Angina without ‘strangling and anxiety of the breast’

Editor - Cooper and colleagues remind us that cardiac pain may be present only in the neck and arm, without there being any chest pain (Clin Med April 2011 pp 201–2). Very rarely, cardiac pain is felt in more unusual positions. Lanza and colleagues reported a case in which cardiac pain consisted purely of headache.¹ The rarity of this presentation may be judged by the fact that the article has never been cited.

I saw a man in his mid-60s who had cardiac pain confined to the vertex of his head. (His exact age was unknown because he was born in a remote village in a developing country and there was no official record of his birth.) He had woken from sleep with sudden onset of severe pain at the top of his head. It was the worse pain he had ever experienced. It lasted about eight hours. There was no meningism or abnormal neurological findings. Subarachnoid haemorrhage was suspected but a computed tompgraphy (CT) brain scan and lumbar puncture were normal. An electrocardiogram (ECG) showed anterior ST elevation consistent with an anterior myocardial infarction. The ECG appearance was initially attributed to a subarachnoid haemorrhage.² That view of the ECG was not revised even after subarachnoid haemorrhage was discounted. After discharge from hospital, he reported similar but less severe pain confined to the vertex of his head when walking uphill. It disappeared almost immediately once he rested. He had identical pain associated with anterior ST segment depression during a treadmill exercise test. Coronary angiography showed a single severe stenosis in the left anterior descending artery. During percutaneous coronary intervention, when there was balloon inflation, he had identical head pain with ECG changes but with no chest discomfort. After coronary intervention he was free of the pain on exertion.

About half of patients with a subarachnoid haemorrhage have ECG abnormalities.² Failure to recognise that ECG abnormalities are common in patients with subarachnoid haemorrhage can lead to them receiving inappropriate cardiac treatment and delayed investigation for subarachnoid haemorrhage. In the case I describe, the localisation of the pain resulted in initial misdiagnosis of cardiac pain as subarachnoid haemorrhage.