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Identifica tion and Management of Cardiac -Adrenal-Pain Syndrome

Severe, chronic, under-treated pain may produce cardiac and adrenal complications, that in some pain patients, can lead to premature death.
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Adrenal Complications

The classic descriptions of Addison’s Disease (adrenal insufficiency) and Cushing’s Disease (adrenal excess) are applicable to pain patients. All of the complications of these two diseases of the adrenal gland can be observed in some pain patients depending on the reserve status of their adrenal glands (see Table 3). In the initial phase of adrenal stimulation there is an excess output of adrenal hormones, with the adrenal gland exhausting if pain is not well controlled. One area of poor understanding is the presence of immune serum abnormalities in severe chronic pain patients. In the studies reported here, ESR was assessed. While it is known that abnormal adrenal secretion patterns are associated with immune serum abnormalities, it is not clear why ESR’s would be elevated with uncontrolled pain and normalize d with pain treatment.10,11 This is clearly an area that demands clinical study.

Table 4. Some Potential Sequelae of Chronic Tachycardia
  • Exhaustion — fatigue
  • Insomnia
  • Attention deficit - memory impairment
  • Immobilization
  • Shun social interaction
  • Angina — sudden death in patients with underlying heart disease
  • Possibly, Arteriosclerosis
Table 5. Recommended Clinical Management Of The
Cardiac-Adrenal-Pain Syndrome
  • Identify its presence at the initial pain evaluation by:
  1. Blood pressure
  2. Pulse rate
  3. Early morning serum cortisol and pregnenolone
  • Monitor control of the syndrome by routine pulse and blood pressure screening. Patient can monitor at home. Repeat serum cortisol and pregnenolone levels to insure patient is in normal range.
  • Develop an aggressive treatment plan which may include:
    1. High dose, multiple opioids for baseline and breakthrough pain
    2. Intrathecal opioid administration
    3. Implanted electrical stimulator
  • Frequent clinical visits for close monitoring - usually monthly
  • Use ancillary medications to bring the pulse rate below 84 per minute. May require benzodiazepines, NMDA antagonists, or carisoprodal, in difficult cases.
  • Supplement pregnenolone deficiency up to 200mg a day if necessary to maintain a normal serum range.
  • Cardiac Complications

    Chronic tachycardia is a relatively unstudied clinical problem, since it is usually only seen with such unusual conditions as hyperthyroidism or pheochromocytoma. Some chronic severe pain patients may, however, endure tachycardia for years with some having having pulse rates over 100 per minute. This extraordinary situation undoubtedly precipitates multiple cardiac complications and is likely a factor in the sudden death of some pain patients. Angina, arrhythmia, and congestive heart failure may be present in an ambulatory, severe pain patient and be remarkably controlled when the patient’s painful condition is adequately treated and the pulse rate lowered below 84 per minute. It is obviously a most serious clinical condition with multiple sequelae, and it must be aggressively treated for the welfare of the pain patient (see Table 4). The hallmark of chronic tachycardia, defined here as a pulse rate over 84 per minute, is exhaustion and fatigue. It is also highly associated with insomnia and attention deficit-memory impairment. A striking clinical observation made by the author in patients with high pulse rates is the presence of immobilization and a shunning of social interaction. This, of course, is additive to the patient’s basic cause of pain which may worsen with movement or activity. Fundamentally, the patient seeks the shelter and calm of a chair or couch, and may remain quite immobilized for hours at a time.

    In addition to tachycardia and hypertension there are likely other cardiac complications. Angina, coronary spasm, and arrhythmias are likely consequences in pain flares which produce excess adrenaline output and central adrenergic discharge. Also, some preliminary studies report that painful conditions may produce significant lipid abnormalities that will aggravate cardiac complications.12-13

    Practical Management

    The most critical component of pain management is simple identification and on-going monitoring of the presence of cardiac-adrenal complications. Once identified, ongoing monitoring, particularly of pulse rate and blood pressure, should be done. Control of pulse and blood pressure is an excellent marker for pain treatment effectiveness. At home BP and pulse readings taken by the patient are very useful. In fact, it is probably a far better, and more objective, measure than the standard 1 to 10 pain scale—particularly in chronic patients. Patients can easily obtain an inexpensive apparatus to monitor blood pressure and pulse rate at home. A copy of the at-home monitoring form used by the author is shown (see Figure 2). It is recommended that the pulse rate be maintained below 84 per minute and the blood pressure below 130/90mm Hg.

    If pulse and blood pressure can’t be controlled by conventional means, it may be necessary to use aggressive therapeutic measures including high dose oral opioids, intrathecal therapy, or an implanted electrical stimulator. It may further be necessary to use a benzodiazepine to achieve control. Carisoprodal may be particularly effective, and this may partly explain its great popularity with pain patients. Methadone and propoxyphene, which have N-methyl D-aspartate (NMDA) receptor antagonism activity, have been used by the author to control tachycardia in some resistant cases.

    Adrenal gland function can easily be screened by an early morning serum cortisol and pregnenolone assay. If the results are high, the adrenal gland is showing good reserve and is being over-stimulated by pain. If pregnenolone or cortisol is low, it indicates inadequate hormone production due to exhausted adrenal output. Consequently, better pain control is essential. Once pain control is adequate, cortisol and pregnenolone levels usually normalize, but there are exceptions. Pregnenolone levels appear slightly more difficult to control than cortisol. Persistent low serum levels of pregnenolone suggest that supplementation with oral pregnenolone may be needed with required dosages ranging from 50 to 200mg per day.14,15

    Cardiac symptoms of angina and even heart failure are quite common in the author’s experience with even young severe, chronic pain patients. Co-management with a cardiologist may be required. An endocrinologist may also need to assist with adrenal hormone replacement.

    The key to managing the cardiac-adrenal-pain syndrome is recognition that it exists in some chronic pain patients, and that it must be monitored and controlled by aggressive pain treatment.

    Last updated on: May 16, 2011