- Email: [email protected]
Craniofacial pain as the sole symptom of cardiac ischemia
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Craniofacial pain as the sole symptom of cardiac ischemia A prospective multicenter study Marcelo Kreiner, DDS; Jeffrey P. Okeson, DMD; Virginia Michelis, MD; Mariela Lujambio, MD; Annika Isberg, DDS, PhD
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Background. Craniofacial pain can be the only symptom of cardiac ischemia. Failure to recognize its N C U cardiac source can put the patient’s life at risk. The A ING EDU 3 authors conducted a study to reveal the prevalence of, RT ICLE the distribution of and sex differences regarding craniofacial pain of cardiac origin. Methods. The authors prospectively selected consecutive patients (N = 186) who had had a verified cardiac ischemic episode. They studied the location and distribution of craniofacial and intraoral pain in detail. Results. Craniofacial pain was the only complaint during the ischemic episode in 11 patients (6 percent), three of them who had acute myocardial infarction (AMI). Another 60 patients (32 percent) reported craniofacial pain concomitant with pain in other regions. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region and teeth. Craniofacial pain was preponderantly manifested in female subjects (P = .031) and was the dominating symptom in both sexes in the absence of chest pain. Conclusions. Craniofacial pain commonly is induced by cardiac ischemia. This must be considered in differential diagnosis of toothache and orofacial pain. Clinical Implications. Because patients who have AMI without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist’s awareness of this symptomatology can be crucial for early diagnosis and timely treatment. Key Words. Angina pectoris; cardiac ischemia; myocardial infarction; orofacial pain; toothache. JADA 2007;138(1):74-9. T
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significant number of patients with atypical symptoms of acute coronary disease die before receiving appropriate hospital care as a result of missed diagnosis and treatment delay.1,2 As has been described in case reports, failure to diagnose cardiac pain that is referred to the face, head, neck and teeth can lead to treatment delay while therapy is directed to the pain site instead of the cardiac source.3,4 Misdirected treatment places the patient’s life at risk. The difficulty in correctly diagnosing an acute myocardial infarction (AMI) is reflected in the reported frequency of missed diagnoses found in emergency departments, which ranges between 2 and 27 percent in the developed world.1,2,5 One-fourth of missed diagnoses was found in one study to result in lethal or potentially lethal complications for the patient.1 In another study, patients with atypical symptoms were more likely to be discharged from emergency departments than were patients with typical symptoms.2 Absence of
Dr. Kreiner is a PhD candidate, Oral and Maxillofacial Radiology, Department of Odontology, Faculty of Medicine, University, Sweden, and the chair, Department of General and Oral Physiology, School of Dentistry, Universidad de la República, Montevideo, Uruguay. Dr. Okeson is professor and the chair, Department of Oral Health Science, and the director, Orofacial Pain Program, College of Dentistry, University of Kentucky, Lexington. Dr. Michelis is an assistant professor, Department of Clinical Medicine, Cardiology Service, Hospital de Clínicas, Montevideo, Uruguay, and a cardiologist, Department of Cardiology, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay. Dr. Lujambio is an adjunct professor, Department of Clinical Medicine, Cardiology Service, Hospital de Clínicas, Montevideo, Uruguay. Dr. Isberg is a professor, Oral and Maxillofacial Radiology, Department of Odontology, Faculty of Medicine, Umeå University, SE-901 85, Umeå, Sweden, e-mail “[email protected]”. Address reprint requests to Dr. Isberg.
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chest pain and lack of ST elevation in electrocardiograms (ECGs) were found to be the main predisposing factors for missed diagnosis.5 In line with this, patients who had suspected AMI but who never experienced chest pain were found to run a risk of death three times higher than that of patients seeking care for chest pain during emergency department evaluation.6 These same patients, who never developed chest pain, had a risk of death eight times greater than that of patients whose chest pain resolved before they received hospital care. And in another study, the one-year mortality rate for patients with symptoms other than chest pain was twice that of patients with chest pain.7 Although several studies have reported on the prevalence of pain in different locations during cardiac ischemia,8-13 the possibility of pain referral to the face, head, neck and mouth has not been well-documented. At this time, the scientific literature links pain that is limited to the craniofacial structures to cardiac ischemia mainly through case reports.3,4,14-17 We undertook a prospective investigation with three goals: dto determine the prevalence and distribution of pain induced by cardiac ischemia and referred to the face, neck, head and mouth; dto reveal the prevalence of craniofacial pain that exists in the absence of chest pain and that is the only symptom of cardiac ischemia; dto analyze sex differences between and to compare patients with and without an AMI. SUBJECTS, MATERIALS AND METHODS
Study population. We selected the subjects from a total of 215 patients who were admitted with signs and/or symptoms suggesting cardiac ischemia to three cardiology departments in three separate hospitals in Montevideo, Uruguay, and were seen consecutively in each unit. The study periods were spread across the four seasons. We included patients in the study if they met the criteria of having a cardiac ischemic episode verified according to the American College of Cardiologists’ (ACC) definition.18 AMI was diagnosed by cardiologists when a patient fulfilled the diagnostic criteria of the ACC definition.18 Exclusion criteria were asymptomatic ischemia, craniofacial pain of noncardiac origin and a severe psychiatric disorder. We excluded 29 patients who had normal ECGs and angiography (n = 15), asymptomatic ischemia that had been
detected in a preoperative routine ECG (n = 8), temporomandibular joint (TMJ) pain disorders (n = 3), chronic headache (n = 2), and chronic craniofacial pain due to neoplasm (n = 1). The study group was composed of 186 patients, 76 women and 110 men, who met the inclusion criteria. Their mean age was 64 years (median 65 years), with a range from 42 to 88 years. Data collection. Three calibrated investigators (M.K., V.M., M.L.) collected the data using a questionnaire that included demographic details on age and sex. In the quest to optimize the patient’s report of atypical symptoms, the investigator encouraged the patient to describe not only the symptoms constituting the main complaint but also any other symptoms. The investigator marked these on a picture of the body divided into numbered anatomical regions representing the thorax, stomach, back, shoulders, arms, face, head, neck and mouth (Figure 1). The investigator showed the marked picture of the body to the patient and discussed it with him or her to ascertain the correctness of the areas marked. Ethical approval. The study protocol was approved by the Research and Ethics Committee of the Universidad de la República and the Ethics Committee of the Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay. All patients gave informed consent to participate in the study. Statistical methods. We used χ2 tests to examine differences in distribution of symptoms between men and women. We performed statistical analysis using SPSS software (SPSS, version 9, Chicago). RESULTS
Pain in the craniofacial region was experienced by 71 patients (38 percent) during an episode of cardiac ischemia and was significantly more prevalent in women than in men (P = .031). Sixty of the patients with referred craniofacial pain (85 percent) reported concomitant pain in typical anginal regions such as the chest, shoulder, back or arms, while 11 of these patients (15 percent) experienced only craniofacial pain (Figure 2, page 77). The ischemic event was associated with an AMI in 74 patients (40 percent). During the AMI, 27 of these patients (36 percent) experienced ABBREVIATION KEY. ACC: American College of Cardiology. AMI: Acute myocardial infarction. ECG: Electrocardiogram. TMJ: Temporomandibular joint. WHO: World Health Organization.
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Figure 1. Figure of the body and the craniofacial structures subdivided into different areas.
craniofacial pain, three of whom were men (4 percent) with no other concomitant symptoms (Figure 2). Figure 3 shows the distribution of craniofacial areas affected by pain induced by cardiac ischemia (n = 71). The areas most frequently affected were the upper part of the throat (n = 58, 81.7 percent) and the left mandible (n = 32, 45.1 percent), followed by the right mandible (n = 29, 40.8 percent) and the left TMJ/ear region (n = 13, 18.3 percent). The maxilla and the posterior neck were the sites least frequently affected by referred craniofacial pain. Toothache occurred in three of the patients, affecting mandibular teeth 76
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bilaterally in two patients and the left maxillary teeth in one patient. Pain in the TMJ/ear was bilateral in 11 patients and unilateral (left) in two. The ratio of bilateral referral pattern of pain to the craniofacial structures versus unilateral was 6:1. The ratio of bilateral versus unilateral referred pain to the arms was 1:1. When arm pain was unilateral, it referred to the left arm in 22 patients and to the right arm in four. Chest pain was absent in 25 patients (13 percent), with no statistically significant difference in frequency between men and women. In the absence of chest symptoms, pain was most frequently reported in the craniofacial region
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Figure 2. Prevalence of referred craniofacial pain during cardiac ischemia and acute myocardial infarction.
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Figure 4. Distribution of pain during cardiac ischemia in the absence of chest pain (n = 25).
(Figure 4) (n = 15, 60 percent), followed by the left arm (n = 5, 20 percent) and the left shoulder (n = 5, 20 percent). The stomach and the back (n = 3, 12 percent) and the right arm (n = 2, 8 percent) were the sites least frequently affected in patients without chest pain. DISCUSSION
The typical presentation of cardiac pain is reported in the left side of the chest, often radi-
Figure 3. Distribution of referred craniofacial pain during cardiac ischemia and myocardial infarction (n = 71). TMJ: Temporomandibular joint.
ating to the left arm and to the neck.8 The results of this prospective study broaden the diagnostic spectrum of common symptoms by revealing that craniofacial pain can be expected in approximately 40 percent of patients during a cardiac ischemic event and was the sole symptom of cardiac ischemia in 6 percent of the patients. The relative distribution for the patients with an AMI was the same. The most common craniofacial pain site was the throat, followed by the mandible, the TMJs and ears, the neck, and teeth. These same regions are typical for referred pain of odontogenic origin.19 It therefore is noteworthy that referred pain of odontogenic origin rarely crosses the midline,19 as opposed to craniofacial pain induced by cardiac ischemia, which, as revealed in this study, is mostly bilateral. In contrast with craniofacial pain, arm pain occurred bilaterally in only onehalf of the patients. The complexity of the central processing of cardiac pain at different levels may explain these clinical differences.20 Anginal pain limited to the jaw was shown in a previous case report to result in misdirected dental treatment and delay of appropriate medical care.3 Our results indicate that referred pain felt in the mandible can be expected in one of six patients with cardiac ischemia. Pain in the ear, the TMJ and head has been reported to be associated with cardiac ischemia.4,12,15 Our results indicate that referral of anginal pain to the TMJ
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and ear region can be expected in one of 14 patients. The prevalence of toothache and headache caused by cardiac ischemia was lower, but these symptoms, as with pain in the other craniofacial areas, constitute a differential diagnostic challenge because of the risk that the practitioner may not link them with cardiac ischemia.3,16,21 Fatal outcome has been reported in patients with anginal headache as the only symptom of cardiac ischemia.15 There is a growing awareness that a considerable number of patients develop an AMI without experiencing any chest pain.6,7,22 Our results are in line with these reports, in that 13 percent of our patients with cardiac ischemia lacked typical chest symptoms, and two-thirds of those reported referred craniofacial pain solely during the ischemic episode. One in three patients with no chest pain developed an AMI. Other researchers6,7,22 have found that in comparison with patients who experienced chest pain, patients who experienced an AMI but no chest pain had a risk of lifethreatening complications five times greater and a risk of death two to eight times greater. In the absence of chest pain, we did not expect to find the craniofacial area to be the most prevalent location of pain—that is, three times more frequent than the left arm and four times more frequent than the stomach and the back. It has been shown that when the diagnosis of an AMI is missed, the failure has been associated with the patient’s presentation of atypical symptoms.1,23 The high frequency of missed diagnosis of AMI has been reported primarily from emergency departments.1,2,5 However, patients with pain only in the head, face or mouth are likely to seek treatment in a general physician’s practice or a dental office, increasing the risk of treatment delay. Because public recognition of craniofacial pain as a symptom of cardiac ischemia is low,24 the prevalence found in this study regarding atypical symptoms—that is, craniofacial referred pain— during cardiac ischemia and during AMI is likely to constitute an underestimation. In no previous study that we found have researchers systematically investigated the prevalence of craniofacial referred pain. Conversely, the questionnaire commonly used in assessing cardiac pain in epidemiologic studies was the World Health Organization (WHO) Rose Angina Questionnaire.25 Its schematic chart does not include the craniofacial structures. Therefore, patients commonly have not been provided the opportunity to report cran78
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iofacial pain. Furthermore, before 2000, authors commonly used the WHO criteria from 1979 in their diagnosis of AMI.26 This may have excluded a considerable number of patients with atypical symptoms. During the last decade, an increasing awareness has evolved regarding sex differences in presentation of symptoms induced by cardiac ischemia.26 Our findings support those of previous reports that craniofacial pain induced by cardiac ischemia was significantly more prevalent in women than in men.9,11,12 CONCLUSIONS
Pain in the craniofacial structures can be the only complaint during cardiac ischemia and AMI. This clinical presentation can be expected in one in 15 patients. TMJ and jaw pain induced by cardiac ischemia tend to occur bilaterally as opposed to referred pain of odontogenic origin. In the absence of chest pain, craniofacial pain is far more common than pain in any other area. Since patients who have myocardial infarction without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist’s awareness of this symptomatology can be crucial for early diagnosis and timely treatment. ■ The Universidad de la República (Comisión Sectorial de Investigación Científica and the School of Dentistry), Montevideo, Uruguay; the Faculty of Medicine, Umeå University, Sweden; and the Swedish Medical Research Council (Project 6877), Stockholm, Sweden, funded this study. The funders had no involvement in the data collection, data analysis, data interpretation or writing of the report, or the decision to submit the report for publication. The authors thank the Instituto Nacional de Cirugía Cardíaca, Montevideo, Uruguay, and its staff for their valuable participation in this study. They thank Anders Waldenström, MD, PhD, Department of Cardiology, Umeå University, Sweden, for constructive discussions and critical revision of the article and adjunct professor Ramón Alvarez, Statistical Institute, Universidad de la República, Uruguay, for the statistical analysis. 1. McCarthy BD, Beshansky JR, D’Agostino RB, Selker HP. Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med 1993;22(3):579-82. 2. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342(16):1163-70. 3. Batchelder BJ, Krutchkoff DJ, Amara J. Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report of case. JADA 1987;115(5):710-12. 4. Rothwell PM. Angina and myocardial infarction presenting with pain confined to the ear. Postgrad Med J 1993;69(810):300-1. 5. Chan WK, Leung KF, Lee YF, Hung CS, Kung NS, Lau FL. Undiagnosed acute myocardial infarction in the accident and emergency departments: reasons and implications. Eur J Emerg Med 1998;5(2): 219-24. 6. Fesmire FM, Wears RL. The utility of the presence or absence of chest pain in patients with suspected acute myocardial infarction. Am J Emerg Med 1989;7(4):372-7. 7. Herlitz J, Karlson BW, Richter A, Strömbom U, Hjalmarson Å. Prognosis for patients with initially suspected acute myocardial infarction in relation to presence of chest pain. Clin Cardiol 1992;15(8):570-6.
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8. Everts B, Karlson BW, Währborg P, Hedner T, Herlitz J. Localization of pain in suspected acute myocardial infarction in relation to final diagnosis, age and sex, and site and type of infarction. Heart Lung 1996;25(6):430-7. 9. Goldberg RJ, O’Donnell C, Yarzebski J, Bigelow C, Savageau J, Gore JM. Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J 1998;136(2):189-95. 10. Herlitz J, Karlsson T, Dellborg M, et al. Occurrence, characteristics, and outcome of patients hospitalized with a diagnosis of acute myocardial infarction who do not fulfill traditional criteria. Clin Cardiol 1998;21(6):405-9. 11. Goldberg R, Goff D, Cooper L, et al. Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial—Rapid Early Action for Coronary Treatment. Coron Artery Dis 2000;11(5):399-407. 12. Philpott S, Boynton PM, Feder G, Hemingway H. Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study—Appropriateness of Coronary Revascularisation study. Soc Sci Med 2001;52(10):1565-75. 13. Culic V, Miric D, Eterovic D. Correlation between symptomatology and site of acute myocardial infarction. Int J Cardiol 2001; 77(2-3):163-8. 14. Tzukert A, Hasin Y, Sharav Y. Orofacial pain of cardiac origin. Oral Surg Oral Med Oral Pathol 1981;51(5):484-6. 15. Takayanagi K, Fujito T, Morooka S, Takabatake Y, Nakamura Y. Headache angina with fatal outcome. Jpn Heart J 1990;31(4):503-7. 16. Kreiner M, Okeson JP. Toothache of cardiac origin. J Orofac Pain 1999;13(3):201-7.
17. Durso BC, Israel MS, Janini ME, Cardoso AS. Orofacial pain of cardiac origin: a case report. Cranio 2003;21(2):152-3. 18. Cannon CP, Battler A, Brindis RG, et al. American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes: a report of the American College of Cardiology Task Force on Clinical Data standards (Acute Coronary Syndromes Writing Committee). J Am Coll Cardiol 2001;38(7):2114-30. 19. Falace DA, Reid K, Rayens MK. The influence of deep (odontogenic) pain intensity, quality, and duration on the incidence and characteristics of referred orofacial pain. J Orofac Pain 1996;10(3):232-9. 20. Foreman RD. Mechanisms of cardiac pain. Annu Rev Physiol 1999;61:143-67. 21. Sathirapanya P. Anginal cephalgia: a serious form of exertional headache. Cephalalgia 2004;24(3):231-4. 22. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with mycardial infarction presenting without chest pain. JAMA 2000;283(24):3223-9. 23. Rusnak RA, Stair TO, Hansen K, Fastow JS. Litigation against the emergency physician: common features in cases of missed myocardial infarction. Ann Emerg Med 1989;18(10):1029-34. 24. Greenlund KJ, Keenan NL, Giles WH, et al. Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001. Am Heart J 2004;147(6):1010-6. 25. Rose GA, Blackburn H. Cardiovascular survey methods. Monogr Ser World Health Organ 1968;56:1-188. 26. Chen W, Woods SL, Puntillo KA. Gender differences in symptoms associated with acute myocardial infarction: a review of the research. Heart Lung 2005;34(4):240-7.
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Craniofacial pain as the sole symptom of cardiac ischemia A prospective multicenter study Marcelo Kreiner, DDS; Jeffrey P. Okeson, DMD; Virginia Michelis, MD; Mariela Lujambio, MD; Annika Isberg, DDS, PhD
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Background. Craniofacial pain can be the only symptom of cardiac ischemia. Failure to recognize its N C U cardiac source can put the patient’s life at risk. The A ING EDU 3 authors conducted a study to reveal the prevalence of, RT ICLE the distribution of and sex differences regarding craniofacial pain of cardiac origin. Methods. The authors prospectively selected consecutive patients (N = 186) who had had a verified cardiac ischemic episode. They studied the location and distribution of craniofacial and intraoral pain in detail. Results. Craniofacial pain was the only complaint during the ischemic episode in 11 patients (6 percent), three of them who had acute myocardial infarction (AMI). Another 60 patients (32 percent) reported craniofacial pain concomitant with pain in other regions. The most common craniofacial pain locations were the throat, left mandible, right mandible, left temporomandibular joint/ear region and teeth. Craniofacial pain was preponderantly manifested in female subjects (P = .031) and was the dominating symptom in both sexes in the absence of chest pain. Conclusions. Craniofacial pain commonly is induced by cardiac ischemia. This must be considered in differential diagnosis of toothache and orofacial pain. Clinical Implications. Because patients who have AMI without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist’s awareness of this symptomatology can be crucial for early diagnosis and timely treatment. Key Words. Angina pectoris; cardiac ischemia; myocardial infarction; orofacial pain; toothache. JADA 2007;138(1):74-9. T
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significant number of patients with atypical symptoms of acute coronary disease die before receiving appropriate hospital care as a result of missed diagnosis and treatment delay.1,2 As has been described in case reports, failure to diagnose cardiac pain that is referred to the face, head, neck and teeth can lead to treatment delay while therapy is directed to the pain site instead of the cardiac source.3,4 Misdirected treatment places the patient’s life at risk. The difficulty in correctly diagnosing an acute myocardial infarction (AMI) is reflected in the reported frequency of missed diagnoses found in emergency departments, which ranges between 2 and 27 percent in the developed world.1,2,5 One-fourth of missed diagnoses was found in one study to result in lethal or potentially lethal complications for the patient.1 In another study, patients with atypical symptoms were more likely to be discharged from emergency departments than were patients with typical symptoms.2 Absence of
Dr. Kreiner is a PhD candidate, Oral and Maxillofacial Radiology, Department of Odontology, Faculty of Medicine, University, Sweden, and the chair, Department of General and Oral Physiology, School of Dentistry, Universidad de la República, Montevideo, Uruguay. Dr. Okeson is professor and the chair, Department of Oral Health Science, and the director, Orofacial Pain Program, College of Dentistry, University of Kentucky, Lexington. Dr. Michelis is an assistant professor, Department of Clinical Medicine, Cardiology Service, Hospital de Clínicas, Montevideo, Uruguay, and a cardiologist, Department of Cardiology, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay. Dr. Lujambio is an adjunct professor, Department of Clinical Medicine, Cardiology Service, Hospital de Clínicas, Montevideo, Uruguay. Dr. Isberg is a professor, Oral and Maxillofacial Radiology, Department of Odontology, Faculty of Medicine, Umeå University, SE-901 85, Umeå, Sweden, e-mail “[email protected]”. Address reprint requests to Dr. Isberg.
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chest pain and lack of ST elevation in electrocardiograms (ECGs) were found to be the main predisposing factors for missed diagnosis.5 In line with this, patients who had suspected AMI but who never experienced chest pain were found to run a risk of death three times higher than that of patients seeking care for chest pain during emergency department evaluation.6 These same patients, who never developed chest pain, had a risk of death eight times greater than that of patients whose chest pain resolved before they received hospital care. And in another study, the one-year mortality rate for patients with symptoms other than chest pain was twice that of patients with chest pain.7 Although several studies have reported on the prevalence of pain in different locations during cardiac ischemia,8-13 the possibility of pain referral to the face, head, neck and mouth has not been well-documented. At this time, the scientific literature links pain that is limited to the craniofacial structures to cardiac ischemia mainly through case reports.3,4,14-17 We undertook a prospective investigation with three goals: dto determine the prevalence and distribution of pain induced by cardiac ischemia and referred to the face, neck, head and mouth; dto reveal the prevalence of craniofacial pain that exists in the absence of chest pain and that is the only symptom of cardiac ischemia; dto analyze sex differences between and to compare patients with and without an AMI. SUBJECTS, MATERIALS AND METHODS
Study population. We selected the subjects from a total of 215 patients who were admitted with signs and/or symptoms suggesting cardiac ischemia to three cardiology departments in three separate hospitals in Montevideo, Uruguay, and were seen consecutively in each unit. The study periods were spread across the four seasons. We included patients in the study if they met the criteria of having a cardiac ischemic episode verified according to the American College of Cardiologists’ (ACC) definition.18 AMI was diagnosed by cardiologists when a patient fulfilled the diagnostic criteria of the ACC definition.18 Exclusion criteria were asymptomatic ischemia, craniofacial pain of noncardiac origin and a severe psychiatric disorder. We excluded 29 patients who had normal ECGs and angiography (n = 15), asymptomatic ischemia that had been
detected in a preoperative routine ECG (n = 8), temporomandibular joint (TMJ) pain disorders (n = 3), chronic headache (n = 2), and chronic craniofacial pain due to neoplasm (n = 1). The study group was composed of 186 patients, 76 women and 110 men, who met the inclusion criteria. Their mean age was 64 years (median 65 years), with a range from 42 to 88 years. Data collection. Three calibrated investigators (M.K., V.M., M.L.) collected the data using a questionnaire that included demographic details on age and sex. In the quest to optimize the patient’s report of atypical symptoms, the investigator encouraged the patient to describe not only the symptoms constituting the main complaint but also any other symptoms. The investigator marked these on a picture of the body divided into numbered anatomical regions representing the thorax, stomach, back, shoulders, arms, face, head, neck and mouth (Figure 1). The investigator showed the marked picture of the body to the patient and discussed it with him or her to ascertain the correctness of the areas marked. Ethical approval. The study protocol was approved by the Research and Ethics Committee of the Universidad de la República and the Ethics Committee of the Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay. All patients gave informed consent to participate in the study. Statistical methods. We used χ2 tests to examine differences in distribution of symptoms between men and women. We performed statistical analysis using SPSS software (SPSS, version 9, Chicago). RESULTS
Pain in the craniofacial region was experienced by 71 patients (38 percent) during an episode of cardiac ischemia and was significantly more prevalent in women than in men (P = .031). Sixty of the patients with referred craniofacial pain (85 percent) reported concomitant pain in typical anginal regions such as the chest, shoulder, back or arms, while 11 of these patients (15 percent) experienced only craniofacial pain (Figure 2, page 77). The ischemic event was associated with an AMI in 74 patients (40 percent). During the AMI, 27 of these patients (36 percent) experienced ABBREVIATION KEY. ACC: American College of Cardiology. AMI: Acute myocardial infarction. ECG: Electrocardiogram. TMJ: Temporomandibular joint. WHO: World Health Organization.
JADA, Vol. 138 http://jada.ada.org Copyright ©2007 American Dental Association. All rights reserved.
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Figure 1. Figure of the body and the craniofacial structures subdivided into different areas.
craniofacial pain, three of whom were men (4 percent) with no other concomitant symptoms (Figure 2). Figure 3 shows the distribution of craniofacial areas affected by pain induced by cardiac ischemia (n = 71). The areas most frequently affected were the upper part of the throat (n = 58, 81.7 percent) and the left mandible (n = 32, 45.1 percent), followed by the right mandible (n = 29, 40.8 percent) and the left TMJ/ear region (n = 13, 18.3 percent). The maxilla and the posterior neck were the sites least frequently affected by referred craniofacial pain. Toothache occurred in three of the patients, affecting mandibular teeth 76
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bilaterally in two patients and the left maxillary teeth in one patient. Pain in the TMJ/ear was bilateral in 11 patients and unilateral (left) in two. The ratio of bilateral referral pattern of pain to the craniofacial structures versus unilateral was 6:1. The ratio of bilateral versus unilateral referred pain to the arms was 1:1. When arm pain was unilateral, it referred to the left arm in 22 patients and to the right arm in four. Chest pain was absent in 25 patients (13 percent), with no statistically significant difference in frequency between men and women. In the absence of chest symptoms, pain was most frequently reported in the craniofacial region
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30
60
Left Maxilla
40
Acute Myocardial Infarction
Posterior Neck
Acute Myocardial Infarction (n = 74)
50
Ischemia Without Infarction
81.7
80
Head
Cardiac Ischemia (n = 186)
Tooth
PERCENTAGE OF SUBJECTS EXPERIENCING PAIN
60
PERCENTAGE OF SUBJECTS EXPERIENCING PAIN
100
LOCATION OF PAIN
Figure 4. Distribution of pain during cardiac ischemia in the absence of chest pain (n = 25).
(Figure 4) (n = 15, 60 percent), followed by the left arm (n = 5, 20 percent) and the left shoulder (n = 5, 20 percent). The stomach and the back (n = 3, 12 percent) and the right arm (n = 2, 8 percent) were the sites least frequently affected in patients without chest pain. DISCUSSION
The typical presentation of cardiac pain is reported in the left side of the chest, often radi-
Figure 3. Distribution of referred craniofacial pain during cardiac ischemia and myocardial infarction (n = 71). TMJ: Temporomandibular joint.
ating to the left arm and to the neck.8 The results of this prospective study broaden the diagnostic spectrum of common symptoms by revealing that craniofacial pain can be expected in approximately 40 percent of patients during a cardiac ischemic event and was the sole symptom of cardiac ischemia in 6 percent of the patients. The relative distribution for the patients with an AMI was the same. The most common craniofacial pain site was the throat, followed by the mandible, the TMJs and ears, the neck, and teeth. These same regions are typical for referred pain of odontogenic origin.19 It therefore is noteworthy that referred pain of odontogenic origin rarely crosses the midline,19 as opposed to craniofacial pain induced by cardiac ischemia, which, as revealed in this study, is mostly bilateral. In contrast with craniofacial pain, arm pain occurred bilaterally in only onehalf of the patients. The complexity of the central processing of cardiac pain at different levels may explain these clinical differences.20 Anginal pain limited to the jaw was shown in a previous case report to result in misdirected dental treatment and delay of appropriate medical care.3 Our results indicate that referred pain felt in the mandible can be expected in one of six patients with cardiac ischemia. Pain in the ear, the TMJ and head has been reported to be associated with cardiac ischemia.4,12,15 Our results indicate that referral of anginal pain to the TMJ
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and ear region can be expected in one of 14 patients. The prevalence of toothache and headache caused by cardiac ischemia was lower, but these symptoms, as with pain in the other craniofacial areas, constitute a differential diagnostic challenge because of the risk that the practitioner may not link them with cardiac ischemia.3,16,21 Fatal outcome has been reported in patients with anginal headache as the only symptom of cardiac ischemia.15 There is a growing awareness that a considerable number of patients develop an AMI without experiencing any chest pain.6,7,22 Our results are in line with these reports, in that 13 percent of our patients with cardiac ischemia lacked typical chest symptoms, and two-thirds of those reported referred craniofacial pain solely during the ischemic episode. One in three patients with no chest pain developed an AMI. Other researchers6,7,22 have found that in comparison with patients who experienced chest pain, patients who experienced an AMI but no chest pain had a risk of lifethreatening complications five times greater and a risk of death two to eight times greater. In the absence of chest pain, we did not expect to find the craniofacial area to be the most prevalent location of pain—that is, three times more frequent than the left arm and four times more frequent than the stomach and the back. It has been shown that when the diagnosis of an AMI is missed, the failure has been associated with the patient’s presentation of atypical symptoms.1,23 The high frequency of missed diagnosis of AMI has been reported primarily from emergency departments.1,2,5 However, patients with pain only in the head, face or mouth are likely to seek treatment in a general physician’s practice or a dental office, increasing the risk of treatment delay. Because public recognition of craniofacial pain as a symptom of cardiac ischemia is low,24 the prevalence found in this study regarding atypical symptoms—that is, craniofacial referred pain— during cardiac ischemia and during AMI is likely to constitute an underestimation. In no previous study that we found have researchers systematically investigated the prevalence of craniofacial referred pain. Conversely, the questionnaire commonly used in assessing cardiac pain in epidemiologic studies was the World Health Organization (WHO) Rose Angina Questionnaire.25 Its schematic chart does not include the craniofacial structures. Therefore, patients commonly have not been provided the opportunity to report cran78
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iofacial pain. Furthermore, before 2000, authors commonly used the WHO criteria from 1979 in their diagnosis of AMI.26 This may have excluded a considerable number of patients with atypical symptoms. During the last decade, an increasing awareness has evolved regarding sex differences in presentation of symptoms induced by cardiac ischemia.26 Our findings support those of previous reports that craniofacial pain induced by cardiac ischemia was significantly more prevalent in women than in men.9,11,12 CONCLUSIONS
Pain in the craniofacial structures can be the only complaint during cardiac ischemia and AMI. This clinical presentation can be expected in one in 15 patients. TMJ and jaw pain induced by cardiac ischemia tend to occur bilaterally as opposed to referred pain of odontogenic origin. In the absence of chest pain, craniofacial pain is far more common than pain in any other area. Since patients who have myocardial infarction without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist’s awareness of this symptomatology can be crucial for early diagnosis and timely treatment. ■ The Universidad de la República (Comisión Sectorial de Investigación Científica and the School of Dentistry), Montevideo, Uruguay; the Faculty of Medicine, Umeå University, Sweden; and the Swedish Medical Research Council (Project 6877), Stockholm, Sweden, funded this study. The funders had no involvement in the data collection, data analysis, data interpretation or writing of the report, or the decision to submit the report for publication. The authors thank the Instituto Nacional de Cirugía Cardíaca, Montevideo, Uruguay, and its staff for their valuable participation in this study. They thank Anders Waldenström, MD, PhD, Department of Cardiology, Umeå University, Sweden, for constructive discussions and critical revision of the article and adjunct professor Ramón Alvarez, Statistical Institute, Universidad de la República, Uruguay, for the statistical analysis. 1. McCarthy BD, Beshansky JR, D’Agostino RB, Selker HP. Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med 1993;22(3):579-82. 2. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342(16):1163-70. 3. Batchelder BJ, Krutchkoff DJ, Amara J. Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report of case. JADA 1987;115(5):710-12. 4. Rothwell PM. Angina and myocardial infarction presenting with pain confined to the ear. Postgrad Med J 1993;69(810):300-1. 5. Chan WK, Leung KF, Lee YF, Hung CS, Kung NS, Lau FL. Undiagnosed acute myocardial infarction in the accident and emergency departments: reasons and implications. Eur J Emerg Med 1998;5(2): 219-24. 6. Fesmire FM, Wears RL. The utility of the presence or absence of chest pain in patients with suspected acute myocardial infarction. Am J Emerg Med 1989;7(4):372-7. 7. Herlitz J, Karlson BW, Richter A, Strömbom U, Hjalmarson Å. Prognosis for patients with initially suspected acute myocardial infarction in relation to presence of chest pain. Clin Cardiol 1992;15(8):570-6.
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8. Everts B, Karlson BW, Währborg P, Hedner T, Herlitz J. Localization of pain in suspected acute myocardial infarction in relation to final diagnosis, age and sex, and site and type of infarction. Heart Lung 1996;25(6):430-7. 9. Goldberg RJ, O’Donnell C, Yarzebski J, Bigelow C, Savageau J, Gore JM. Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J 1998;136(2):189-95. 10. Herlitz J, Karlsson T, Dellborg M, et al. Occurrence, characteristics, and outcome of patients hospitalized with a diagnosis of acute myocardial infarction who do not fulfill traditional criteria. Clin Cardiol 1998;21(6):405-9. 11. Goldberg R, Goff D, Cooper L, et al. Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial—Rapid Early Action for Coronary Treatment. Coron Artery Dis 2000;11(5):399-407. 12. Philpott S, Boynton PM, Feder G, Hemingway H. Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study—Appropriateness of Coronary Revascularisation study. Soc Sci Med 2001;52(10):1565-75. 13. Culic V, Miric D, Eterovic D. Correlation between symptomatology and site of acute myocardial infarction. Int J Cardiol 2001; 77(2-3):163-8. 14. Tzukert A, Hasin Y, Sharav Y. Orofacial pain of cardiac origin. Oral Surg Oral Med Oral Pathol 1981;51(5):484-6. 15. Takayanagi K, Fujito T, Morooka S, Takabatake Y, Nakamura Y. Headache angina with fatal outcome. Jpn Heart J 1990;31(4):503-7. 16. Kreiner M, Okeson JP. Toothache of cardiac origin. J Orofac Pain 1999;13(3):201-7.
17. Durso BC, Israel MS, Janini ME, Cardoso AS. Orofacial pain of cardiac origin: a case report. Cranio 2003;21(2):152-3. 18. Cannon CP, Battler A, Brindis RG, et al. American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes: a report of the American College of Cardiology Task Force on Clinical Data standards (Acute Coronary Syndromes Writing Committee). J Am Coll Cardiol 2001;38(7):2114-30. 19. Falace DA, Reid K, Rayens MK. The influence of deep (odontogenic) pain intensity, quality, and duration on the incidence and characteristics of referred orofacial pain. J Orofac Pain 1996;10(3):232-9. 20. Foreman RD. Mechanisms of cardiac pain. Annu Rev Physiol 1999;61:143-67. 21. Sathirapanya P. Anginal cephalgia: a serious form of exertional headache. Cephalalgia 2004;24(3):231-4. 22. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with mycardial infarction presenting without chest pain. JAMA 2000;283(24):3223-9. 23. Rusnak RA, Stair TO, Hansen K, Fastow JS. Litigation against the emergency physician: common features in cases of missed myocardial infarction. Ann Emerg Med 1989;18(10):1029-34. 24. Greenlund KJ, Keenan NL, Giles WH, et al. Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001. Am Heart J 2004;147(6):1010-6. 25. Rose GA, Blackburn H. Cardiovascular survey methods. Monogr Ser World Health Organ 1968;56:1-188. 26. Chen W, Woods SL, Puntillo KA. Gender differences in symptoms associated with acute myocardial infarction: a review of the research. Heart Lung 2005;34(4):240-7.
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