Orion Diagnostic & Chiropractic Center - Dr. Khaled Khorshid
Chicago Ridge Medical Center
9830 Ridgeland Ave. Suite 5 - Chicago Ridge, IL 60415
Tel: (708) 288-2239

Two Cases of Chest Pain

Commentators (in alphabetical order): Khaled Khorshid, M.B.B.Ch., M.S., D.C., Rand Swenson, D.C., M.D., Ph.D., and Harry Wallner, M.D. (JNMS: Journal of the Neuromusculoskeletal System 8:98-103, 2000)

 

GRAND ROUNDS PRESENTATION

Case 1


            A 65-year-old male, prior to presenting at the office, had an episode of substernal chest pain that awakened him from sleep at approximately 5:15 a.m. It lasted 2-3 hours and was not accompanied by shortness of breath, nausea, sweating, or radiation of the pain. After it disappeared, he had no further symptoms and continued with his usual routine. He stated that he had seen someone approximately 1 year ago in a chiropractic clinic for similar complaints. At that time, he had a “rib adjusted”; however, he continued to have this discomfort. On further questioning, he felt that the discomfort generally occurs in the evening when walking his god and lasts 10 minutes. He was a difficult historian, but, on further coaxing from his wife, the discomfort seemed to be exertional in nature.

His past medical history is negative for heart disease, previous myocardial infarction, rheumatic fever, scarlet fever, tuberculosis, lung disease, hypertension, kidney disease, cancer, or diabetes mellitus. He does have a history of hyperlipidemia.

Past surgical history included left knee surgery 25 years ago. He also had a motor cycle accident and injured his right elbow requiring a skin graft. In addition, he had a fracture of the fourth metacarpal of his right hand.

Medications on initial assessment included several herbs and vitamins, including vitamin E and vitamin C, chromium, and selenium. He had no known allergies to medications.

He is married and has five children and works in an office. He has not had anything alcoholic to drink for 30 years. He smokes two cigars per day and drinks one pot of coffee per day or approximately 40 ounces. He has never used street drugs.

His family history is negative for heart disease. His father died from a stroke at the age of 78. Cancer was the cause of his mother’s decease at the age of 97.

Review of systems was essentially unremarkable except for some mild urinary hesitancy and frequency. He has also had complaints of “cervical stiffness.”

A physical examination revealed the patient’s weight to be 180 lbs and height 5 feet nine inches. Blood pressure was 120/68 mm Hg. Pulse was 72 beats per minute and regular. Pupils were equal and reactive to light. There were no xanthelasmas noted on his eyelids. The oral mucosa was moist and without cyanosis. The jugular venous pressure was not elevated. Carotid pulses were normal and without bruit. No thyroid enlargement was palpable. The lungs were clear to auscultation.

PMI was in the fifth intercostals space, midclavicular line. S1 and S2 were normal. There was no S3; however, S4 was present. No murmur was audible. The abdomen was soft and without organomegaly. No masses were present and bowel sounds were normal. The aorta was not palpable. No clubbing, cyanosis, or pedal edema was present. Peripheral pulses were all good and equal. Neurologically, no deficits were noted.

The EKG showed a normal sinus rhythm and left atrial enlargement (Fig. 1A). No significant ST-T wave changes were observed.

Laboratory data was significant with triglycerides at 423 mg/dL and total cholesterol at 289 mg/dL. The initial impression was suggestive of angina pectoris. In addition, laboratory data confirmed hyperlipidemia. Subsequently, the patient was started on one Aspirin-EC daily as well as nitroglycerin-SL 0.4 mg as needed.

The patient was then scheduled for a sestamibi stress test the following week and it revealed markedly abnormal EKG changes (Fig. 1B) as well as the development of chest discomfort, both of which resolved at cessation of exercise. This is consistent with ischemia. The sestamibi portion of the study was reported separately and stated no gross abnormalities of SPECT myocardial perfusion scan. The ejection fraction of the left ventricle was calculated at 54%.

The patient was advised to undergo coronary angiography at this time because of strong clinical suspicion of coronary artery disease, suggesting the possibility of a false-negative sestamibi stress test; however, he was reluctant and sought a second opinion. The second opinion concurred and strongly advised him to undergo coronary angiography, which discovered severe three-vessel coronary artery stenosis requiring coronary artery bypass surgery.

 

Case 2

            A 51-year-old male presented to the emergency room with complaints of chest pain radiating across the substernal area. It began earlier the morning of admission while the patient was shoveling dirt. It lasted approximately 1 hour, with some shortness of breath, but without sweating or nausea. The patient stated that he had had similar episodes in the past.

Several years ago, he was diagnosed with coronary artery disease and underwent angioplasty and stenting of the right coronary artery. Six months ago, while at a party, he had developed a sudden feeling that was difficult to describe and subsequently was brought to the emergency room. At that time, he underwent a coronary angiography and was found to have significant stenosis of the left anterior descending artery as well as the diagonal artery. Both vessels required angioplasty and stenting.

His past medical history, in addition to coronary artery disease as described above, includes peptic ulcer disease as well as gastroesophageal reflux. He is also being treated for hyperlipidemia. A review of systems was, otherwise, unremarkable.

The patient is married and stopped smoking 15 years ago. He drinks alcohol occasionally. His medications on presentation included enteric-coated aspirin, Lipitor, imipramine, and alprazolam.

The patient is a well nourished male who appears to be his stated age and does not appear to be in any acute distress. His blood pressure was 120/78 mm Hg, and his pulse was 66 beats per minutes and regular. No jugular venous pressure elevation was observed. The carotid pulses were normal in upstroke and without evidence of bruit. His skin appeared normal, but was daiaphoretic. His lungs were clear and without evidence of wheezing or rales. Examination of the heart was as well as the remainder of the physical exam was unremarkable. The electrocardiogram was within normal limits. The laboratory data were as follows: WBC count is 5.9; hemoglobin, 14.1; and hematocrit, 40.2. CK-MB is 1.0; myoglobin, 59.8; and troponin I, less than 0.5. The second set of cardiac enzymes remained within normal limits.

A stress test performed 4 months earlier was reviewed and found to be negative for ischemia. The impression was that of unstable angina. The patient was begun on intravenous nitroglycerin and Lovenox therapy in the emergency room. He was then transferred to the cardiac catheterization laboratory for emergency coronary angiography. The findings demonstrated overall normal contractility of the left ventricle. The right coronary artery contained luminal irregularities of 20-30%. The previously placed stent appeared to be open. The left coronary system also contained irregularities, of 30-40%. These abnormalities were not considered significant enough to require further interventional therapy, and medical management was suggested. The following day, a stress test in conjunction with a Cardiolite scan of the heart was performed. This did not show any ischemia.

Following the stress test the patient related that on the previous day he had performed a particularly physical strenuous job. In retrospect, he stated that the chest discomfort correlated to tenderness in the same areas, suggesting a musculoskeletal source of pain.

 

GRAND ROUNDS DISCUSSION #1

            In the first case, the patient had severe retrosternal pain, which lasts for many hours. This presentation can be alarming and may indicate severe life-threatening conditions which require rapid but careful evaluation. If the patient has severe chest pain on presenting to a chiropractic office, medical emergency services should be called immediately. Patient evaluation, examination, and adjustment can be completed while waiting for the ambulance. If the patient gives a history of occurrence or recurrence of chest pain, but currently does not present with such pain, he should be referred to his medical doctor or to the emergency room for rapid careful evaluation. If the patient is already under a cardiologist’s care, he should contact his cardiologist immediately with any change of condition (e.g., increased frequency or severity of chest pain attacks, resistance of pain to sublingual nitroglycerin, irregular pulse, low or high blood pressure, developing a heart murmur, etc). If the patient reports that he has had a complete investigation for his chest pain in a medical center that proved no visceral disorder, records should be requested. Management in that case would most probably include treatment of the musculoskeletal system.

Many patients have more than one type of chest pain simultaneously, producing a presentation that is puzzling and atypical. Causes of episodic chest pain are many. They include but are not limited to the items in Table 1 (1).

TABLE 1. Causes of Episodic Chest Pain


Type

Causes

Chest wall

Costochondritis, rib disease, Tietze’s syndrome, xiphoidagia, myodnia, fibrositis, breast disorders, Mondor’s disease, Herpes zoster, pectoral muscle syndromes, thoracic outlet syndromes, sternoclavicular disease, cervical and thoracic vertebral subluxation complex, rib subluxation, sternocostal, sternoclavicular, and shoulder joint subluxation  

Gastrointestinal

Esophagitis, esophageal spasm, peptic ulcer disease, cholecystitis/biliary colic, pancreattis, colonic flexure syndrome

Psychogenic

Hyperventilation, anxiety, hypochondriasis, depression, malingering, cardiac neurosis, panic disorder, somatoform, disorders, fixed delusions

Angina pectoris

Typical and atypical angina, stable and unstable angina (2).

Other cardiopulmonary diseases

Mitral valve prolapsed, pulmonary embolism, pleuritis, bronchitis, asthma, chronic obstructive pulmonary disease, pericarditis, pneumonia, pneumothorax, dissecting aortic aneurysm

            Proper history taking is crucial to differentiate these causes. Such factors as pain location, radiation, and character as well as what makes it better or worse will help in the diagnosis. Other important factors are whether the pain is related to exertion, breathing, meals, cold air inspiration, etc. History and management of previous attacks of chest pain are also important. Medications, hospitalization or injuries should also be covered.

Angina pectoris is characterized by retrosternal pain or pain across the anterior portion of the upper chest. It is described as an aching, heavy, tight, or squeezing chest pain. It lasts from one to several minutes. It is relieved by rest or administration of nitroglycerin tablets sublingually. It can be precipitated by exercise, heavy meals, cold air, or an emotional upset. Unstable angina may occur at rest or during less vigorous exertion. It may last from 15-30 minutes and may resist relief by medication.

Chest pain in myocardial infarction may be retrosternal, central, or left sided. It may radiate to the left shoulder, arm, or neck, lasting for 30 minutes or larger. The patient may describe it as heavy, viselike pressure on the chest, which is sometimes accompanied by shortness of breath, weakness, and diaphoresis. Infarction in the inferior wall of the ventricles may manifest in nausea and vomiting (1).

Physicians need to rule out life-threatening conditions before thinking about the less serious causes of chest pain. Chiropractors should be alert for atypical presentations of visceral disorders. The patient may have a mixed cause of chest pain as we have mentioned earlier. We must not overlook serious possibilities just because we found one cause of our patient’s chest pain.

Because the majority of chest pain cases are due to musculoskeletal causes chiropractors have a significant role in management of this major health problem. Vertebral subluxation complex as well as subluxations of the costochondral, sternocostal, shoulder, and rib articulations are the major areas of chiropractic diagnosis in chest pain. Adjustment of these problems usually does not require frequent sessions. It is very often one or a small numb er of adjustments that are needed.  

In our experience, patients with rib subluxations often have very confusing presentations that simulate angina pectoris. This confusing picture may occur if the involved ribs are the left second and third ones. Many patients with this presentation have been investigated repeatedly by medical centers with negative results, suggesting that visceral disorders are not involved. Patients usually are not referred to chiropractors and continue suffering pain along with the fear of having an undiagnosed heart problem. Chiropractors often see these patients accidentally while taking care of other spinal problems.

Rib subluxation may present with chest pain, upper back pain, or midback pain. The pain may be dull aching, sharp, or tearing. It is usually localized to the involved ribs or associated with vertebral discomfort. Occasionally, tender swollen costosternal joints are present. Decreased range of motion of this joint may be detected in inspiratory, expiratory, or both phases of respiration. Rib elevation may be noticed with accompanying pain. Many chiropractic adjustment techniques can be used to manage this condition with good results.

Statistically, heart disease is the health problem with the highest mortality in the western hemisphere. Because of this, patients with chest pain live with anxiety and fear of sudden death due to heart attacks. Anxiety may decrease after medical evaluation rules out heart disease, but the continuation of chest pain may prolong this anxiety. Patients may think they have heart disease that is not diagnosed yet. Many of these patients seek multiple medical centers for re-evaluation of their chest pain.

High-cost hospital investigators, high number of work days lost, and high numbers of patients suffering mandate that chiropractors be included in the management of chest pain. To document this need, data must be collected to substantiate the number of chiropractic cases presenting with chest pain.


REFERENCES

  1. Reilly BM. Practical Strategies in Outpatient Medicine. Philadelphia: W.B. Saunders, 1991:440-524.
  2. Forbes CD, Jackson WF. Color Atlas and Text of Clinical Medicine. Baltimore: Mosby, 1997:129-131.

Khaled Khorshid, M.B.B.Ch., M.S., D.C.
Kentuckiana Children’s Center
Lousiville, Kentucky

 

GRAND ROUNDS DISCUSSION #2

            These two cases represent an interesting and important contrast, both falling under the general rubric of chest pain. While many cases of chest pain are due to musculoskeletal problems or to less serious visceral pathology (reflux disease or hiatal hernia), more serious pathology, particularly disorders affecting the heart, lungs, pleura, aorta, or esophagus, is unfortunately common. It is critical to have an approach to the evaluation of patients and to have a generally low threshold for referral for workup.

It is important to take a systematic approach to these patients and to consider the various serious causes before entertaining a diagnosis of musculoskeletal pain. This systematic evaluation begins with risk factors and family history, factors that all too often get overlooked in the evaluation of presumed orthopedic disease. Patients with a history of hypertension, diabetes, high cholesterol, smoking, or early cardiac disease in their families should be treated with suspicion. Unfortunately, when treating an elderly population, there are a distressing number of patients who have one or more of these risk factors.

The history of the chest pain is clearly important. Onset with exertion or with exposure to cold, with subsequent resolution at rest, suggests angina. This pain typically builds relatively slowly and is often described as a “deep ache” or “pressure,” Radiation of pain may be to the arm (usually, but not always, the left), the neck, throat, or jaw. Occasionally, it can produce a sense of “indigestion.” Association with a cough suggests pulmonary pathology.  Respirophasic chest pain can be due to irritation of the pleura or the chest wall, and can provide a difficult diagnostic challenge, especially if unassociated with other pulmonary symptoms. A ripping or tearing pain that extends through the chest can be seen in dissecting aneurysms of the aorta. These are constant pains that usually build to a very severe level.

Relieving or exacerbating factors may be most helpful. With musculoskeletal chest pain there are typically activities or movements that clearly provoke pain and positions or movements that improve it. Respiration can provoke pleural or chest wall pain, and it is important to keep in mind the possibility of pleural involvement in any respirophasic chest pain. However, the pain of pleurisy is usually broader than musculoskeletal pain, cannot be reproduced by pressure on chest structures, and has a much closer relationship to respiration than does chest wall pain. Pain that persists even at rest, and for which there are no positions of relief, must be treated with suspicion. A history of anginal pain increases the likelihood that the current pain arises from the heart. The relationship of pain to eating or particular types of food increases the possibility that the pain may be due to gastrointestinal problems such as reflux.

Associated symptoms are also important. Rarely does chest wall pain result in diaphoresis, pallor, or shortness of breath. Additionally, fever or constitutional symptoms, such as weight loss or asthenia, may mandate medical workup.

Paradoxically, physical examination is rarely helpful in ruling out cardiac disease as a cause of chest pain. Usually, by the time there are physical signs of cardiac disease (such as signs of heart failure or significant murmurs) the condition is quite advanced. Pulmonary disease may reflect in abnormal breath sounds or a pleural rub, but there are typically enough pulmonary symptoms to indicate at least a chest X-ray. A normal chest X-ray is usually sufficient to identify most causes of chest pain arising from the lungs.

The importance of physical examination is primarily in identifying movements or positions that precisely reproduce the patient’s primary compliant. This could take the form of identifying muscular trigger points, rib cage problems, or vertebral problems that produce the exact symptoms that the patient is describing. This affords a fair degree of comfort in treating patients with chest pain since organic causes of chest pain should not be reproducible by such maneuvers.

There are many methods of identification of patients with cardiogenic chest pain. EKG is a simple and quick procedure that can be very helpful in a relatively low-risk situation in which the patient is having ongoing chest pain at the time of the EKG. However, EKG can miss ischemia in some portions of the heart and is not particularly sensitive if the patient is in between episodes of chest pain. There are two more sensitive methods of detection of ischemia. These include direct observation (such as with angiography) or provocation of ischemia with a stress test. Perfusion imaging (with radionuclides) can be added to the stress test in order to get a better feel for the precise blood vessels that are involved. The angiographic methods have the advantage, in high probability cases, of being able to permit angioplasty to treat stenosis of the coronary circulation. As time goes by, more noninvasive methods may be established in order to make cardiac evaluation simpler and more cost-effective.

Some causes of chest pain can be difficult to diagnose under the best of circumstances. These include pericarditis and dissecting aneurysm of the thoracic aorta. Both of these can be very serious (especially the dissecting aneurysm), but they should not produce symptoms that are readily reproduced by mechanical tests of chest wall function. Therefore, the precise reproduction of the chest pain becomes a prime consideration in the evaluation of these patients.

In summary, chest pain must be treated with a high degree of caution. Patients with significant risk factors for cardiac disease or who have physical signs and symptoms suggestive of underlying pulmonary disorders should be carefully evaluated and treated with care. Attention must be directed to the factors that relieve and exacerbate the pain, since patients who do not have a clear mechanical origin for their pain are likely to require additional test prior to assuming that their symptoms are of musculoskeletal chest wall or thoracic spinal origin. Of course, when managing such patients, if they do not respond well to your treatments, timely re-evaluation can be a key to proper diagnosis and to good clinical outcome.

Rand S. Swenson, D.C., M.D., Ph.D.
Dartmouth Medical School
Hanover, New Hampshire

 

 

GRAND ROUNDS DISCUSSION #3


            Both cases revolve around the compliant of chest pain, a common symptom presentation to the office as well as to the hospital, and generally via the Emergency Department (ED). Even though the cause of the chest pain differs, each case presents similar challenges of assessment and evaluation.  

Chest pain as a symptom is commonly found in many disease entities involving several different organ systems. Although cardiovascular disease, and more specially, coronary artery disease (CAD) comes to mind when we think of chest pain, many other structures outside of the heart must also be considered. These would include but are not limited to: the aorta, pulmonary artery, mediastinum, esophagus, diaphragm, neck, chest wall, costochondral junctions, breast, spinal chord, stomach, duodenum, gallbladder, pancreas, as well as the skin. Angina pectoris, myocardial infarction, pericarditis, myocarditis, mitral valve prolapse, and aortal stenosis are al different cardiovascular diseases that may present with chest pain (1).

In the assessment of a patient with chest pain, generally a cardiac origin is first explored because of the great number of patients with coronary artery disease and potential dire consequence resulting from CAD. The leading cause of mortality in the United States is cardiovascular disease with approximately 1 million deaths per year. There are approximately 1.5 million patients with acute myocardial infarction per year with about 500,000 associated deaths (2). Therefore, both accuracy and speed become essential components to affect a good outcome.

Case 1 is of a 65-year-old male who presents to an office with an episode of substernal pain lasting 2-3 hours. It resolved on its own, allowing the patient to continue with his usual routine. Prior episodes started 1 year earlier and were generally precipitated by exertion. The history in part was also obtained from his wife. Family is often a good source of information, particularly if the patient is reluctant to provide an adequate history, as was indicated in this case. Risk factors included hyperlipidemia. The pain 1 year ago resulted in a chiropractic assessment and subsequent “rib adjustment”; however, his symptoms continued. A physical examination revealed a normal blood pressure. The remainder was unremarkable with the exception of a fourth heart sound that could correlate with coronary ischemia. An EKG was also normal; however, this test has a low sensitivity, particularly when the patient is pain free, for diagnosing ischemia.  

Exercise testing risk stratification was ordered because symptoms fulfilled criteria for typical angina pectoris. This was done in conjunction with single-photon emission computed tomography (SPECT) perfusion imaging with technetium-99m sestamibi in order to increase specificity and sensitivity. In the absence of EKG changes of pre-excitation syndrome, >1 mm rest ST depression, complete left bundle-branch block, or electronically paced ventricular rhythm, a stress test without imaging might have been adequate (3).

The stress test was carried out and was abnormal due to the development of chest pain and markedly abnormal EKG readings. If these changes occurred during the first 3 minutes of testing, left main (LM) or three-vessel CAD would be suggested. No abnormalities were noted on SPECT myocardial perfusion scan. This lack of correlation is frequently seen in three-vessel CAD because of the diffuse nature of the disease. Dual isotope perfusion SPECT may have helped to clarify the discrepancy of EKG and imaging (4). The patient eventually underwent coronary angiography, which indeed confirmed three-vessel CAD requiring surgical revascularization.

Case 2 is of a 51-year-old male with a history of known CAD and previous angioplasty 6 months prior. He presented to the ED with symptoms of coronary ischemia. The EKG did not demonstrate changes of ischemia; however, clinically the case was consistent with unstable angina in a high-risk individual. Coronary angiography in this patient is appropriate (5). Stress testing, unless symptoms stabilize within 48 hours; is contraindicated. The coronary angiogram did not show any significant restenosis. Of interest is the fact that after the patient’s initial cardiac assessment, a different history was obtained that was more consistent with a musculoskeletal diagnosis. A more accurate history at the onset might have avoided an invasive workup.

These cases underscore the need for an adequate history. Chest pain description by patients is often sketchy and incomplete. Patients deny chest pain even though they have chest discomfort that could have typical radiation or relief with nitroglycerin consistent with angina pectoris. We are therefore obligated to obtain the best history available in order to direct diagnostic testing or to refer to other health professionals as appropriate. Only after coronary artery disease is ruled out should we proceed with further testing of other organ systems to make a diagnosis and, eventually, provide satisfactory treatment.

 

REFERENCES

  1. Braunwald E. The history. In: Braunwald E. ed. A Textbook of Cardiovascular Medicine. Philadelphia: W.B. Saunders, 1997:1-14.
  2. American Heart Association. Heart and Stroke Statistical Update. Dallas: American Heart Association, 1998.
  3. Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACPASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Associated Task Free Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 1999;99:2829-2848.
  4. Williams KA. Increased stress right ventricular activity on dual isotope perfusion SPECT. J Am Coll Cardiol 1999:34(2):420-427.
  5. White HD. Unstable angina ischemia syndromes. In: Topol EJ, ed. Textbook of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 1998:365-393.

Harry Wallner, M.D.
Cardiovascular Medicine P.C.
Rock Island, Illinois

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