According to the World Health Organization, Cardiovascular diseases (CVDs) are the world’s leading non-communicable cause of deadly diseases.
In Australia, around 18.3% of adults reported having circulatory systems conditions such as heart attack and stroke. Common factors such as sedentary lifestyle, smoking, hypertension, hyperlipidemias, diabetes, obesity and family history have been found to be largely associated with CVDs due to the high risk of forming atherosclerotic plaques. At the same time, genetic factors and ageing also play an important role in the development of CVDs. People with diabetes have been found to have twice the risk of developing CVDs, five times greater chances of having a stroke and ten times greater possibilities of having a heart attack in their lifetime. Symptoms such as chest pain, dyspnea, nausea and fatigue are usually presented for patients who are suspected with CVDs.
In this case study, it is difficult to give a specific medical diagnosis without assessing the patient’s history and performing any physical examinations. However, from the patient’s age (60 years old) and his symptoms (left-sided chest pain), it is suspected to have been suffer from coronary heart issues such as angina pectoris or myocardial infarction or pulmonary embolism.
Coronary heart disease (CHD) refers to a narrowing or blockage of blood vessels caused by a blood clot or constriction of the blood vessel. Blood vessels narrowing are most often caused by building up plaques due to atherosclerosis. This will result in inadequate oxygen-rich blood flow to meet the demands of the heart. It can be an acute or chronic situation, depending on the degree and the site of obstruction. Research has shown that there is a high prevalence in the western world and has a higher risk in males. For people aged 40 years, the lifetime risk of developing CHD was 49% in men and 32% in women whereas for those reaching age 70 years, the lifetime risk was 35% in men and 24% in women.
Angina pectoris is a chronic condition which is caused by a temporary and reversible inadequate blood flow in coronary arteries which have been already narrowed because of atherosclerosis. It usually precipitates when the heart is suffering from heavy workload which requires a high demand for oxygen. As a result, the heart starts to work harder. As such, patients usually result in discomfort heaviness, squeezing, tightening, choking pain and might even complain of having a tight band across the chest. The pain can spread to the lower shoulder and down to the arm, elbow and fingers. This usually lasts for three to four minutes and can be relieved by glyceryl trinitrate and rest.
Myocardial infarct is an acute condition which is caused by a complete and irreversible obstruction of a coronary artery due to thrombosis in blood vessels that have been already narrowed because of atherosclerosis. The constriction of blood flow will result in severe crushing pain in the chest region. The pain often spreads to the neck, throat, jaw, shoulders, arms, or the back from left to right direction. The duration usually lasts for 30-40 minutes or even hours, and there are no relieving factors nor precipitate factors. However, acute ischemia will be automatically healed with scarring and local ischemia and necrosis may develop in the myocardial tissues. Therefore, multiple symptoms such as dyspnea, pallor, cold sweat, nausea and vomiting may develop, and the patient may undergo shock in severe condition.
Pulmonary embolism is a life-threatening blockage of pulmonary arteries in the lung by blood clots which mostly come from the deep veins of the legs. This condition is a complication of deep vein thrombosis, the constriction of blood flow to the rest of the body will result in shortness of breath and chest pain. Family history, poor lifestyle habits and presence of heart disease, physically inactivity as well as surgeries contributes to a high risk of experiencing pulmonary embolism. While, the risk of blood clots developing increases as travel increases, so it is always recommended to drink plenty of waters, take breaks between long duration of sitting and flex the ankles every 15 to 30 minutes
Angina pectoris, myocardial infarction and pulmonary embolism can all cause different degrees of chest pain in relevant mechanisms:
In angina pectoris, patient’s coronary arteries are usually narrowed by plagues that made up of fatty deposits, cholesterol, calcium, and other substances found in the blood as well as scar tissues deposits due to atherosclerosis. Over time, plaque hardens and stiff which narrows the arteries and restricts the flow of oxygen-rich blood to the heart. The supply is still enough to compensate the demand from the heart when patient is at rest. However, when the patient gets physically active due to exercise, severe emotional stress, or after a heavy meal, the heart needs to work harder and the narrowed arteries may not be able to supply adequate amount of blood to the myocardium. Insufficient oxygen available to the tissues cause anaerobic respiration, lactic acid and other metabolites to accumulate thus stimulating the nerve endings resulting in chest pain. Nevertheless, when the patient stops exercising, heart demand decrease, and the anaerobic respiration will revert to aerobic respiration causing the pain to be relieved. Therefore, angina pectoris presents with a short duration of discomfort and no permanent damage to the myocardium. Early detection of angina pectoris may prevent the onset of myocardial infarction.
In myocardial infarction, patient’s coronary arteries are also narrowed by plagues due to atherosclerosis. Once severe narrowing of all arteries happens and has already caused pain in the previous weeks due to the insufficient of oxygen-rich blood supply to meet the demand and results in angina pectoris ; or an acute thrombosis superimposed, the arteries will be totally blocked, and no blood nor oxygen and nutrients will be transferred to the myocardium. When ischemia occurs, chest pain will be resulted as the results of anaerobic respiration and lactic acid build up. Moreover, as the coronary arteries are completely blocked, the severe pain is not able to be relieved by any relieving factors such as vasodilators. Finally, causing cell damage and necrosis to the myocardium due to hypoxia. The longer the blockage occurs, the more damage that can be cause.
In pulmonary embolism, one or more arteries of the lung are blocked by a clot transporting from the deep vein of the leg after being inactive for a period. When the patient start moving, the blood clots in the lower body will start to move following the blood flow and eventually reaches the heart and causes inflammation of the lung walls and cause sharp chest pain. The clot can be caused by a change in the body such as long period of bed rest, pregnancy or recent surgeries, however 40% of cases are unprovoked.
Angina pectoris Myocardial infarction Pulmonary embolism
Degree of pain Heaviness, squeezing, tightening, choking pain and describe like having a tight band across the chest Severe crushing pain and being describe as the worst pain in ever Sharp chest pain and get worse during coughing or taking a deep breath
- Duration of pain Short, 3-4 minutes Long, 30-40 minutes to hours Very short
- Precipitate factors Physically activities such as exercise Nothing Start moving after being inactive for a period
- Relieving factors Rest and vasodilators Nothing Anticoagulants
Fig. 1 Comparison of angina pectoris and myocardial infarction
After comparing the mechanisms and the degree of pain felt in angina pectoris, myocardial infarction and pulmonary embolism, in this case, a 60-year-old male suddenly experienced left-sided chest pain while playing golf is more possibly associated with angina pectoris. Firstly, the gender and age of the patient is at high risk of cardiovascular disease as well as atherosclerosis which assumes there should be a degree of narrowing of arteries by plagues, as well as thickening and weakening vessel walls. As soon as he exercises (play golf), the blood and oxygen supply and demand will fail to maintain the balance due to the incomplete obstruction of the coronary arteries. Hence, resulting in anaerobic respiration and buildup of lactic acid causing a short tightening, squeezing and choking pain. Once he stops exercise, the blood and oxygen demand can be resumed and compensated, so the pain will be relieved.
In this case study, the patient is possibly associated with angina pectoris due to his sudden onset left chest pain triggered by exercising which fits the main clinical features of angina. However, without further medical history taking and physical examination such as electrocardiogram, blood test and chest x-rays which able the health professionals to trace and measure markers of the heart and look at the circulatory systems, it is difficult to give any detailed medical diagnosis. That’s why as a chiropractor, a part of the primary health care practitioners, we are here to treat patients whole body, if they come with symptoms of pain, we can use our knowledge to assess the whole picture and not just focusing on the site of pain and rule out the serious conditions behind which may cause serious complications and even dead. Our clinical decision-making centers on fundamental principles of avoiding patient harm and providing effective care so if serious conditions can be early identified and treated by relevant medical professionals, this can highly increase the survival rates.