Craniofacial Pain of Cardiac Origin Is Associated with Inferior Wall Ischemia

Aims: To investigate possible associations between the presence of craniofacial pain of cardiac origin and the location of cardiac ischemia and conventional risk factors. Methods: A total of 326 consecutive patients with confirmed myocardial ischemia (192 males, 134 females, mean age 64 years) were studied. Demographic details, health history, risk factors, prodromal symptoms, electrocardiogram (ECG) findings, and pain characteristics during the ischemic episode were assessed. The location of the ischemia according to the ECG findings was categorized as anterior, inferior, or lateral. Univariate chi-square analyses and a multivariate logistic regression model were used for data analysis. Two age subgroups (< 65 and > 65) were established when controlling for covariates. Results: Craniofacial pain of cardiac origin was significantly associated with an inferior localization of cardiac ischemia (P < .001) and was more frequently reported in diabetic patients (P = .014). Thirty-eight patients (12%) did not experience chest pain during the myocardial ischemia. Nine patients (3%) experienced a prodromal angina episode without chest pain. Conclusion: The occurrence of craniofacial pain during myocardial ischemia, with or without an acute myocardial infarction, was associated with ischemia within the inferior wall. This result suggests the involvement of the vagal afferent system in the mechanisms of craniofacial pain of cardiac origin.

acute myocardial infarction; cardiac ischemia; chest pain; craniofacial pain; dental pain

1. Uretsky BF, Farquhar DS, Berezin AF, Hood WB Jr. Symptomatic myocardial infarction without chest pain: Prevalence and clinical course. Am J Cardiol 1977;40:498–503.

2. Fesmire FM, Wears RL. The utility of the presence or absence of chest pain in patients with suspected acute myo-cardial infarction. Am J Emerg Med 1989;7:372–377.

3. Herlitz J, Karlson BW, Richter A, Strombom U, Hjalmarson A. Prognosis for patients with initially suspected acute myocardial infarction in relation to presence of chest pain. Clin Cardiol 1992;15:570–576.

4. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283: 3223–3229.

5. Shlipak MG, Go AS, Frederick PD, Malmgren J, Barron HV, Canto JG. Treatment and outcomes of left bundle-branch block patients with myocardial infarction who present with-out chest pain. National Registry of Myocardial Infarction 2 Investigators. J Am Coll Cardiol 2000;36:706–712.

6. Dorsch MF, Lawrance RA, Sapsford RJ, et al. Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain. Heart 2001;86:494–498.

7. Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: Insights from the global registry of acute coronary events. Chest 2004;126:461–469.

8. Hirakawa Y, Masuda Y, Kuzuya M, Iguchi A, Uemura K. Japanese patients with acute myocardial infarction who present without chest pain. Int Heart J 2006;47:483–490.

9. Zdzienicka J, Siudak Z, Zawis´lak B, et al. Patients with non-ST-elevation myocardial infarction and without chest pain are treated less aggressively and experience higher in-hospital mortality. Kardiol Pol 2007;65:769–775.

10. Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A. Craniofacial pain as the sole symptom of cardiac ischemia: A prospective multicenter study. J Am Dent Assoc 2007;138:74–79.

11. Chandler MJ, Qin C, Yuan Y, Foreman RD. Convergence of trigeminal input with visceral and phrenic inputs on primate C1–C2 spinothalamic tract neurons. Brain Res 1999;829:204–208.

12. Qin C, Chandler MJ, Miller KE, Foreman RD. Responses and afferent pathways of superficial and deeper C1–C2 spinal cells to intrapericardial algogenic chemicals in rats. J Neurophysiol 2001;85:1522–1532.

13. Foreman RD, Qin C. Neuromodulation of cardiac pain and cerebral vasculature: Neural mechanisms. Cleve Clin J Med 2009;76(Suppl 2):S75–S79.

14. Culic´ V, Miric´ D, Eterovic´ D. Correlation between symptomatology and site of acute myocardial infarction. Int J Cardiol 2001; 77:163–168.

15. 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; 38:2114–2130.

16. Kreiner M, Falace D, Michelis V, Okeson JP, Isberg A. Quality difference in craniofacial pain of cardiac vs dental origin. J Dent Res 2010;89:965–969.

17. McSweeney JC, Cody M, O´Sullivan P, Elberson K, Moser DK, Garvin BJ. Women’s early symptoms of acute myocardial infarction. Circulation 2003;108:2619–2623.

18. Graham MM, Westerhout CM, Kaul P, Norris CM, Armstrong PW. Sex differences in patients seeking medical attention for prodromal symptoms before an acute coronary event. Am Heart J 2008;156:1210–1216.

19. Hothorn T, Hornik K, van de Wiel M, Zeileis A. A Lego system for conditional inference. Am Stat 2006;60:257–263.

20. Zeileis A, van de Wiel M, Hornik K, Hothorn T. Implementing a class of permutation tests: The coin package. J Stat Softw 2008;28:1–23.

21. Quigg M. Distribution of vagal afferent fibers of the guinea pig heart labeled by anterograde transport of conjugated horseradish peroxidase. J Auton Nerv Syst 1991;36:13–24.

22. Chandler MJ, Zhang J, Foreman RD. Vagal, sympathetic and somatic sensory inputs to upper cervical (C1-C3) spinothalamic tract neurons in monkeys. J Neurophysiol 1996;76:2555–2567.

23. Foreman RD. Neurological mechanisms of chest pain and cardiac disease. Cleve Clin J Med 2007;74(Suppl 1):S30–S33.

24. McNeill DL, Chandler MJ, Fu QG, Foreman RD. Projection of nodose ganglion cells to the upper cervical spinal cord in the rat. Brain Res Bull 1991;27:151–155.

25. Ansari S, Chaudhri K, Al Moutaery KA. Vagus nerve stimulation: Indications and limitations. Acta Neurochir Suppl 2007; 97:281–286.

26. Myers DE. Vagus nerve pain referred to the craniofacial region. A case report and literature review with implications for referred cardiac pain. Br Dent J 2008;204:187–189.

27. Shih JJ, Devier D, Behr A. Late onset laryngeal and facial pain in previously asymptomatic vagus nerve stimulation patients. Neurology 2003;60:1214.

28. Carius A, Schulze-Bonhage A. Trigeminal pain under vagus nerve stimulation. Pain 2005;118:271–273.

29. Meller ST, Gebhart GF. A critical review of the afferent pathways and the potential chemical mediators involved in cardiac pain. Neuroscience 1992;48:501–524.

30. Foreman RD. Mechanisms of cardiac pain. Annu Rev Physiol 1999;61:143–167.

31. Isaksson RM, Holmgren L, Lundblad D, Brulin C, Eliasson M. Time trends in symptoms and prehospital delay time in women vs. men with myocardial infarction over a 15-year period. The Northern Sweden MONICA Study. Eur J Cardiovasc 2008; 7:152–158.

32. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clini-cal characteristics, and mortality among patients with myo-cardial infarction presenting without chest pain. JAMA 2000; 283:3223–3229.

33. Donahoe SM, Stewart GC, McCabe CH, et al. Diabetes and mortality following acute coronary syndromes. JAMA 2007; 298:765–775.

34. Hwang SY, Park EH, Shin ES, Jeong MH. Comparison of factors associated with atypical symptoms in younger and older patients with acute coronary syndromes. J Korean Med Sci 2009; 24:789–794.

35. Francois SJ, Erne P, Urban P, et al. Impact of a normal or non-specific admission ECG on the treatment and early out-come of patients with myocardial infarction in Swiss hospitals between 2003 and 2008. Swiss Med Wkly 2010;140: 13078.