There are multiple causes of chest pain, like muscular aches and pains, pain related to pneumonia, chest injury etc. All have their own pathognomonic signs and symptoms
With today’s information explosion, people have become mortally afraid of an impending heart attack because of over-hyped risk factors and unnecessary advice. Doctors have added to this mess too and, in this situation, it is probably difficult for patients to remain calm and not get worried about a heart attack. As a result, cardiac neurosis is on the rise.
Although cardiac neurosis was a rare disease when I was a student in the 1950s, today, I see one or two such patients almost daily. It is much easier to treat real myocardial ischaemic pain than imaginary ‘heart pain’ in the chest. Years ago, a Canadian study had shown that in the period that a doctor sees one heart attack, he or she will have seen more than 36,000 minor illness syndromes.
In my experience, the best diagnosis of a cardiac origin for chest pain depends on good history taking and bedside evaluation, even with all the scanners, echoes and angiograms.
Coronary angiograms are not the gold standard for the diagnosis of coronary artery disease as majority of healthy adults and even some children have multiple blocks in the coronary vessels that get compensated by innumerable collaterals stimulated by the slow atherosclerotic intraluminal blocks, which pre-condition the myocardium for any sudden future blockage of the coronaries by a blood clot.
A doctor’s responsibility towards making an accurate diagnosis of coronary artery disease becomes much more important in view of the cardiac neurotics ending up on the catheter laboratory table for angiograms. Some of these unfortunate victims might even end up with surgical coronary bypass grafts!
The chest pain due to coronary artery disease does not follow a typical pattern, although there are some telltale signs of it in the nature of the pain. Usually, significant coronary artery disease produces chest pain because of the momentary defects in the contraction of the muscle wall, called wall motion abnormality.
Heart muscle, as such, has no pain fibres that can give rise to pain. But the pericardium, the outer cover of the heart, is flooded with pain fibres, especially at its apex. When there is significant loss of blood supply to a portion of the heart muscle, there is a corresponding wall motion abnormality which produces shear-stress on the pericardial sac, resulting in pain. This pain can manifest anywhere between the neck and the abdomen and can range from a minor niggle to a severe unbearable pain, at times, spreading to the left shoulder, left hand, the throat and even the lower jaw.
However, the pain, in all these locations, is usually secondary to the central chest pain. The sine-qua-non of ischaemic chest pain is the accompanying feeling of tightness in the chest, leading, in severe cases, to shortness of breath. An intelligent doctor who develops the capacity to listen to his/her patients can make an accurate diagnosis in his office or on the bedside. The usual neurotic, with non-cardiac chest pain, could be diagnosed with history alone. Many a time, the pain lasts all day, which is very unlikely in cardiac pain, as any angina pain lasting more than half an hour results in a heart attack.
From the patient’s point of view, the best doctor to consult in case of chest pain is the family physician who knows the patient’s background to make an accurate diagnosis.
The specialist seeing the patient for the first time might over-diagnose cardiac pain and take up the patient for further investigation right away, not to speak of the usual disease-mongering effort in these times of hi-tech competitive medical practice. Such doctors justify their actions by saying, they did not want to miss any coronary artery disease; this is called defensive medicine in the USA.
Some intelligent neurotics might even complain of shortness of breath with their chest pain. This might mislead an anxious doctor, afraid of missing a heart attack. If one carefully analyses the shortness of breath, one quickly realises that they are just ‘sighs’ and not true breathlessness. The telltale sign of coronary-related shortness of breath is the inability of the patient to hold his breath.
There are multiple causes of chest pain, like muscular aches and pains, pain related to pneumonia, chest injury etc. All have their own pathognomonic signs and symptoms. In conclusion, doctors must be acutely aware of cardiac neurosis as a significant cause of chest pain.
Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.
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regards