About Atypical Localization of the Pain in Myocardial Ischemia


N.Т. Vatutin1, 2, G.G. Taradin1, 2, О.I. Stolika2, V.B. Kostogryz2, N.А. Glinskaya2, А.V. Dmitriev2

1Department of Hospital Therapy, Donetsk National Medical University named after M. Gorky, Donetsk, Ukraine/DPR

2Department of Emergency Cardiac Care and Surgery, Institute of Urgent and Reconstructive Surgery named after V.K. Gusak, Donetsk, Ukraine/DPR

For correspondence: Gennadiy G. Taradin — PhD in Med, Ass. Prof., Department of Hospital Therapy, Donetsk National Medical University named after M. Gorky, High Senior Officer of Department of Emergency Cardiac Care and Surgery, Institute of Urgent and Reconstructive Surgery named after V.K. Gusak; e-mail: taradin@inbox.ru

For citation: Vatutin NТ, Taradin GG, Stolika ОI, Kostogryz VB, Glinskaya NА, Dmitriev АV. About Atypical Localization of the Pain in Myocardial Ischemia. Intensive Care Herald. 2016;3:70–75.

Introduction. The pain syndrome is leading clinical manifestation of angina pectoris and myocardial infarction. The pain syndrome is characterized by as rule pressing and constricting pains which are located predominantly in retrosternal area or in the left side of the chest.

Clinical case. The presented clinical case describes a clinical situation when a patient had initially been complaining of pungent pains in 3rd, 4th, and 5th fingers of the left arm occurring in exercise and rest. In consultation we suspected ischemic genesis of these pains on basis of a rapid reaction to molsidomine and detection of typical for ischemia electrocardiographic (ECG) and echocardiographic changes. The patient underwent contrast coronary angiography which allowed visualizing critical stenosis of the left anterior interventricular branch of left coronary artery. Further we performed balloon angioplasty of the stenotic part and as a result the artery lumen was enlarged. The coronary stenting of the affected coronary segment was accomplished with complete restoration of the artery lumen. No abnormalities on ECG recorded in rest, exercise (treadmill test) and Holter monitoring were revealed in the post-operation period.

Conclusion. Given ischemic heart disease and, as a part, acute coronary syndrome may manifest with pains of various locations and radiations, the general practitioners and cardiologic department doctors should pay special attention to all cases accompanying by painful sensations of atypical localization that would dramatically influence on the disease course and outcome of patients.

Keywords: ischemic heart disease, acute coronary syndrome, diagnostics, pain syndrome, localization, radiation, percutaneous coronary intervention

Received: 31.07.2016


  1. Ватутин Н.Т. Неотложная кардиология. Донецк: ФО-П, 2012. [Vatutin N.T. Neotlozhnaya kardiologia (Urgent Cardiology). Donetsk: FO-P, 2012. (In Russ)]
  2. Fihn S.D., Gardin J.M., Abrams J. et al. Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society Task Force on Practice Guidelines, and the American College of Physicians, American Report of the American College of Cardiology Foundation/American Heart Association Management of Patients With Stable Ischemic Heart Disease: Executive Summary: a 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012; 126: 3097–3137. doi: 10.1161/CIR.0b013e3182776f83.
  3. Rybicki F.J., Udelson J.E., Peacock W.F. et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J. Am. Coll. Cardiol. 2016; 67(7): 853–879. doi: 10.1016/j.jacc.2015.0 9.011.
  4. Bosner S., Bonisch K., Haasenritter J. et al. Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients? — A cross sectional study. BMC Fam. Pract. 2013; 14: 154. doi: 10.1186/1471-2296-14-154.
  5. Hamm C.W., Mollmann H., Bassand J.P., Van de Werf F. Acute Coronary Syndromes. The ESC Textbook of Cardiovascular Medicine. Oxford, 2009: 535–596.
  6. Cervellin G, Rastelli G. The clinics of acute coronary syndrome. Ann. Transl. Med. 2016; 4(10): 191. doi: 10.21037/atm.2016.05.10.
  7. Thygesen K., Alpert J.S., Jaffe A.S. et al. Third universal definition of myocardial infarction. J. Am. Coll. Cardiol. 2012; 60: 1581–1598. doi: 10.1161/CIR.0b013e31826e1058.
  8. Malik M.A., Khan S.A., Safdar S., Taseer I.U.H. Chest pain as a presenting complaint in patients with acute myocardial infarction (AMI). Pak. J. Med. Sci. 2013; 29(2): 565–568. doi: 10.12669/pjms.292.2921
  9. Chatterjee K. Coronary artery disease. In: Panvascular medicine: integrated clinical management, Eds: P. Lanzer, E. Topol. Springer-Verlag. 2013; 24: 379–387.
  10. Foreman R.D. Mechanisms of cardiac pain. Annu. Rev. Physiol. 1999; 61: 143–167.
  11. Renker M., Baumann S., Rier J. et al. Imaging coronary artery disease and the myocardial ischemic cascade: clinical principles and scope. Radiol. Clin. North Am. 2015; 53(2): 261–269. doi: 10.1016/j.rcl.2014.11.010.
  12. Карпов Р.С., Дудко В.А. Атеросклероз: патогенез, клиника, функциональная диагностика, лечение. Томск: STTТМ, 1998. [Karpov R.S., Dudko V.A. Ateroskleroz: patogenez, klinika, funktsional’naya diagnostika, lechenie. Tomsk: STTТМ, 1998. (In Russ)]
  13. Culic V., Miric D., Eterovic D. Correlation between symptomatology and site of acute myocardial infarction. Int. J. Cardiol. 2001; 77(2–3): 163–168.
  14. Karnath B., Holden M.D., Hussain N. Chest pain: differentiating cardiac and noncardiac causes. Hospital Physician. 2004; 38: 24–27.
  15. Fazlyab M., Esnaashari E., Saleh M. et al. Craniofacial pain as the sole sign of prodromal angina and acute coronary syndrome: a review and report of a rare case. Iran. Endod. J. 2015; 10(4): 274–80. doi: 10.7508/iej.2015.04.013.
  16. Batchelder B.J., Krutchkoff D.J., Amara J. Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report of case. J. Am. Dent. Assoc. 1987; 115(5): 710–712.
  17. Kreiner M., Okeson J.P. Toothache of cardiac origin. J. Orofac. Pain. 1999; 13(3): 201–207.
  18. Rothwell P.M. Angina and myocardial infarction presenting with pain confined to the ear. Postgrad. Med. J. 1993; 69(810): 300–301.
  19. Хороших О.А. Атипичные варианты инфаркта миoкарда. Клинический случай редкой формы острого коронарного синдрома с периферическим эквивалентом стенокардии. Бюллетень ВСНЦ СО РАМН. 2013; 5(93): 104–107. [Choroshich OA. Atypical variants of myocardial infarction. The clinical case of rare form acute coronary syndrome with peripheral angina equivalent. Bulletin of the East Siberian Scientific Center of the Academy of Medical Sciences. 2013; 5(93): 104–107. (In Russ)]