Skip to main content
SpringerLink
Log in

Visceral chest pain in unstable angina pectoris and effects of transcutaneous electrical nerve stimulation (TENS)

Viszerale brustschmerzen bei instabiler angina pectoris und wirkung der transkutanen elektrischen nervenstimulation (TNS). Eine Übersicht

A review

  • Published:
Herz Aims and scope Submit manuscript

Abstract

A substantial proportion of patients with chest pain referred to hospital, show signs of coronary artery disease. Anginal pain could be conceptualized as a warning signal for coronary artery disease and impending death. But, for many reasons this theory is partly disputed. Firstly, not all ischemic episodes are accompanied by anginal pain (silent ischemia). Secondly, chest pain indistinguishable from true angina pectoris may be the result of other abnormalities of thoracic viscera.

Nevertheless acute severe cardiac ischemia often gives rise to anginal chest pain. Unstable angina pectoris is carrying a higher risk for future events in spite of intensive medical treatment. A special problem are patients awaiting coronary intervention because of severe ischemia and maximum medical treatment, who experience ischemic pain. New treatment regimens are needed for these patients.

This review discusses the symptom of visceral pain from the heart, angina pectoris, its relation to ischemia and unstable angina pectoris. It also addresses the role of afferent nerve stimulation (transcutaneous electrical nerve stimulation, TENS) in the treatment of severe angina pectoris as well as recent findings of TENS applicability in unstable angina.

Zusammenfassung

Eine große Zahl von Patienten, die zur Klinikaufnahme kommen, klagt über Brustschmerzen, die typisch für eine koronare Herzerkrankung sind. Die Angina pectoris ist ein Warnsignal für die koronare Herzerkrankung und geht als Präinfarktangina dem Herzinfarkt und plötzlichen Herztod voraus. Problematisch ist, daß nicht alle ischämischen Herzattacken von einer Angina pectoris begleitet werden (stumme Ischämie) und Brustschmerzen, die von der wahren Angina pectoris nicht getrennt werden, auch von anderen Organen des Thorax stammen können.

Die Angina pectoris zeigt die typischen Eigenschaften eines viszeralen Schmerzes. Er ist oft wenig genau lokalisiert, auf andere anatomische Regionen projiziert (linker Arm, Unterkiefer) aber auch von motorischen, autonomen Reflexen begleitet (Übelkeit, Schweißausbruch). Unspezifische Schmerzrezeptoren wurden im Bereich des Herzens lokalisiert. Der Stimulus, der über diese Rezeptoren Schmerzsensationen hervorruft, ist wahrscheinlich multifaktoriell. Viele verschiedene Stimuli sind diskutiert worden: chemische Stimulationen durch Lactate, Kalium und Adenosin, mechanische Stimulation durch das ischämische Herz wie auch durch Sensibilitätsstörungen und Entzündungen. Der Schmerz könnte aber durch eine Kombination verschiedener Stimuli ausgelöst sein, so daß eine genügend hohe Intensität erreicht wird, um die Nerven zu aktivieren.

Auf verschiedenen Ebenen kann die afferente Nervenbahn moduliert (verstärkt oder vermindert) werden durch afferente Aktivierung anderer viszeraler thorakaler Organe und somatischer Strukturen, wie lokaler Plexus, Ganglien und verschiedener segmentaler Ebenen des Rückenmarks. Verschiedene Schmerzmodulationsmechanismen, wie endogene Peptide, deszendierende inhibitorische und afferente Stimulatoren, konnten segmental aktiviert werden. Die sekundären Neuronen bewirken eine zentrale Weiterleitung, bevor der sensorische Kortex erreicht ist und die Empfindung wahrgenommen wird. Es wird verständlich, daß die Schmerzempfindung nicht automatisch zur Schwere der Ischämie in Bezug zu setzen ist. Die akute kardiale Ischämie führt häufig zur Angina pectoris. Die instabile Angina pectoris beinhaltet ein erhöhtes Risiko, im weiteren Verlauf Komplikationen zu entwickeln. Ein spezielles Problem haben die Patienten, die auf eine koronare Intervention warten, weil schwere Ischämien bestehen oder eine maximale medikamentöse Behandlung die Schmerzsymptomatik nicht beherrschen kann. Neue Behandlungsstrategien sind für diese Patienten notwendig. Die afferente Nervenstimulation hat eine gewisse Popularität erhalten, nachdem sie erstmalig durch Melzack u. Walls als “Gate Control Theory” 1965 veröffentlicht wurde. Der Effekt der transkutanen elektrischen Nervenstimulation (TENS) ist sowohl bei akuter als auch bei neuropathischer Schmerzsymptomatik hilfreich. Durch elektrische Stimulation können die afferenten Nervenfasern stimuliert werden. Der Schmerzverlust wird sekundär durch den segmentalen Mechanismus des Rückenmarks bewirkt.

TENS ist vermehrt bei ischämischem Schmerzstatus eingesetzt worden, so auch bei peripherer arterieller Verschlußkrankheit, primäre Dysmenorrhöen und seit 1970 bei myokardialer Ischämie. Die Methode scheint die Ischämie zu vermindern, wahrscheinlich weil der myokardiale Sauerstoffverbrauch gesenkt wird. Bei chronischer, schwerer Angina pectoris wird aus praktischen Gründen die TENS durch die spinale Rückenmarksstimulation (SCS) abgelöst. Kürzlich ist die Anwendung von TENS bei akutem Koronarsyndrom der instabilen Angina pectoris als Zusatzbehandlung eingeführt worden. TENS wurde als praktikable Methode erkannt, die nicht mit dem weiteren Standardmanagement für die Patienten interferiert und die Phasen der stummen Ischämie reduzieren kann.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Andrews TC, Raby K, Barry J, et al. Effect of cholesterol reduction on myocardial ischemia in patients with coronary disease. Circulation 1997; 95: 324–8.

    PubMed  CAS  Google Scholar 

  2. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996; 335: 1342–9.

    PubMed  CAS  Google Scholar 

  3. Areskog M, Tibbling L, Wranne B. Non-infarction coronary unit patients. Acta Med Scand 1981; 209: 51–7.

    PubMed  CAS  Google Scholar 

  4. Augustinsson L, Linderoth B, Mannheimer C. Spinal cord stimulation in various ischemic conditions In: Illis L, ed. Spinal cord dysfunction, Vol III. Functional stimulation. Oxford University Press, Oxford, 1992: 272–95.

    Google Scholar 

  5. Baker DG, Coleridge HM, Coleridge JCG, et al. Search for a cardiac nociceptor: stimulation by bradykinin of sympathetic afferent nerve endings in the heart of the cat. J Physiol 1980; 306: 519–36.

    PubMed  CAS  Google Scholar 

  6. Barish CF, Castell DO, Richter JE. Graded esophageal balloon distention-a new provocative test for non-cardiac chest pain. Dig Dis Sci 1986; 31: 1292–8.

    PubMed  CAS  Google Scholar 

  7. Bates JAV, Nathan PW. Transcutaneous electrical nerve stimulation for chronic pain. Anaesthesia 1980; 35: 817–22.

    PubMed  CAS  Google Scholar 

  8. Becker RC, Cannon CP, Bovill EG, et al. Prognostic value of plasma fibrinogen concentration in patients with unstable angina and non-Q wave myocardial infarction (TIMI IIIB trial). Am J Cardiol 1996; 78: 142–7.

    PubMed  CAS  Google Scholar 

  9. Bennett JR, Atkinson M. The differentiation between oesophageal and cardiac pain. Lancet 1966; 2: 1123–7.

    PubMed  CAS  Google Scholar 

  10. Bishop VS, Malliani A, Thorén P. Cardiac mechanoreceptors. In: Shepherd JT, Abboud FM. Geiger SR. Handbook of physiology, Vol. III. Washington. Am Physiological Soc 1983: 497–55.

  11. Blackwell JN, Castell DO. Oesophageal chest pain: a point of view. Gut 1984; 25: 1–6.

    PubMed  CAS  Google Scholar 

  12. Blair RW, Weber RN, Foreman RD. Responses of thoracic spinothalamic neurones to intracardiac injection of bradykinin in the monkey. Circ Res 1982; 51: 83–94.

    PubMed  CAS  Google Scholar 

  13. Bortolotti M, Bacchelli S, Esposti SD, et al. Angina-like chest pain of esophageal origin: a possible side-effect of the chronic anti-anginal therapy. Gastroenterology 1990: A 24. abstract.

  14. Bosch X, Theroux P, Waters D, et al. Early post-infarction ischemia: Clinical, angiographic, and prognostic significance. Circulation 1987; 75: 988–95.

    PubMed  CAS  Google Scholar 

  15. Börjesson M, Eriksson P, Dellborg, et al. Transcutaneous electrical nerve stimulation in unstable angina pectoris. Coron Art Dis 1997; 8: 543–50.

    Google Scholar 

  16. Börjesson M, Pilhall M, Eliasson T, et al. Esophageal dysfunction in syndrome X. Am J Cardiol 1998; 82: 1187–91.

    PubMed  Google Scholar 

  17. Caffrey JL, Gaugl JF, Jones CE. Local endogenous opiate activity in dog myocardium: Receptor blockade with naloxone. Am J Physiol 1985; 248: H382–8.

    PubMed  CAS  Google Scholar 

  18. Campbell JA. A critical appraisal of the electrical output characteristics of ten transcutaneous nerve stimulators. Clin Phys Measurement 1982; 3: 141–50.

    CAS  Google Scholar 

  19. Campbell JN, Taub A. Local analgesia from percutaneous electrical stimulation. Arch of Neurol 1973;28:347–350.

    CAS  Google Scholar 

  20. Cannon CP, McCabe CH, Stone PH, et al. Circadian variation in the onset of unstable angina and non-Q wave acute myocardial infarction (the TIMI III registry and TIMI IIIB). Am J Cardiol 1997;79:253–8.

    PubMed  CAS  Google Scholar 

  21. Cannon RO. The sensitive heart. A syndrome of abnormal cardiac pain perception. JAMA 1995;273:883–7.

    PubMed  Google Scholar 

  22. Cervero F. Sensory innervation of the viscera: peripheral basis of visceral paint. Physiol Rev 1994;74:95–138.

    PubMed  CAS  Google Scholar 

  23. Cervero F, Lumb BM. Bilateral inputs and supraspinal control of viscerosomatic neurones in the lower thoracic spinal cord of the cat. J Physiol 1988;403:221–37.

    PubMed  CAS  Google Scholar 

  24. Cervero F, Tattersall JEH. Somatic and visceral sensory integration in the thoracic spinal cord. In: Cervero F, Morrison JFB. Visceral sensation. Progress in brain research, Vol 67 Amsterdam: Elsevier 1986:189–205.

    Google Scholar 

  25. Chandler MJ, Brennan TJ, Garrison DW et al. A mechanism of cardiac pain suppression by spinal cord stimulation: implications for patients with angina pectoris. Eur Heart J 1993;14:96–105.

    PubMed  CAS  Google Scholar 

  26. Chauhan A, Mullins PA, Thuraisingham SI, et al. Effect of transcutaneous electrical nerve stimulation on coronary blood flow. Circulation 1994;89:694–702.

    PubMed  CAS  Google Scholar 

  27. Chauhan A, Petch MC, Schofield PM. Effect of oesophageal acid instillation on coronary blood flow. Lancet 1993;341:1309–10.

    PubMed  CAS  Google Scholar 

  28. Cherniack NS, Runold M, Prabhakar NR, et al. Effect of adenosine on vagal sensory pulmonary afferents. Fed Proc 1987;46:825.

    Google Scholar 

  29. Cohn PF. Silent myocardial ischemia in patients with a defective anginal warning system. Am J Cardiol 1980;45:697–702.

    PubMed  CAS  Google Scholar 

  30. Cook AW, Oygar A, Baggenstos P. et al. Vascular disease of extremities-Electric stimulation of spinal cord and posterior roots. NY State J Med 1976;76:366–8.

    CAS  Google Scholar 

  31. Dawood MY, Ramos J. Transcutaneous electrical nerve stimulation (TENS) for the treatment of primary dysmenorrhea: a randomized crossover comparison with placebo TENS and ibuprofen. Obstet Gynecol 1990;75:656–60.

    PubMed  CAS  Google Scholar 

  32. De Landsheere C, Mannheimer C, Habets A, et al. Effect of spinal cord stimulation on regional myocardial perfusion assessed by positron emission tomography. Am J Cardiol 1992;69:1143–9.

    PubMed  Google Scholar 

  33. Deanfield JE, Shea M, Ribiero P, et al. Transient ST-segment depression as a marker of myocardial ischemia during daily life. Am J Cardiol 1984;54:1195–200.

    PubMed  CAS  Google Scholar 

  34. Deedwania PC, Carbajal EV. Silent myocardial ischemia-a clinical perspective. Arch Intern Med 1991;151:2373–82.

    PubMed  CAS  Google Scholar 

  35. Deedwania PC, Carbajal EV, Nelson JR, et al. Anti-ischemic effects of atenolol versus nifedipine in patients with coronary artery disease and ambulatory silent ischemia. J Am Coll Cardiol 1991;17:963–9.

    PubMed  CAS  Google Scholar 

  36. DeJongste MJL, Haaksma J, Hautvast RWM, et al. Effects of spinal cord stimulation on myocardial ischemia during daily life in patients with severe coronary artery disease. Br Heart J 1993;71:413–8.

    Google Scholar 

  37. DeMeester TR, O’Sullivan GC, Bermudez G, et al. Esophageal function in patients with angina-type chest pain and normal coronary angiograms. Ann Surg 1982;196:488–98.

    PubMed  CAS  Google Scholar 

  38. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–8.

    PubMed  CAS  Google Scholar 

  39. Droste C, Roskamm H. Experimental pain measurement in patients with asymptomatic myocardial ischemia. J Am Coll Cardiol 1983;1:940–5.

    PubMed  CAS  Google Scholar 

  40. Edlund A, Fredholm BB, Patrignani P, et al. Release of two vasodilators — adenosine and prostacyclin — from isolated rabbit hearts during controlled hypoxia. J Physiol 1983;340:487–501.

    PubMed  CAS  Google Scholar 

  41. Eliasson T, Jern S, Augustinsson L-E, et al. Safety aspects of spinal cord stimulation in severe angina pectoris. Coron Art Dis 1994;5:845–50.

    CAS  Google Scholar 

  42. Eliasson T, Mannheimer C, Waagstein F, et al. Myocardial turnover of endogenous opioids and calcitonin-gene-related peptide in the human heart and the effects of spinal cord stimulation on pacing induced angina pectoris. Cardiology 1998;89:170–7.

    PubMed  CAS  Google Scholar 

  43. Epstein SE, Quyyumi AA, Bonow RO. Myocardial ischemia: Silent or symptomatic. N Engl J Med 1988;318:1038–43.

    PubMed  CAS  Google Scholar 

  44. Eriksson MBE, Rosén I, Sjölund B. Thermal sensitivity in healthy subjects is decreased by a central mechanism after TNS. Pain 1985;22:235–42.

    PubMed  CAS  Google Scholar 

  45. Fazzini PF, Prati PL, Rovelli F, et al. Epidemiology of silent myocardial ischemia in asymptomatic middle-aged men (the ECCIS Project). Am J Cardiol 1993;72:1383–8.

    PubMed  CAS  Google Scholar 

  46. Foreman RD. Spinothalamic tract and cardiac afferents. In: Lown B, Malliani A, Prosdocimi M. Fidia research series, Vol. 5. Padova Liviana Press 1986;169–81.

    Google Scholar 

  47. Friedman M, Breall WS, Goodwin ML, et al. Effect of type A behavioral counseling on frequency of episodes of silent myocardial ischemia in coronary patients. Am Heart J, 1996;132:933–7.

    PubMed  CAS  Google Scholar 

  48. Garcia-Pulido J, Patel PH, Hunter WC, et al. Esophageal contribution to chest pain in patients with coronary artery disease. Chest 1990;98:806–10.

    PubMed  CAS  Google Scholar 

  49. Geft IL, Fishbein MC, Ninomiya K. Intermittent brief periods of ischemia have a cumulative effect and may cause myocardial necrosis. Circulation 1982;66:1150–3.

    PubMed  CAS  Google Scholar 

  50. Gelford M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical manometric and radionuclide evaluation. Gastroenterology 1982;83:963–9.

    Google Scholar 

  51. Gilbert NC, LeRoy GV, Fenn GK. The effect of distention of abdominal viscera on the blood flow in the circumflex branch of the left coronary artery of the dog. Am Heart J 1940;20:519–24.

    Google Scholar 

  52. Glazier JJ, Chierchia S, Brown MJ, et al. Importance of generalized defective perception of painful stimuli as a cause of silent myocardial ischemia in chronic stable angina pectoris. Am J Cardiol 1986;58:667–72.

    PubMed  CAS  Google Scholar 

  53. Gottlieb S, Weisfeldt M, Ouyang P, et al. Effect of the addition of propranolol to therapy with nifedipine for unstable angina pectoris: a randomized, double-blind placebo-controlled trial. Circulation 1986;73:331–7.

    PubMed  CAS  Google Scholar 

  54. Gottlieb SO, Gottlieb SH, Achuff SC, et al. Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients. JAMA 1988;259:1030–5.

    PubMed  CAS  Google Scholar 

  55. Gottlieb SO, Weisfeldt ML, Ouyang P, et al. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med 1986;314:1214–9.

    PubMed  CAS  Google Scholar 

  56. Hautwast RWM, Blanksma PK, DeJongste MJL, et al. Effect of spinal cord stimulation on myocardial flow assessed by positron emission tomography in patients with refractory angina pectoris. Am J Cardiol 1996;77:462–7.

    Google Scholar 

  57. Held PH, Yusuf S, Furberg CD. Calcium channel blockers in acute myocardial infarction and unstable angina. An Overview. Br Med J 1989;299:1187–92.

    CAS  Google Scholar 

  58. Hoberg E. Symptomatic, versus asymptomatic ischemic episodes during Holter monitoring: patterns of high resolution trend recordings of ST segment and heart rate. In: von Arnim T: Maseri A. Silent ischemia. Darmstadt: Steinkopff 1987:125–30.

    Google Scholar 

  59. Jacobs MJMH, Jörning PJG, Beckers RCY, et al. Foot salavage and improvement of microvacular, blood flow as a result of epidural spinal cord electrical stimulation. J Vasc Surg 1990;12:354–60.

    PubMed  CAS  Google Scholar 

  60. Janes RD, Brandys JC, Hopkins DA, et al. Anatomy of human extrinsic cardiac nerves and ganglia. Am J Cardiol 1986;57: 299–309.

    PubMed  CAS  Google Scholar 

  61. Janssens J, Vantrappen G, Ghillebert G. 24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain. Gastroenterology 1986;90:1978–84.

    PubMed  CAS  Google Scholar 

  62. Jivegård LEH, Augustinsson L-E, Holm, J, et al. Effects of spinal cord stimulation (SCS) in patients with inoperable severe lower limb ischaemia: a prospective randomised controlled study. Eur J Vasc Endovasc Surg 1995;9:421–5.

    PubMed  Google Scholar 

  63. Johnson MI, Ashton CH, Bousfield DR, et al. Analgesic effects of different, frequencies of transcutaneous electrical nerve stimulation on cold induced pain in normal subjects. Pain 1989;39:231–6.

    PubMed  CAS  Google Scholar 

  64. Johnson MI, Ashton CH, Thompson JW. An in-depth study of long-term users of transcutaneous electrical nerve stimulation (TENS). Implications for clinical use of TENS. Pain 1991;44:221–9.

    PubMed  CAS  Google Scholar 

  65. Kaada B Promoted healing of chronic ulceration by transcutaneous nerve stimulation (TNS). VASA 1983;12:262–9.

    PubMed  CAS  Google Scholar 

  66. Kannel WB, Abbott RD. Incidence and prognosis of unrecognized myocardial infarction. N Engl J Med 1984;311:1144–7.

    PubMed  CAS  Google Scholar 

  67. Kaplan B, Peled Y, Pardo J, et al. Transcutaneous electrical nerve stimulation (TENS) as a relief for dysmenorrhea Clin Exp Obstet Gynecol 1994;21:87–90.

    PubMed  CAS  Google Scholar 

  68. Katon W, Vitaliano DD, Russo J, et al. Panic disorder: Epidemiology in primary care. J Fam Pract 1986;23:233–9.

    PubMed  CAS  Google Scholar 

  69. Katz PO, Dalton CB, Richter JE, et al. Esophageal testing of patients with noncardiac chest pain or dysphagia-results of three years’ experience with 1161 patients. Ann Intern Med 1987;106: 593–7.

    PubMed  CAS  Google Scholar 

  70. Keele CA, Armstrong D. Substances producing pain and itch. London: Arnold, 1964:329–37.

    Google Scholar 

  71. Kellermann JJ, Braunwald E. silent myocardial ischemia: a critical appraisal. Basel: Karger, 1990.

    Google Scholar 

  72. Knatterud GL, Bourassa MG, Pepine CJ, et al. Effects of treatment strategies to suppress ischemia in patients with coronary artery disease: 12-week results of the Asymptomatic Cardiac Ischemia Pilot (ACIP) study. J Am Coll Cardiol 1994;24:11–20.

    PubMed  CAS  Google Scholar 

  73. Lam HGT, Dekker W, Kan G, et al. Acute noncardiac chest pain in a coronary care unit. Gastroenterology 1992;102:453–60.

    PubMed  CAS  Google Scholar 

  74. Lindahl B, Andrén B, Ohlsson J, et al. Risk stratification in unstable coronary artery disease. Additive value of troponin T determination and pre-discharge exercise tests. Eur Heart J 1997;18: 762–70.

    PubMed  CAS  Google Scholar 

  75. Lindahl B, Venge P, Wallentin L. Relation between troponin T and the risk of subsequent cardiac events in unstable coronary artery disease. Circulation 1996;93:1651–7

    PubMed  CAS  Google Scholar 

  76. Linderoth B, Fedorcsak I, Meyerson BA. Peripheral vasodilatation after spinal cord stimulation animal studies of putative effector mechanisms Neurosurgery 1991;28:187–95.

    PubMed  CAS  Google Scholar 

  77. Liuzzo G, Biasucci LM, Gallimore JR, et al. The prognostic value of C-reactive protein and serum amyloid A protein in severe unstable angina. N Engl J Med 1994;331:417–24.

    PubMed  CAS  Google Scholar 

  78. Malliani A. The conceptualization of cardiac pain as a nonspecific and unreliable alarm system. In: Gebhart GF. Visceral pain, Vol. 5. Seattle: IASP Press, 1995;63–74.

    Google Scholar 

  79. Malliani A, Brown AM. Reflexes arising from coronary receptors. Brain Res 1970;24:352–5.

    PubMed  CAS  Google Scholar 

  80. Malliani A, Lombardi F. Consideration of the fundamental mechanisms eliciting cardiac pain. Am Heart J 1982;103:575–8.

    PubMed  CAS  Google Scholar 

  81. Malliani A, Pagani M, Lombardi F. Positive feedback reflexes. In: Zanchetti A, Tarazi RC, Handbook of hypertension. Vol. 8. Pathophysiology of hypertension. Amsterdam: Elsevier, 1986: 69–81.

    Google Scholar 

  82. Malliani A, Recordati G, Schwartz PJ. Nervous activity of afferent cardiac sympathetic fibres with atrial and ventricular endings. J Physiol 1973;229:457–69.

    PubMed  CAS  Google Scholar 

  83. Mannheimer C, Carlsson C-A, Vedin A, et al. Transcutaneous electrical nerve stimulation (TENS) in angina pectoris. Pain 1986;26:291–300.

    PubMed  CAS  Google Scholar 

  84. Mannheimer C, Carlsson CA, Emanuelsson H, et al. The effects of transcutaneous electrical nerve stimulation in patients with severe angina pectoris. Circulation 1985;71:308–16.

    PubMed  CAS  Google Scholar 

  85. Mannheimer C, Carlsson CA, Ericson K, et al. Transcutaneous electrical nerve stimulation in severe angina pectoris. Eur Heart J 1982;3:297–302.

    PubMed  CAS  Google Scholar 

  86. Mannheimer C, Eliasson T, Andersson B, et al. Effects of spinal cord stimulation in angina pectors induced by pacing and possible mechanisms of action. Br Med J 1993;307:477–80.

    CAS  Google Scholar 

  87. Marcassa C, Galli M, Baroffio C, et al. Ischemic burden in silent and painful myocardial ischemia: A quantitive exercise sestamibi tomographic study. J Am Coll Cardiol 1997;29:948–54.

    PubMed  CAS  Google Scholar 

  88. Martin SJ, Gorham LW. Cardiac pain. An experimental study with reference to the tension factor. Arch Intern Med 1938;62: 840–52.

    Google Scholar 

  89. Maseri A, Crea F, Kaski JC, et al. Mechanisms and significance of cardiac ischemic pain. Prog Cardiovasc Dis 1992;35:1–18.

    PubMed  CAS  Google Scholar 

  90. Mellow MH, Simpson AG, Watt L, et al. Esophageal acid perfusion in coronary artery disease. Induction of myocardial ischemia. Gastroenterology 1983;85:306–12.

    PubMed  CAS  Google Scholar 

  91. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971–9.

    PubMed  CAS  Google Scholar 

  92. Milsom I, Hedner N, Mannheimer C. A comparative study of the effect of high-intensity transcutaneous nerve stimulation and oral naproxen on intrauterine pressure and menstrual pain in patients with primary dysmenorrhea. Am J Obstet Gynecol 1994;170:123–9.

    PubMed  CAS  Google Scholar 

  93. Mulcahy D, Keegan J, Crean P, et al. Silent myocardial ischemia in chronic stable angina: a study of its frequency and characteristics in 150 patients. Br Heart J 1988;60:417–23.

    PubMed  CAS  Google Scholar 

  94. Mulcahy R, Awadhi AH, de Bulleor M, et al. Natural history and prognosis of unstable angina. Am Heart J 1985;109:753–8.

    PubMed  CAS  Google Scholar 

  95. Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 1987;57:23C-30C.

    Google Scholar 

  96. Norrsell H, Eliasson T, Mannheimer C, et al. Effects of pacinginduced myocardial stress and spinal cord stimulation on whole body and cardiac norepinephrine spillover. Eur Heart J 1997; 18:1890–6.

    PubMed  CAS  Google Scholar 

  97. Pepine CJ, Coha PF, Deedwania PC, et al. Effects of treatment on outcome in mildly symptomatic patients with ischemia during daily life. The atenolol silent ischemia study (ASIST). Circulation 1994;90:762–8.

    PubMed  CAS  Google Scholar 

  98. Perl ER. Is pain a specific sensation? J Psychiat Res 1971;8: 273–87.

    PubMed  CAS  Google Scholar 

  99. Perna G, Stanislao M, Salavatori MP, et al. Basal plasma betaendorphin and beta-lipotropin in patients, with symptomatic and asymptomatic myocardial ischemia. Cardiologia 1988;33:765–9.

    PubMed  CAS  Google Scholar 

  100. Richter JE. Investigation and management of non-cardiac chest pain. Baillière’s Clin Gastroenterol 1991;5:281–306.

    CAS  Google Scholar 

  101. Richter JE. The esophagus and noncardiac chest pain. In: Castell DO. The esophagus, 2nd edn. Little Brown and Company. Boston 1995;699–724.

    Google Scholar 

  102. Richter JE, Barish CF, Castell DO. Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology 1996;91: 845–52.

    Google Scholar 

  103. Ros E, Armengol X, Grande L, et al. Chest pain at rest in patients with coronary artery disease. Dig Dis Sci 1997;42:1344–53.

    PubMed  CAS  Google Scholar 

  104. Ruch TC. Visceral sensation and referred pain. In: Howell’s textbook of physiology. Philadelphia. Saunders 1946:385–401.

    Google Scholar 

  105. Sanderson JE, Woo KS, Chung HK, et al. The effect, of transcutaneous electrical nerve stimulation on coronary and systemic haemodynamics in syndrome X. Coron Art Dis 1996;7:547–52.

    CAS  Google Scholar 

  106. Schuster EH, Bulkley BH. Early post-infarction angina: Ischemia at a distance and ischemia in the infarct zone. N Engl J Med 1981;305:1101–5.

    PubMed  CAS  Google Scholar 

  107. Serneri GGN, Prisco D, Martini F, et al. Acute T-cell activation is detectable in unstable angina. Circulation 1997;95:1806–12.

    Google Scholar 

  108. Singh S, Richter JE, Hewson EG, et al. The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease. Ann Intern Med 1992;117:824–30.

    PubMed  CAS  Google Scholar 

  109. Stone PH, Gibson RS, Glasser SP, et al. Comparison of propranolol, diltiazem and nifedipine in the treatment of ambulatory ischemia in patients with stable angina. Circulation 1990;82:1962–72.

    PubMed  CAS  Google Scholar 

  110. Sylvén C. Angina pectoris. Clinical characteristics, neurophysiological and molecular mechanisms — a review. Pain 1989;36: 145–67.

    PubMed  Google Scholar 

  111. Sylvén C, Beermann B, Jonzon B, et al. Angina pectoris-like pain provoked by intravenous adenosine in healthy volunteers. Br Med J 1986;293:227–30.

    Google Scholar 

  112. Sylvester K, Kendall GPN, Lennard-Jones JE. Treatment of functional abdominal pain by transcutaneous nerve stimulation. Br Med J 1986;293:481–2.

    CAS  Google Scholar 

  113. Taylor P, Hallett M, Flaherty L. Treatment of osteoarthritis of the knee with transcutaneous electrical nerve stimulation. Pain 1981;11:233–40.

    PubMed  CAS  Google Scholar 

  114. Ten Vaarweerk IAM, Jessurun GAJ, Hautwast R, et al. Mortality and morbidity in patients treated with spinal cord stimulation for intractable angina pectoris. Heart (accepted for publication).

  115. Thompson SG, Kienast J, Pyke SDM, et al. Homeostatic factors and the risk of myocardial infarction or sudden death in patients with angina pectoris. N Engl J Med 1995;332:635–41.

    PubMed  CAS  Google Scholar 

  116. Thorsteinsson G, Stonnington HH Stillwell GK, et al. Transcutaneous electrical stimulation: a double-blind trial of its efficacy for pain. Arch Phys Med Rehab 1977;58:8–13.

    CAS  Google Scholar 

  117. Tijssen JG, Lubsen J. Early treatment of unstable angina with nifedipine and metoprolol — the HINT trial. J Cardiovasc Pharmacol 1988;12:Suppl 1:S71–7.

    Google Scholar 

  118. Toss H, Lindahl B, Siegbahn A, et al. Prognostic influence of increased fibrinogen and C-reactive protein level in unstable coronary artery disease. Circulation 1997;96:4201–10.

    Google Scholar 

  119. Traube M, Albibi R, McCallum RW. High-amplitude peristaltic esophageal contractions associated with chest pain. JAMA 1983;250:2655–9.

    PubMed  CAS  Google Scholar 

  120. Tzivoni D, Gavish A, Zin D, et al. Prognostic significance of ischemic episodes in patients with previous myocardial infarction. Am J Cardiol 1988;62:661–4.

    PubMed  CAS  Google Scholar 

  121. Vander Ark GD, McGrath KA. Transcutaneous electrical stimulation in treatment of postoperative pain. Am J Surg 1975; 130:338–40.

    Google Scholar 

  122. Vantrappen G, Janssens J. Angina and oesophageal pain — a gastroenterologist’s point of view. Eur Heart J 1986;7:828–34.

    PubMed  CAS  Google Scholar 

  123. von Arnim T. Prognostic significance of transient ischemic episodes: Response to treatment shows improved prognosis. Results of the Total ischemic burden bisoprolol study (TIBBS). Follow up. J Am Coll Cardiol 1996;28:20–4.

    Google Scholar 

  124. Wall PD, Melzack R. Textbook of pain. 3rd edn. New York: Churchill Livingstone 1997.

    Google Scholar 

  125. Walsh DM. TENS Clinical applications and related theory. New York: Churchill Livingstone, 1997.

    Google Scholar 

  126. Walsh DM, Foster NF, Baxter GD, et al. Transcutaneous electrical nerve stimulation. Relevance of stimulation parameters to neurophysiological and hypoalgesic effects. Am J Phys Med Rehab 1995;74:199–206.

    CAS  Google Scholar 

  127. Webb SC, Poole-Wilson PA. Potassium exchange in the human heart during atrial pacing and myocardial ischaemia. Br Heart J 1986;55:554–9.

    PubMed  CAS  Google Scholar 

  128. Weidinger F, Hammerle A, Sochor H, et al. Role of beta-endorphins in silent myocardial ischemia. Am J Cardiol 1986;58: 428–30.

    PubMed  CAS  Google Scholar 

  129. White CW. Clinical applications of Doppler coronary flow reserve measurements. Am J Cardiol 1993;71:10D-6D.

    PubMed  CAS  Google Scholar 

  130. Willerson JT, Golino P, Eidt J, et al. Specific platelet mediators and unstable coronary artery lesions. Circulation 1989;80: 198–205.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, Multidisciplinary Pain Center, Sahlgrenska University Hospital/Östra, S-416 85, Göteborg, Sweden

    Mats Börjesson MD

Authors
  1. Mats Börjesson MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mats Börjesson MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Börjesson, M. Visceral chest pain in unstable angina pectoris and effects of transcutaneous electrical nerve stimulation (TENS). Herz 24, 114–125 (1999). https://doi.org/10.1007/BF03043850

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03043850

Key Words

Schlüsselwörter

Search

Navigation