Is heart pain always constant?

Is Heart Pain Always Constant?

No, heart pain is not always constant. It can present with various patterns including constant, intermittent, or fluctuating intensity depending on the underlying cause and individual factors.1

Characteristics of Cardiac Pain

Typical Angina Presentation

• Classic angina (cardiac chest pain) often presents as substernal pressure that commonly begins with exertion and is relieved by rest 1
• Severe continuing pain is a feature that may indicate high-risk patients requiring immediate care in a coronary care unit 1
• Pain may be described using terms like "squeezing," "griplike," "suffocating," and "heavy" rather than "sharp" or "stabbing" 1

Variable Patterns of Cardiac Pain

• Cardiac pain can be:
  • Prolonged (>20 minutes) at rest (seen in 80% of acute coronary syndrome cases)
  • Intermittent as in new onset or crescendo angina (seen in 20% of cases) 1
  • Transient due to spontaneous thrombolysis causing temporary vessel occlusion/subocclusion 1

Atypical Presentations

• Heart pain can present atypically, especially in:
  • Younger patients (25-40 years)
  • Older patients (>75 years)
  • Diabetic patients
  • Women 1
• Atypical presentations may include:
  • Pain predominantly at rest
  • Epigastric pain
  • Recent onset indigestion
  • Stabbing chest pain
  • Chest pain with some pleuritic features
  • Increasing dyspnea 1
• In the Multicenter Chest Pain Study, acute myocardial ischemia was diagnosed in 22% of patients with sharp or stabbing chest pain 1

Mechanisms and Variability of Cardiac Pain

• Cardiac pain shows "sensitive dependence on initial conditions" suggesting a mechanism with deterministic chaotic dynamics for the association between myocardial ischemia and pain 2
• Pain often appears late during an ischemic event, and many ischemic attacks can actually be symptomless 2
• Neurophysiological mechanisms involve spinal cardiac afferent fibers mediating typical anginal pain and vagal cardiac afferent fibers likely mediating atypical anginal pain 3
• The psychological state of an individual can modulate cardiac nociception, affecting how pain is perceived 3

Clinical Implications

• The majority of ischemic attacks may be symptomless, making the absence of pain an unreliable indicator 2
• Patients with recurrent chest pain but no evidence of physiological cause after thorough evaluation may benefit from referral to a cognitive-behavioral therapist 1
• Risk stratification should identify high-risk patients, including those with recurrent ischemia (either recurrent chest pain or dynamic ST-segment changes) 1
• Contrary to what might be expected, one study found no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal ECG and those without chest pain during acquisition of a normal ECG 4

Important Considerations for Evaluation

• A careful history focusing on symptoms is essential for proper diagnosis 1
• Chest pain is one of the most common symptoms in emergency departments (5-20% of visits), yet only 10-15% of chest pain patients have acute myocardial infarction 1
• When evaluating patients with chest pain, it's important to consider both cardiac and non-cardiac causes, as approximately half of chest pain cases are of cardiac origin and half are due to non-cardiac causes 5

Pitfalls to Avoid

• Do not assume that intermittent pain rules out cardiac origin 1, 3
• Do not dismiss atypical presentations, especially in women, elderly, and diabetic patients 1
• Do not rely solely on pain characteristics for diagnosis; further testing such as ECG, cardiac biomarkers, and sometimes stress testing or angiography may be necessary 1
• Do not overlook the possibility that psychological factors may modulate or exacerbate cardiac pain perception 1, 3