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Article author: Dr Apurva C Madia. Consultant Cardiologist.
Ahmedabad, India.


Friday 26th May, 2006

 
"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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