoms.
Pneumonia
Infection of the lung tissue
(pneumonia) can cause chest pain. This pain is often located on one side of the
chest and is usually worse with breathing and coughing. There will often be a
fever, there may be a productive cough where the sputum is yellow, green or
blood stained and the patient may be short of breath and confused. The doctor
will often be able to detect the presence of infection in the lung during the
examination. Treatment is with appropriate antibiotics and if warranted
admission to hospital for further support and oxygen.
Pulmonary
embolism (clot on the lung)
A pulmonary embolus occurs
when a clot from a vein, originating in the calf muscles or especially the thigh
or the pelvis, detaches and becomes lodged in the arteries in the lung. The pain
may start suddenly with an associated episode of collapse. There may be angina
pain as well if the clot is large. There is often shortness of breath, the lips
and tongue may be blue and there may be a mild fever. The pain will continue as
pleurisy which is a sharp knife like pain worse on deep breathing. Blood may be
coughed up. A pulmonary embolus can be very serious or fatal. More often it is
successfully treated and then thought must be paid to why it occurred.
Risk factors for clots
include immobility (e.g. during and after surgery, or after a prolonged journey
on a plane or coach) and conditions that make the blood more likely to clot
(e.g. taking the combined contraceptive pill which contains oestrogens).
Patients with cancer are more likely to suffer from clots.
If your doctor thinks this
is a possibility you will be investigated in hospital. It is possible to look
for clots in a variety of ways including radioactive scanning, x-ray scanning of
the chest and by injecting dye that shows up on x-rays. The treatment of clots
will include identifying the cause and thinning the blood with drugs like
warfarin. The duration of treatment will depend on the precipitating cause.
Pneumothorax
(punctured lung)
Rarely, the lining of the
lung in the chest can rupture causing a small leak of air around the lung. This
causes the lung to collapse, making breathing more difficult and may be
accompanied by pain. Young, tall men seem to the most vulnerable in the absence
of other risk factors. Smoking
causes an increased risk of a spontaneous pneumothorax: nine fold increase
in females, 22 fold increase in males. Patients with asthma and emphysema are at
higher risk and the condition may follow trauma to the ribs.
Possible features include a
sudden onset of sharp knife like pain made worse by breathing and accompanied by
sweating and a fast pulse. The patient may look pale. Shortness of breath is a
common but not inevitable feature. Your doctor may be able to detect a possible
pneumothorax on examination, although a chest x-ray would usually be taken to
confirm the diagnosis.
Treatment options include
watchful waiting if the degree of lung collapse is small or insertion of a tube
to drain the air from around the lung to allow it to re-expand.
Pleurisy
This is inflammation of the
lining of the lung. Features are principally chest pain, which is localised,
sharp, and made worse by coughing or deep inspiration. Causes include viral
infection, pneumonia, pulmonary embolus, cancer affecting the lung or its lining
and tuberculosis. The pain may be treated with anti-inflammatory medication
(e.g. ibuprofen), although the cause needs to be determined.
Nerve pain
affecting the chest
Shingles
Shingles is an infection
caused by chicken pox virus reactivation. After the original chicken pox
infection (usually in childhood) the virus hides in the nervous system.
Occasionally (and unpredictably) the infection can reactivate itself. It usually
affects a stripe of skin on one side of the body that is supplied by one nerve.
There is a rash characterised by crops of small, initially clear, blisters on an
inflamed red base. These crust over and settle over a 1-2 week period. The pain
may be described as burning in quality. The pain may precede the rash by a week
but the rash is diagnostic and your doctor should have no difficulty identifying
shingles once the rash is out. Shingles will usually settle without treatment
but vulnerable patients may be offered anti-viral drugs like aciclovir to settle
the rash quickly. Unfortunately, some patients can go on to experience a very
unpleasant burning pain in the area of skin that was affected by shingles. This
can go on for months and sometimes years and occurs more commonly the older the
patient is. It is very difficult to treat but your doctor may suggest a low dose
of an anti-depressant drug called amitriptyline which is sometimes very helpful
for treating nerve type pain. Amitriptyline can make people dopey and tired and
tends to cause a dry mouth and eyes and constipation.
Pain from the
spine
The sensation of the muscles
of the chest wall and the overlying skin is supplied by nerves that come off the
spine at the level of each rib. Pain affecting these nerves will often be felt
spreading around the chest in a stripe from the back towards the front of the
breast bone. Depending on the cause there may also be pain affecting the spine
itself or tenderness where the rib and spine join. Causes include dislocation of
the rib from the spine, fracture of the spine (for example, patients with
osteoporosis), infection or cancer. The former two tend to have a sudden onset
and settle with time (often weeks) whilst the latter tend to start insidiously
and get progressively worse. There may be associated feature, for example, fever
in the presence of infection or symptoms such as general ill health and weight
loss in the case of undiagnosed cancer.
Cardiac neurosis
Some patients develop pain
that they believe is heart pain in the absence of heart disease. It is usually
very worrying. The pain is often situated around or under the left breast (where
the heart lies, but not where the body actually feels heart pain) and may be
associated with a tender spot. Unlike true heart pain this tends to be of long
duration and not eased by rest. Associated symptoms such as difficulty
breathing, palpitations, headaches and fatigue may suggest associated
hyperventilation. If your doctor is sure that your pain is not from the heart,
then he will provide an explanation and reassurance. Further tests are often
unnecessary and can lead to further worry and stress in this situation.
Bornholm
disease— epidemic myalgia
Bornholm disease is due to
infection with Coxsackie B virus. It is an uncommon condition that is
characterised by a severe immobilising, pleuritic chest pain and sometimes
abdominal pain. There may be variable symptoms of fever and sometimes sore
throat. The condition will persist for several days before spontaneous
resolution. Diagnosis of the condition may made by isolation of the virus from
the throat or stool. The diagnosis may be made retrospectively by blood tests.
Aortic dissection
About 500 people in the UK
are affected annually by a tear in the main blood vessel running out of the
heart - the aorta. Aortic dissection presents with the sudden onset of a
'tearing' pain of extreme severity. The site of the pain depends on that of the
dissection and will alter as the dissection progresses. Often, the pain starts
in the anterior or posterior chest or in the abdomen, and nearly always involves
the upper back. The neck, arms, trunk or legs may also be involved. The patient
often appears shocked - pale, sweaty, and a racing pulse. Alternatively,
presentation may be with acute abdominal pain, a stroke affecting one whole side
of the body with paralysis, or a heart attack (due to involvement of the
coronary arteries reducing the blood supply to the heart. In this situation you
will be admitted to hospital as an emergency for further investigation and
emergency treatment. This condition carries a high mortality depending on
whether surgical repair can be achieved.
Pericarditis
(inflammation of the lining of the heart)
Pericarditis is inflammation
of the lining layer of the heart. We do not see this very often. The most common
cause is viral e.g. Coxsackxie virus. Other causes include heart attack,
pneumonia next to the heart, Dressler's syndrome (inflammation of the lining of
the heart occurring about 3 weeks after a heart attack), kidney failure,
tuberculosis, an underactive thyroid, trauma, connective tissue disorders e.g.
Systemic Lupus Erythematous, Rheumatoid Arthritis, Polyarteritis Nodosa, breast
or lung cancer invading the lining of the heart, and radiotherapy.
Possible symptoms include
chest pain that is sharp, localized, relieved by leaning forward, and. Sometimes
pain may spread to left shoulder, or down the arm or into the abdomen.
Your doctor may be able to
detect pericarditis when he listens to the heart with the stethoscope. An ECG
will show characteristic changes and if there is concern you will be
referred to the hospital for further investigation.
