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CLINICAL STUDIES

Low hot pain threshold predicts shorter time to exercise-induced angina: results from the psychophysiological investigations of myocardial ischemia (PIMI) study

David S. Sheps, MD, MSPH, FACC^*, Robert P. McMahon, PhD, Kathleen C. Light, PhD, William Maixner, PhD, DDS, Carl J. Pepine, MD, FACC, Jerome D. Cohen, MD, FACC^||, A. David Goldberg, MD^¶, Robert Bonsall, PhD^#, Robert Carney, PhD^#, Peter H. Stone, MD, FACC^**, David Sheffield, PhD^*, Peter G. Kaufmann, PhD the PIMI Investigators

^* East Tennessee State University, Johnson City, Tennessee, USA
Maryland Medical Research Institute, Baltimore, Maryland, USA
University of North Carolina, Chapel Hill, North Carolina, USA
University of Florida, Gainesville, Florida, USA
^|| St. Louis University Medical Center, St. Louis, Missouri, USA
^¶ Henry Ford Hospital, Detroit, Michigan, USA
^# Emory University School of Medicine, Atlanta, Georgia, USA
^** Brigham and Women’s Hospital, Boston, Massachusetts, USA
National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA

Manuscript received August 21, 1998; revised manuscript received January 25, 1999, accepted February 15, 1999.

Reprint requests and correspondence: Dr. David S. Sheps, 2 Professional Park Drive, Suite 15, Johnson City, Tennessee 37604

OBJECTIVES

The purpose of this study was to test whether cutaneous thermal pain thresholds are related to anginal pain perception.

BACKGROUND

Few ischemic episodes are associated with angina; symptoms have been related to pain perception thresholds.

METHODS

A total of 196 patients with documented coronary artery disease underwent bicycle exercise testing and thermal pain testing. The Marstock test of cutaneous sensory perception was administered at baseline after 30 min of rest on two days and after exercise and mental stress. Resting hot pain thresholds (HPTs) were averaged for the two baseline visits and divided into two groups: 1) average HPT <41°C, and 2) average HPT 41°C, to be clearly indicative of abnormal hypersensitivity to noxious heat.

RESULTS

Patients with HPT <41°C had significantly shorter time to angina onset on exercise testing than patients with HPT 41°C (p < 0.04, log-rank test). Heart rates, systolic blood pressure and rate–pressure product at peak exercise were not different for the two groups. Resting plasma beta-endorphin levels were significantly higher in the HPT <41°C group (5.9 ± 3.7 pmol/liter vs. 4.7 ± 2.8 pmol/liter, p = 0.02). Using a Cox proportional hazards model, patients with HPT <41°C had an increased risk of angina (p = 0.03, rate ratio = 2.0). These differences persisted after adjustment for age, gender, depression, anxiety and history of diabetes or hypertension (p < 0.01).

CONCLUSIONS

Occurrence of angina and timing of angina onset on an exercise test are related to overall hot pain sensory perception. The mechanism of this relationship requires further study.

Abbreviations and Acronyms   ECG = electrocardiogram   HPA = hypothalamic–pituitary–adrenal   PIMI = Psychophysiological Investigations of Myocardial Ischemia

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