Craniofacial pain as the sole symptom of cardiac ischemia: A prospective multicenter study

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ABSTRACT

Background

Craniofacial pain can be the only symptom of cardiac ischemia. Failure to recognize its cardiac source can put the patient's life at risk. The authors conducted a study to reveal the prevalence of, 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 pre-ponderantly 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.

Section snippets

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

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

DISCUSSION

The typical presentation of cardiac pain is reported in the left side of the chest, often radiating 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

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

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    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

    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.

    2

    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.

    3

    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.

    4

    Dr. Lujambio is an adjunct professor, Department of Clinical Medicine, Cardiology Service, Hospital de Clínicas, Montevideo, Uruguay.

    5

    Dr. Isberg is a professor, Oral and Maxillofacial Radiology, Department of Odontology, Faculty of Medicine, Umeå University, SE-901 85, Umeå, Sweden

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