Identification and Management of Cardiac-Adrenal-Pain Syndrome
by Forest Tennant, MD, DrPH
 Severe pain is well-known to stimulate the cardiac and adrenal
systems.1-7 Despite this knowledge, there are few reported systematic
investigations of these complications in clinical patients. More importantly, clinical
treatment of pain’s complications on the cardiac and adrenal systems has not
heretofore been practically addressed.
Those chronic pain patients who demonstrate physiologic complications involving the
heart and adrenal glands are obviously those who have a most serious pain problem and who
must be managed with the most aggressive measures.6,7 Reported here are two
systematic investigations of some cardiac and adrenal complications in severe, chronic
pain patients. The results of these efforts clearly show that some patients demonstrate
cardiac and adrenal complications that can be easily diagnosed in an outpatient clinical
setting and which can usually be controlled or ameliorated by aggressive pain treatment.
The most obvious and easily detectable cardiac complications are tachycardia and
hypertension. Severe pain causes the adrenal glands to secrete abnormal levels of
catecholamines (e.g., adrenalin) and glucocorticoids (e.g., cortisol). Pain’s impact
on the adrenal gland is biphasic.2 Severe pain initially causes an outpouring
of catecholamines and glucocorticoids in an effort to neutralize pain’s adverse
affects (see Figure 1), but the adrenal gland may later exhaust if pain is severe and
unremitting.2 At this time, serum testing may demonstrate severe hormonal
deficiencies.4 The tachycardia and hypertension observed in severe chronic pain
patients is at least partially the result of excess adrenal hormone production, but
central nervous system over-stimulation produced by severe pain also contributes to
tachycardia and hypertension.6,7 Over-stimulation of the pituitary-adrenal axis
and other adrenergic centers in the brain appear to act concordantly. It is pain’s
over-stimulation of the nervous system that is the root cause of most cardiac and adrenal
complications, and they can be identified by simple clinical screens. Once identified,
treatment can be partially guided by on-going monitoring of these complications.
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— September 2006
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