I am sorry about your difficulties. You describe a very frustrating four year experience. Unfortunately, there are many women with similar stories. In the medical world your main problem is described as “atypical” chest pain to distinguish it from “typical” angina chest pain cause by coronary artery blockages. Unfortunately what is considered “typical” for men is often not how things present in women. The evaluation and treatment of atypical chest pain, especially in women, can be difficult and frustrating for the doctor and more importantly the patient. The difficulty arises from the fact that the symptoms can be vague and unpredictable; there are a wide variety of possible causes not just from the heart but other areas such as the esophagus, the chest wall, etc.
As with most women in your situation, you have over time had a variety of standard tests by several doctors to rule out the most typical causes of chest pain including stress tests, echocardiograms, CT scans and a heart cath (coronary angiogram). These can rule out serious problems like coronary artery blockages, valve problems, heart muscles problems, etc.
A couple of things I did not see in your history. One is a gastrointestinal evaluation. Esophageal problems like spasm and reflux (GERD) can mimic heart pains. Another is a more complete evaluation for heart arrhythmias like atrial fibrillation, flutter or other types of SVT. You describe episodes of a rapid heartbeat and wearing a heart monitor while in the hospital but there are monitors that can be worn up to a month to see if your symptoms correlate with episodes of an abnormal heart rhythm.
Finally, there are a couple of heart conditions that can mimic angina-type heart pains. Again, the typical cause of angina is a blockage in a coronary artery that can be clearly seen on a heart cath. In some patients with variant angina (also known as Prinzmetal’s angina) the arteries do not have visible blockages but can develop intermittent spasm or tightening.
The other condition, which your cousin mentioned, is called microvascular angina or cardiac syndrome X (CSX). In this condition the problem is not in the bigger arteries on the surface of the heart that can be visualized on the heart cath but in the small microscopic arteries within the heart muscle. The precise mechanism is not well understood but they appear to difficulty relaxing to the usual triggers. There is also a suggestion that the pain signaling mechanisms in the heart are extra sensitive. CSX is more common in women, especially post-menopausal women, and there has been some evidence that estrogen deficiency may play a role. In the classic definition of CSX patients, unlike you, have an abnormal stress test but many now feel it can occur with a normal stress test. There are several additional studies that can help in showing the microvascular problem. A heart cath with measurement of “coronary flow reserve” can show that the microscopic arteries don’t relax to a chemical trigger (adenosine). PET scans and MRI can also pick up microvascular flow abnormalities. There are a variety of treatment options for CSX, not all are 100% effective and the response can vary among patients. As always, the traditional advice for staying heart health apply – diet, exercise, stress reduction, blood pressure control, cholesterol control, not smoking, good sleep habits, etc.
The most important thing is to not give up and assume you have to live with your symptoms. Continue to take an active role in your health. It is important to try and find a specialist with experience evaluating unusual causes of chest pain in women like I have described above. We might be able to help you in that search.
Comment Reply
Dear Dianne,
I am sorry about your difficulties. You describe a very frustrating four year experience. Unfortunately, there are many women with similar stories. In the medical world your main problem is described as “atypical” chest pain to distinguish it from “typical” angina chest pain cause by coronary artery blockages. Unfortunately what is considered “typical” for men is often not how things present in women. The evaluation and treatment of atypical chest pain, especially in women, can be difficult and frustrating for the doctor and more importantly the patient. The difficulty arises from the fact that the symptoms can be vague and unpredictable; there are a wide variety of possible causes not just from the heart but other areas such as the esophagus, the chest wall, etc.
As with most women in your situation, you have over time had a variety of standard tests by several doctors to rule out the most typical causes of chest pain including stress tests, echocardiograms, CT scans and a heart cath (coronary angiogram). These can rule out serious problems like coronary artery blockages, valve problems, heart muscles problems, etc.
A couple of things I did not see in your history. One is a gastrointestinal evaluation. Esophageal problems like spasm and reflux (GERD) can mimic heart pains. Another is a more complete evaluation for heart arrhythmias like atrial fibrillation, flutter or other types of SVT. You describe episodes of a rapid heartbeat and wearing a heart monitor while in the hospital but there are monitors that can be worn up to a month to see if your symptoms correlate with episodes of an abnormal heart rhythm.
Finally, there are a couple of heart conditions that can mimic angina-type heart pains. Again, the typical cause of angina is a blockage in a coronary artery that can be clearly seen on a heart cath. In some patients with variant angina (also known as Prinzmetal’s angina) the arteries do not have visible blockages but can develop intermittent spasm or tightening.
The other condition, which your cousin mentioned, is called microvascular angina or cardiac syndrome X (CSX). In this condition the problem is not in the bigger arteries on the surface of the heart that can be visualized on the heart cath but in the small microscopic arteries within the heart muscle. The precise mechanism is not well understood but they appear to difficulty relaxing to the usual triggers. There is also a suggestion that the pain signaling mechanisms in the heart are extra sensitive. CSX is more common in women, especially post-menopausal women, and there has been some evidence that estrogen deficiency may play a role. In the classic definition of CSX patients, unlike you, have an abnormal stress test but many now feel it can occur with a normal stress test. There are several additional studies that can help in showing the microvascular problem. A heart cath with measurement of “coronary flow reserve” can show that the microscopic arteries don’t relax to a chemical trigger (adenosine). PET scans and MRI can also pick up microvascular flow abnormalities. There are a variety of treatment options for CSX, not all are 100% effective and the response can vary among patients. As always, the traditional advice for staying heart health apply – diet, exercise, stress reduction, blood pressure control, cholesterol control, not smoking, good sleep habits, etc.
The most important thing is to not give up and assume you have to live with your symptoms. Continue to take an active role in your health. It is important to try and find a specialist with experience evaluating unusual causes of chest pain in women like I have described above. We might be able to help you in that search.
Hope that helps and good luck.
Dr. Aklog
August 6, 2010 - 1:45pmThis Comment
Reply