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 Article
author: Dr Apurva C Madia. Consultant Cardiologist.
Ahmedabad, India.
Friday 26th May, 2006
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"Not all times is a chest pain necessarily
originating from or caused by diseases of the
heart", says Dr. Madia.
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Chest pain is one of the common complaints heard in medical
OPDs as well as at the GP?s clinic. Chest pain causes a lot of
anxiety in the patient as it is many a time related to ?heart
attack? or angina and people are quite aware of the serious
consequences of the symptom. Anyone having a chest pain would
first think of the heart and would like to know if he/she is
having a ?heart attack?.
However not all times is a chest pain necessarily originating
from or caused by diseases of the heart. There are plenty of
other structures in the thoracic cavity and a systematic
approach is needed to arrive at the correct diagnosis or in
other words to find out the ?real culprit? causing the chest
pain.
Of special importance is the issue of chest pain in women, as
this group is less liable to get heart disease till menopause.
Estrogen is said to confer a protective effect and prevents the
development of atherosclerosis. Myocardial infarction or
Coronary artery disease (CAD) is very rare in menstruating
women. As menopause approaches and estrogen levels go down, the
probability of development of CAD catches up with those in men.
Even then, there are lots of young to middle aged,
menstruating women complaining of chest pain and quite
distressed about it. Before I highlight the special features of
this particular issue lets first review the differential
diagnosis of chest pain.
Differential Diagnosis of Chest Pain
1. Angina Pectoris/Myocardial Infarction
2. Other Cardiovascular Causes
a. Possibly Ischemic Pain
1) Aortic Stenosis
2) Hypertrophic Cardiomyopathy
3) Severe Systemic Hypertension
4) Severe Right Ventricular Hypertension
5) Aortic Regurgitation
6) Severe Anemia/hypoxia
b. Non Ischemic in Origin
1) Aortic Dissection
2) Pericarditis
3) Mitral Valve Prolapse
3. Gastrointestinal
a. Esophageal Spasm
b. Esophageal Reflux
c. Esophageal Rupture
d. Peptic Ulcer Disease
4. Psychogenic
a. Anxiety
b. Depression
c. Cardiac Psychosis
d. Self Gain
5. Neuromusculoskeletal
a. Thoracic Outlet syndrome
b. Lesions of Cervical/Thoracic Spine
c. Costochondritis[Tietze?s Syndrome]
d. Herpes Zoster
e. Chest wall pain
6. Pulmonary
a. Pulmonary Embolus/Infarction
b. Pneumothorax
c. Pneumonia with pleural involvement
7. Pleurisy
As most patients are anxious of their chest pain being that
of Heart origin, we shall first have a look at the features of
Cardiac Pain.
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Clinical features of Angina Pectoris and Myocardial Infarction
Cardiac Pain or Angina Pectoris ( reversible loss of blood
supply to the heart muscle) is retrosternal, vague, poorly
localized, heavy, compressive, squeezy feeling. It rarely lasts
less than 1 minute or more than 20 minutes, unless it is a heart
attack. Patients get prompt relief in less than 5 minutes on
cessation of all activities or use of sublingual nitrates.
Angina pain can also be in the left shoulder, left arm, neck or
the jaws.
Pain of a Myocardial Infarction ( total sudden blockage of an
artery supplying blood to the heart muscle) would be similar to
this but more severe and can last longer, will not be relieved
by rest or sublingual nitrate and associated with palpitation,
perspiration, nausea/vomiting, dizziness, blackout or even
collapse.
Pain that is unlikely to be of cardiac origin is
typically well localized, sharp, pricky, lancinating type
sometimes lasting less than 15 seconds. It can be aching type
too but mostly will be aggravated on deep inspiration and
coughing. Patient will be able to localize it with the tip of
her finger.
Pain that is localized just below left nipple is almost NEVER
of cardiac origin.
Common causes of chest pain in young females
1. Valvular Heart Disease
Mitral Prolapse: This is a common and benign
condition. Leaflets of the Mitral valve are long, bulky and
redundant. They prolapse into the left atrium during systole. It
is unknown how this causes chest pain. Suffice to say that the
pain occurs at rest, is sharp, non- radiating and prolonged in
duration.
Rheumatic Valve Disease: Mitral stenosis is a common
rheumatic valve condition in females and can cause chest pain
and dyspnea. The patient will have associated cough,
expectoration, there would be a low pitched rumbling diastolic
murmur which will clinch the diagnosis. A 2D echocardiography
will be confirmatory.
2. Anxiety/Depression
There are a lot of personal/social causes for a young female
to get into a vicious cycle of anxiety causing various physical
symptoms, and those symptoms in turn causing more anxiety.
Depression also causes ?somatization? and produces various
symptoms, chest pain being one of them. This chest pain can take
any form; it can even mimic Anginal pain accurately. One needs
to rule out organic causes before stamping the diagnosis of
anxiety/depression.
3. Neuromusculoskeletal
The pain is very well localized, tender on touch, aggravated
on deep inspiration, and not aggravated on exertion. Underlying
cause can be pinpointed by suitable investigations like X ray of
cervical spine, chest (thoracic outlet syndrome) etc. Pain of
herpes Zoster sometimes defies diagnosis until the rash
develops.
4. Gastrointestinal
Esophageal reflux is one of the most common causes of
retrosternal pain. The pain is mostly burning in nature, occurs
more often in reclining posture, and is relieved by assuming
upright position. It is more frequent after an oily, heavy meal.
Esophageal spasm is a variety of the same disease. Sometimes
peptic ulcer disease can also cause pain in lower chest.
5. Pulmonary
Pulmonary cause of chest pain in young female could be a
pulmonary embolism/infarct caused by deep vein thromboembolism
resulting from oral contraception usage. The pain is acute,
severe and patient generally is in a critical condition.
Pneumonia can also cause chest pain if there is pleural
involvement with it, which usually is the case.
Pneumothorax, which is rupture of a lung alveolus into the
pleural cavity will cause sudden acute filling up of air
pressure in pleura and will cause severe acute chest pain if it
is Tension Pneumothorax and moderate dull aching pain if it is
simple Pneumothorax.
6. Pleurisy
Tubercular involvement of the pleura is called pleurisy. The
pain is sharp stab like, occurring on slightest act of
breathing. Associated features are low grade fever, cough, and
malaise, loss of appetite and loss of weight.
Chest pain in a young female has lots of reasons as we have
seen. Most of the time they are not of cardiac origin. A
thorough clinical examination, appropriate investigations, and
reassurance will go a long way in resolving this issue.
Dr. Apurva Madia
References
1. Hurst?s The Heart. 11th Edition, Mcgrow Hill. P 219
2. Sullivan J I: Are menstruating women protected from heart
disease because of or in spite of Estrogen? Relevance to the
iron hypothesis. Am Heart J 145:190, 2003
3. Mikkola B, Clarkson TB: Estrogen replacement therapy,
atherosclerosis and vascular function. Cardiovasc Res 53: 605,
2002
4. Douglas PS, Ginsberg GS: The evaluation of chest pain in
women. N Eng J Med 334: 1311, 1996.
5. Marroquin OC, Hloubkov R, Edmindowocz D et al:
Heterogenity of microvascular dysfunction in women with chest
pain not attributable to coronary artery disease: Implication
for clinical practice. Am Heart J 145: 628, 2003.
6. D?Anton B, Dupis G, Fleet R et al: Sex differences in
chest pain & predilection of exercise induces ischemia. Can J
Cardiol 19:515, 2003
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