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Craniofacial pain can be the sole prodromal symptom of an acute myocardial infarction: an interdisciplinary study
Umeå University, Faculty of Medicine, Department of Odontology, Oral and Maxillofacial Radiology. Department of General and Oral Physiology, Universidad de la República, School of Dentistry, Montevideo, Uruguay.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
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2016 (English)In: Acta odontológica latinoamericana : AOL, ISSN 0326-4815, Vol. 29, no 1, p. 23-28Article in journal (Refereed) Published
Abstract [en]

We recently found craniofacial pain to be the sole symptom of an acute myocardial infarction (AMI) in 4% of patients. We hypothesized that this scenario is also true for symptoms of prodromal (pre-infarction) angina. We studied 326 consecutive patients who experienced myocardial ischemia. Intra-individual variability analyses with respect to ECG findings and pain characteristics were performed for those 150 patients who experienced at least one recurrent ischemic episode. AMI patients (n=113) were categorized into two subgroups: "abrupt onset" (n=81) and "prodromal angina" (n=32). Age, gender and risk factor comparisons were performed between groups. Craniofacial pain constituted the sole prodromal symptom of an AMI in 5% of patients. In those who experienced two ischemic episodes, women were more likely than men to experience craniofacial pain in both episodes (p<0.01). There was no statistically significant difference between episodes regarding either ECG findings or the use of the two typical pain quality descriptors "pressure" and "burning". This study is to our knowledge the first to report that craniofacial pain can be the only symptom of a pre-infarction angina. Craniofacial pain constitutes the sole prodromal AMI symptom in one out of 20 AMI patients. Recognition of this atypical symptom presentation is low because research on prodromal AMI symptoms has to date studied only patients with chest pain. To avoid a potentially fatal misdiagnosis, awareness of this clinical presentation needs to be brought to the attention of clinicians, researchers and the general public.

Place, publisher, year, edition, pages
2016. Vol. 29, no 1, p. 23-28
Keywords [en]
facial pain, Myocardial infarction, myocardial ischemia
National Category
Health Sciences Dentistry
Identifiers
URN: urn:nbn:se:umu:diva-43288Scopus ID: 2-s2.0-85029549864OAI: oai:DiVA.org:umu-43288DiVA, id: diva2:412762
Note

Originally included in thesis in manuscript form. 

Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2023-03-24Bibliographically approved
In thesis
1. Craniofacial pain of cardiac origin: an interdisciplinary study
Open this publication in new window or tab >>Craniofacial pain of cardiac origin: an interdisciplinary study
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Referred pain is frequently associated with misdiagnosis and unnecessary therapy directed to the pain location instead of its origin. When craniofacial pain is the sole symptom of myocardial ischemia, failure to recognize its cardiac source can endanger the patient. In particular, patients with acute myocardial infarction (AMI) who do not experience chest pain run a very high risk of misdiagnosis and death. Pain that is limited to the craniofacial region during myocardial ischemia has so far been described only in case reports and its overall prevalence is unknown. Experimental research in animals suggests a vagal involvement in the pathological mechanisms of cardiac pain referred to the face.

The aim of this study was to gain knowledge about the prevalence, clinical characteristics and possible mechanisms of craniofacial pain of cardiac origin, in order to improve the clinician’s ability to make a correct diagnosis. It was hypothesized that the quality of craniofacial pain from cardiac versus dental origin would differ, implying a high diagnostic validity. It was also hypothesized that craniofacial pain can be the sole symptom of a prodromal (pre-infarction) angina episode and that this pain location would be especially associated with cardiac ischemia in the areas more densely innervated by vagal afferent fibres.

The study group was comprised of consecutive patients who experienced craniofacial pain of a verified cardiac (n=326) or dental (n=359) origin. Demographic details on age, gender and pain characteristics (location, quality and intensity) were assessed in both groups. Cardiovascular risk factors, cardiac diagnosis and ECG signs of ischemia were also assessed in the cardiac pain group. Ethics approval and informed consent for each patient was obtained.

Craniofacial pain was found to be the sole symptom of myocardial ischemia in 6% of patients and was the sole symptom of an AMI in 4% of patients; this craniofacial pain was more prevalent in women (p=0.031). In those patients without chest pain, it was the most frequent pain location and was the only symptom of prodromal angina in 5% of AMI patients. The craniofacial pain included the throat, the jaws, the temporomandibular joints/ears and the teeth, mainly bilaterally. The pain quality descriptors “pressure” and “burning” were statistically associated with pain of cardiac origin, while “throbbing” and “aching” were associated with an odontogenic cause (p<0.001). In myocardial ischemia patients, the occurrence of craniofacial pain was associated with an inferior localization of ischemia in the heart (p<0.001).

In conclusion, this study showed that pain in the craniofacial region could be the sole symptom of cardiac ischemia and AMI, particularly in women. Craniofacial pain of cardiac origin was commonly bilateral, with the quality pain descriptors “pressure” and “burning”, and pain provocation with physical activity and pain relief at rest. The association between the presence of craniofacial pain and inferior wall ischemia suggests a vagal involvement in the mechanisms of cardiac pain referred to the craniofacial region. Since the possibility of misdiagnosis and death in this group of patients is high, awareness of this clinical presentation needs to be brought to the attention of researchers, clinicians and the general public.

Place, publisher, year, edition, pages
Umeå: Umeå university, 2011. p. 70
Series
Umeå University odontological dissertations, ISSN 0345-7532 ; 117
Keywords
Acute myocardial infarction, myocardial ischemia, craniofacial pain, referred pain
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-43148 (URN)978-91-7459-160-6 (ISBN)
Public defence
2011-05-20, 933, byggnad 3A 9tr, Norrlands Universitetssjukhus, Umeå, 13:00 (English)
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Available from: 2011-04-29 Created: 2011-04-20 Last updated: 2018-06-08Bibliographically approved

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Kreiner, MarceloWaldenström, AndersIsberg, Annika

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