Anatomical Notes

The human heart is estimated to contain more than 14,000 neurons14 of autonomic origin. The sympathetic supply is via the cervical and upper thoracic sympathetic chains. The parasympathetic supply is via the vagus nerve. Both merge together to form the cardiac plexus which is an intricate network embedded in the tissues of the myocardium and the coronary and mediastinal vessels. This plexus is formed by afferent and efferent fibers that include chemoreceptors, pressoreceptors, mechan-oreceptors, and pain receptors. These are connected by a number of pathways to the central nervous system (CNS). The stellate ganglion is the fusion of the inferior cervical and the superior thoracic. It can be identified consistently in normal persons.15 There are four cardiac rami from the T2-T6 segment of the thoracic sympathetic trunk that

Somatic from cervical or thoracic spine Neuropathic from thoracic nerves

Table 39.1 Structures within the chest from where a chronic chest pain may originate.

Visceral Somatic Referred also form part of the deep cardiac plexus.16'17 Recent work has elucidated more details of these pathways, but it is apposite to remember that silent ischemia often coexists with painful ischemia in the same patient. The evidence suggests that there is no correlation between the degree of pain and the severity of the lesion or ischemia.18

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