Cardialgia

Cardialgia - pain in the heart, differing in their characters from angina (see); Characterized by stitching, burning, aching, less pressing pressure in the heart; They can irradiate throughout the left half of the thorax, the left arm and the left scapula; They are fleeting (lightening "puncture"), short (minutes, hours) and very long (days, weeks, months). As a rule, cardialgia do not stop from taking nitrates. The presence of cardialgia does not exclude the existence of coronary arteries of the heart in some patients and can sometimes be intermixed or combined with true attacks of angina pectoris.

Any pain in the left half of the chest can be regarded as cardialgia, until the diagnosis is specified. Cardialgia occur in a number of clinical syndromes and pathological conditions.

Cardialgia with lesions of the peripheral nervous system. Cervical osteochondrosis and a herniated intervertebral disk can cause compression of the nerve roots; Cardial syndrome can also be a consequence of irritation of the sympathetic plexus of the vertebral artery. Q first and second case, the appearance of pain in the left half of the breast is associated with certain positions and movements of the arm, head, but not with physical stress; Pain may increase or arise at night, with the tension of the cervico-thoracic roots (drawing the arm behind the back, stretching it to the side). There is an increase or decrease in reflexes and hypo- or hyperesthesia on the arm. In the third case, when the sympathetic plexus of the vertebral artery is compressed, the puffiness of the hand is sometimes associated with the described symptoms, which is associated with a violation of vasoconstrictive sympathetic innervation; When pressing on the head in the direction of the longitudinal axis of the spine and when bending the head turned towards the lesion, pain occurs.

It is necessary to treat the underlying disease.

The prognosis is favorable.

Cardialgia can be a consequence of the cervico-brachial syndrome, which appears as a result of compression of the subclavian arteries, vein and brachial plexus with an additional cervical rib (Falconer-Weddel syndrome) or in pathological hypertrophy ("syndrome") of the anterior staircase (Nuffziger syndrome). The peculiarities of the pain syndrome in these cases include the appearance of pain when wearing small weights in the hand, while working with your hands up. The examination reveals a thickened painful anterior staircase, an expansion of the subcutaneous veins above the large pectoral muscle, a decrease in temperature, and sometimes a puffiness of the hand, a decrease in blood pressure on the radial artery on the side of the lesion. On the roentgenogram, an additional rib can be identified, an increase in the transverse process of the VIl cervical vertebra.

Treatment. With an additional cervical rib in the case of severe pain and compression of subclavian vessels, removal of this rib is indicated; In the case of the syndrome of the anterior staircase, in the mild cases, analgin, indomethacin (methindol) is administered in usual doses, 2% solution of novocaine (2 ml) or hydrocortian solution (2 ml) is injected into the hypertrophied anterior staircase 2 to 3 times, day. In very severe cases, you have to resort to muscle dissection.

The outlook is usually favorable.

Cardialgia can occur with left-side intercostal neuralgia, shingles, neurinoma rootlets (in the latter case, the pain can be so intense that it is not even inferior to the introduction of morphine - this is of diagnostic importance). In herpes zoster, sometimes changes in the ECG are seen as a reduction in the ST segment, flattening or inversion of the T wave. Treatment of the corresponding diseases is necessary.

Painful thickening of the costal cartilage (usually II-IV ribs), or Tietze syndrome, is a fairly common disease in people over 40 years old, accompanied by cardialgia. The etiology is unknown. The pathogenesis is based on aseptic inflammation of the costal cartilage.

Treatment is symptomatic (analgin, ibuprofen or brufen). The prognosis is favorable.

Cardialgia can be observed with a high diaphragm standing, caused by bloating of the stomach or intestines, obesity, etc. (Remkheld's syndrome). Pain often occurs after eating, if the patient lies, but disappears when going to the vertical position, when walking; Sometimes they are combined with real angina (differentiation is easy even with a correctly collected history). The prognosis is favorable.

Cardialgia can be caused by diaphragmatic hernia, which occurs more often in the elderly with the dilatation of the esophageal aperture of the diaphragm, as well as in the traumatic rupture of the dome of the diaphragm. Aching pains, retrosternal or other localization, arise as a result of displacement of the organs of mediastinum or infringement of the stomach, or in the formation of ulcers in the prolapse of the stomach. Pain appears immediately after ingestion or in a horizontal position, sometimes at night (with late eating). Pain disappears when walking, after eructation, when moving to a vertical position. Often cardiac syndrome is combined in these patients with signs of iron deficiency anemia, caused by repeated bleeding. If the hernia is infringed, shortly after eating the strongest chest pain may occur, which does not stop with the use of conventional analgesic agents, morphine, nitrates, but disappears suddenly when the body position changes (usually in an upright position). The diagnosis is established radiological (study with the lowered head end of the body). Perhaps a combination with angina.

Peptic ulcer of the esophagus, cardiospasm, esophagitis can be accompanied by cardialgia, the distinctive feature of which is a clear connection with the passage of food through the esophagus.

When the transverse colon is located above the liver (Kilaidity syndrome), either severe pain to the right of the sternum (with bowel entrapment) or aching chest pain (with bowel swelling) may occur. It is possible to suspect this disease if a tympanitis is found over the liver; The diagnosis is established radiologically.

The outlook is usually favorable.

Cardiac syndrome can be observed with primary pulmonary hypertension, lung infarction (it can be accompanied by angina attack), parapneumonic pleurisy. Aching and stitching pain in the heart can occur with myocarditis (one of the signs of recurrence of rheumatic heart disease), pericarditis.

Treatment and prognosis are determined by the underlying disease.

The syndrome of the anterior thoracic wall - the appearance of pain and tenderness in the heart after the end of the acute period of myocardial infarction, a typical version of cardialgia, can simulate a recurrence of a coronary attack with an unclearly collected history. The pathogenesis of the syndrome is unclear. Aching pains can be of different intensity, sometimes they are expressed sharply, in other cases, subjective sensations are almost absent, only the morbidity of the near-cardiac region is noted.

Treatment - analgesic drugs.

The prognosis of kardialgia proper is favorable.

Dyshormonal cardiopathies are manifested by pronounced cardialgia, but irrespective of them some cardiac arrhythmias, registered as ventricular extrasystoles, negative T wave, more often in leads V1-V4, less often in the sternal thoracic leads of the ECG, The same leads (a non-indicative sign), transitory blockades of the legs of the bundle of His. In these cases, we should not talk about cardialgia (although it usually takes place), but about cardiopathy (myocardiopathy). The pathogenesis of pain syndrome and cardiac dysfunctions with dyshormonal states remains insufficiently elucidated. Dyshormonal cardiopathies can occur with thyrotoxicosis (see) and other endocrine diseases.

These changes are most pronounced in menopause, when climacteric cardialgia often occurs, and less often climacteric cardiopathy. The syndrome occurs against the background of autonomic disorders characteristic of menopause, sometimes several years before the termination of menstruation, less often, a few years after the onset of amenorrhea. Patients complain of a feeling of heaviness, tightness behind the sternum, more often to the left of it, cutting, burning, piercing pain in the area of ​​apical impulse. Pain can be short-term, long-lasting (hours, weeks, months), sometimes occurs at night, imitating resting angina. There are often complaints of lack of air: this is not a question of true dyspnoea, but of a feeling of dissatisfaction with inhalation, the wings of the nose do not expand, the auxiliary muscles (an objective sign of dyspnea) do not participate in breathing. Pain, as a rule, is not provoked by physical stress, the frequency and intensity of attacks do not reduce the bed rest, nitrates of pain do not stop or lead to their weakening after a long period of time (with angina in a few minutes!), More often nitrates cause only a severe headache. There are often complaints of fits of loss of consciousness, however, in those cases when the doctor manages to observe these episodes, it is almost a hysterical fit with small clinical cramps. Fainting is possible. Usually the pain is accompanied by "hot flashes", sweating, paresthesia; Patients are irritable, emotionally labile, mood is reduced. Sometimes complaints are made about severe headaches, palpitation, a feeling of cardiac arrest, spasms in the throat, dizziness. When the examination reveals a small tachycardia, vascular dystonia is possible. The attack ends with a sensation of severe weakness, profuse sweating, polyuria. Cardialgia can be accompanied by fear of death.

The appearance of changes on the ECG, especially the negative T wave, which can be deep and symmetrical, requires differentiation with focal lesions of the myocardium (ischemia, small-focal infarction). Distinctive electrocardiographic signs of climacteric cardiopathy: absence of the opposite direction of the T wave to the displacement of the segment ST (shifted downwards with a negative T wave, and with myocardial infarction shifted upward with a negative T wave); Negative T wave persists for weeks (often months and years), with inappropriate pain syndrome fluctuations, until the appearance of a positive T wave (in the infarction it gradually normalizes); In cardiopathy, in contrast to infarction, a negative T wave becomes positive one hour after taking 40 mg of indirals (indiginal assay) or 5 g of potassium chloride (a test with potassium chloride). To reject the presence of myocardial infarction helps determine the activity of enzymes in the blood, myoglobin in the blood and urine. In contrast to menopausal cardiopathy with myocardial ischemia, the negative T wave persists for 1-2 days. The most important role in differential diagnosis is played by correctly collected anamnesis. In all doubtful cases, it is necessary to treat patients, as with myocardial infarction, before finding out the diagnosis.

In the treatment of climacteric cardialgia and cardiopathy, the main role is played by psychotherapy: explaining to patients full safety as a pain syndrome (its incoherence with angina pectoris), and detectable changes on the ECG. Bed rest is not shown. As a rule, patients remain able to work. Drug therapy is reduced to the appointment of valerian preparations (in particular, drops of Zelenin) in the case of persistent cardialgia. With climacteric cardiopathy, accompanied by the appearance of negative T wave, a good effect (normalization of the ECG, cessation of pain) is given by verapamil (isoptin), anaprilin (inderal) in a dose of 40 mg 1-3 times a day (with severe bradycardia, conduction disorders not prescribed !). Sex hormones are used only for other severe manifestations of menopause. The most important indicator of the effectiveness of therapy is the disappearance or significant relief of pain, regardless of the ECG parameters.

The prognosis is favorable.

Dyshormonal cardiopathy with a clinical picture similar to that described above is observed with the treatment of sex hormones of adenoma or prostate cancer. Therapy itself cardiopathy is the same.

Cardialgia, ventricular extrasystole occur during puberty (pubertal heart). In this syndrome, both vegetative and behavioral features of the dyshormonal state are observed, although they are much less pronounced than in menopause. Special treatment is not available. The prognosis is favorable.

All the features of climacteric cardiopathy (including the appearance of a negative T wave on the ECG) can be observed before and during the first days of menstruation - premenstrual syndrome (see). Special therapy is not available.