Presented by: Abha Khandelwal, MD, MS; Eryn Bryant, MSN, NP-C; Valerie Hoover, PhD
May 4, 2017
Chest pain can be a mystery. Sometimes it’s the tipoff to a heart attack. Other times it’s a clue that heart disease is slowly, gradually, choking the major arteries that deliver blood to the heart.
Then again, sometimes chest pain happens during a time of high anxiety and distress, triggered by a major life upset like losing a spouse or a child. This kind of trauma may trigger a chain of events in the body that can lead to a heart attack.
For women, especially, it can take a specialist in women’s heart health care to recognize and diagnose the multiple causes of chest pain. Not all chest pain comes from the heart. Sometimes it’s caused by other organ systems in the chest cavity or elsewhere in the body.
“We often can’t know someone’s pain experience simply by looking at them,” said Abha Khandelwal, MD, MS, in a recent presentation to the Stanford Health Library. “It can be tricky.”
Diagnosing women can be more challenging than diagnosing men, said Dr. Khandelwal, who is a clinical assistant professor of medicine and a cardiologist at the Women’s Heart Health Clinic at Stanford.
Even when the chest pain is caused by a heart attack, women often report different kinds of pain than men, said Eryn Bryant, nurse practitioner at the Women’s Heart Health Clinic. Women may feel pain going to their arms, their shoulder, or to their back or neck, or even to the jaw. Some feel short of breath, getting lightheaded or even passing out. Others get sweaty and nauseous.
Doctors haven’t always recognized this difference between women’s and men’s symptoms. Decades ago, death rates in women with cardiovascular disease were much higher than in men. “The gap has closed, a lot,” said Bryant.
Still, heart disease is the leading killer of both women and men. Heart disease deaths are 6 times higher in women than deaths from breast cancer alone, Bryant said.
Heart disease happens when the inner lining of the arteries get clogged with plaque. Built-up plaque can limit or even block the flow of blood to the heart.
The slow build-up of plaque in arteries can cause chronic chest pain, called angina.
“How do you know if you have cardiovascular disease, or if you’re having a heart attack?” Bryant said. While many people think of sudden chest pain as the sign of a heart attack, sometimes the pain from heart disease can start gradually over years.
When someone having chest pain comes to an emergency room having a heart attack , they are often given a test called an angiogram. In that test, small tubes like straws are inserted in an artery to deliver dye that shows if the artery is blocked. If so, doctors insert a tiny balloon or other device to clear out the area and restore blood flow.
But even standard tests for heart disease or other cardiac conditions don’t always show what’s causing chest pain. Both women and men can have symptoms of chest pain, but show clear arteries on an angiogram. This situation is much more common in women, Bryant said.
One study of about 1,000 women with chest pain but normal angiograms found:
- About 60 percent had a condition called microvascular disease. In this disease, smaller arteries in the heart–arteries too small to be stented or even seen on routine angiography–can cause chest pain. These women didn’t have the typical cause of chest pain or angina—blocked major arteries.
- Over 50 percent also showed an abnormal pattern in the cells lining their arteries. These cells are called endothelial cells, and they are critical to enabling the arteries to expand or shrink. Arteries must expand or shrink so they can deliver more or less blood to the heart, depending on the body’s needs.
“When someone is exercising or stressed, relaxed or sleeping, their job is to decide how dilated or constricted the arteries are going to be,” Dr. Khandelwal said, referring to endothelial cells in the arteries.
Under stress, certain chemicals in the blood, including catecholamines, tell the endothelial cells to relax and open up, so the heart muscle can get more blood flow. But in people with endothelial dysfunction or with abnormally functioning endothelial cells, they do just the opposite: they make the artery constrict, limiting blood flow.
People who have symptoms of a heart attack who show no sign of blocked major arteries can be given tests to find evidence of small vessel disease or endothelial cell problems, Dr. Khandelwal said.
There are other cardiac causes of chest pain beyond blocked blood vessels. They include:
- Heart failure, when the heart muscle is too weak to pump enough blood. It has multiple causes including heart disease; heart valves that are leaking or too stiff; high blood pressure; inflamed heart muscle; a heart defect from birth; alcohol and some illicit drugs, and chemotherapy or radiation treatment for cancer.
- Takotsubo’s cardiomyopathy, sometimes called the “broken heart syndrome,” which usually occurs after a person has endured a traumatic event like the death of a spouse or child. The cause is not clearly understood, although adrenaline may be involved. The good news is that most patients recover very well within 2 to 4 weeks without similar problems in the future.
- Pericarditis, when the sack that covers the heart gets inflamed, sometimes from a virus or a blow to the chest. A telltale symptom is chest pain that’s worse when the person lies down or takes a deep breath. Treatment may include anti-inflammatory drugs.\
- Heart arrhythmias, which are irregular patterns of heartbeats.
- A condition present at birth called a “myocardial bridge.” That’s when a large artery that usually sits on the outside of the heart muscle instead is covered by the heart muscle. That can cause heart pain.
“Most patients lived and died without ever knowing they have this,” Dr. Khandelwal said. It is only in a select few that this can be responsible for their pain. Jennifer Tremmel, MD, and Ingela Schnittger, MD, are currently doing research on how to decipher which features identify those who will have problems from it.
- Spontaneous coronary artery dissection, which is a tear in the inner lining of a major artery to the heart. This condition can occur more often in women who are pregnant. While this was thought previously to be rare, some evidence suggests it may be more common, Dr. Khandelwal said.
There are also noncardiac causes of chest pain:
- Esophageal spasm, which afflicts the esophagus. “We have GI causes of chest pain that can be quite debilitating,” Bryant said, referring to this.
- Heartburn (GERD, or gastroesophageal reflux disease).
- A blood clot in the lung, called a pulmonary embolism.
- Costochondritis, which is an inflammation of the muscle and cartilage between the ribs.
- Panic attacks and other neurologic, and psychiatric conditions.
Having a multispecialty medical team to diagnose chest pain can be an advantage given the variety of potential causes. Stanford’s Women Heart Health Clinic also has behavioral therapists to spot psychological and behavioral factors that can contribute to chest pain.
Treating women and men for psychological issues—including anxiety, depression and stress—can reduce death rates from heart disease as well as from other causes, said Valerie Hoover, PhD, a psychologist and clinical instructor in cardiovascular medicine at Stanford.
One study in women who had a previous heart attack found a 3-fold lowering of death from all causes 7 years after they had cognitive behavioral treatment. Another study in women and men found a 45 percent lower rate of a second heart attack 8 years after cognitive behavioral treatment.
Not all stress is bad. A mild to moderate amount of stress may actually improve performance in daily life, possibly due to increases in concentration and attention. But if stress reaches a level where people feel unable to cope, performance declines and physical health may also be affected.
Studies have found too much stress can trigger the body’s ancient “fight or flight” response, inherited from ancestors who had to respond to threats to their survival.
In this response, stress-related hormones like adrenaline and cortisol are released into the bloodstream and lead to certain physical changes, like increased heart rate, blood pressure, and breathing rate. These are things that “are going to help you fend off an attack, or be able to run really fast in the opposite direction,” Hoover said.
But in modern times, “we’re walking around with this chronically elevated level of stress,” Hoover said. What can happen is that this fight-or-flight response “gets stuck in the ‘on’ position,” which increases the risk for heart disease. Psychological distress increases the risk for heart disease and heart attack, and is also associated with worse outcomes following heart attack.
Cognitive behavioral treatment for reducing psychological distress involves helping people to change unhelpful thinking patterns and behaviors that may be contributing to distress, as well as training in how to activate the body’s relaxation response to lower heart rate and blood pressure. Therapists in Stanford Cardiology provide this treatment, as well as other related techniques for easing distress.
Stanford doctors also work with heart patients to change lifestyle behavior to reduce risk, Hoover said. Studies show that even people who have inherited a high genetic risk for heart disease can lower their risk for heart attacks and other heart problems by 46 percent if they follow a healthy diet, maintain a healthy weight, stop smoking and get regular exercise, Hoover said.
“That’s pretty powerful stuff,” she said.
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