Extrathoracic Pain

Intermittent claudication of the lower extremities due to peripheral atherosclerosis (see Chap. 90) may present as discomfort during exercise in the arch of the foot, calf of the leg, thighs, hips, or gluteal region.7-9 Acute arterial occlusion in the lower extremities due to systemic embolism may cause the sensation of hypesthesia.2 Intermittent claudication of the upper extremities or masseter muscles is usually due to nonatherosclerotic causes of arterial disease, such as arteritis.2 The pain of Raynaud's disease may be noted in the fingers after exposure to cold, with pallor of the fingers prior to the sensation of pain. Pain and swelling of lower extremities may be caused by thrombophlebitis (see Chap. 90).

Head pain secondary to myocardial ischemia may be felt in the jaw, hard palate, cheek, and sometimes deep in the ear canals. The pain of temporal arteritis, commonly localized to the temporal area, often is associated with abnormal vision and polymyalgia rheumatica.76 Migraine headache, frequently accompanied by nausea, scotoma, and intolerance to light, is vascular in origin and may be incapacitating.2 A severe headache may be present in patients with uncontrolled hypertension (see Chap. 51).

Pain in the abdomen, often localized to the midabdomen and lower portion of the back, may be produced by an expanding or rupturing atherosclerotic abdominal aneurysm. Abdominal angina due to vascular disease of the mesenteric arteries is discussed in Chap. 88. The liver is often painful and tender in severe right-sided heart failure, with worsening of the pain during activity.2

Various types of joint pain may be associated with heart disease. Rheumatic fever, rheumatoid arthritis, lupus erythematosus, psoriatic arthritis, ankylosing spondylitis, gonococcal arthritis, Reiter's syndrome, and Lyme disease may be associated with valvular, myocardial, or pericardial disease.2

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