DISEASES AND CONDITIONS THAT
MAY CAUSE CHEST PAIN
A large number of conditions other than obstructive coronary artery disease may
cause chest pain. The source may be from other structures and organs within the
chest, the chest wall itself, the spinal column, or the abdomen. Some diseases
will indirectly cause coronary artery disease, that has been present in silent
form for many years, to become symptomatic. In such cases, treatment should be
directed at the primary cause rather than the fact that coincidental coronary
artery disease is causing chest pain. The following is a list of some of the
more common causes of chest pain. It is by no means a complete list.
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VASCULAR CAUSES OF CHEST PAIN
Hypertension
(high blood pressure) as a cause of chest pain in both men and women is listed
first because it is the single most common cause of chest pain, including
coronary artery disease itself. In other words, more people suffer from chest
pain due to high blood pressure than those who have chest pain because of
obstructive coronary artery disease. Considering the fact that 64 million people
in this country have hypertension, and approximately 75% of them are either
unaware of its presence, or are not adequately treated, it is not hard to
understand why so many individuals with high blood pressure are having chest
pain.
Although it is a long known fact that hypertension can cause chest pain, it is
not a commonly known fact. Indeed, most doctors including cardiologists seem to
be completely unaware of it. Complicating this lack of awareness on the part of
doctors is the fact that hypertension may exist for years with both patient and
doctor being unaware of its presence. This is because typically such patients
will have a rise in their blood pressure only during periods of stress or
extraordinary physical activity. At rest, or in the absence of stress, their
blood pressure is normal. Thus, their blood pressure is apt to be normal during
a routine office examination in which blood pressure is typically taken while
the patient is at rest. Eventually the blood pressure of such patients will
become elevated even at rest, but not until there has been extensive damage to
the kidneys, heart, vascular system and brain. This is why hypertension has been
called the "silent killer."
The mechanism of an elevated blood pressure causing chest pain is similar to the
changes that occur when a blood pressure cuff around the arm is inflated. The
pressure within the cuff is transmitted to the arm itself, and directly to the
brachial artery within the arm. When the pressure within the cuff becomes
greater than the pressure within the artery, the artery will collapse and blood
flow will stop. In the case of the heart, when the blood pressure is elevated,
that pressure is transmitted back to the cavity of the left ventricle. The
increase in pressure is transferred to the heart muscle itself. When the
transmitted pressure within the heart wall is great enough, it will cause the
small coronary arteries within the muscle, that are branches and smaller in
diameter than the surface coronary arteries, to collapse. Therefore, blood flow
within the muscle will be reduced or cease altogether, and chest pain will
result.
It should be apparent that if an individual is having chest pain, and a resting
blood pressure is normal, and that patient is made to undergo angiograms,
coincidental coronary artery disease may well be found. The cardiologist is
likely to conclude that it is the coronary artery disease that is responsible
for the patient's symptoms. In such a situation, the patient should purchase a
blood pressure cuff, and take his own blood pressure during episodes of his
chest pain. If he finds his blood pressure is elevated, then he should insist
that his blood pressure be brought down to normal with medications. Obviously,
if medication causes his blood pressure to return to normal, and his chest pain
disappears, then he doesn't need angioplasty or coronary artery bypass surgery.
Finally, it would make sense to investigate the cause of your chest pain before
undergoing angiograms. See additional causes below.
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ESOPHAGEAL CAUSES OF CHEST PAIN
GERD
or gastroesophageal reflux disease is causes by failure of the sphincter at the
lower end of the esophagus to close properly. As a result, there is often
regurgitation of gastric acid from the stomach into the lower esophagus
producing spasm and inflammation of the lining that may produce chest pain that
is very similar to angina pectoris, including the fact that it may be
precipitated by exertion, and relieved by sublingual nitroglycerine. In fact,
esophageal disorders often coexist with coronary artery disease. Chest pain from
esophageal disorders is usually precipitated by eating of food, or by lying down
after eating, and it can be relieved by antacids and milk. Often it is
accompanied by heartburn and difficulty swallowing (dysphagia). Unlike angina
pectoris, which typically radiates across the upper and mid chest, esophageal
pain tends to be located at the lower end of the sternum (breastbone) and
radiates to the epigastrium. Certain kinds of food more characteristically
produce esophageal pain. These include alcohol, spicy food, Mexican food, and
coffee. Unlike angina, which tends to last less than 5-10 minutes, esophageal
pain may last for hours and fluctuate in intensity. GERD can be effectively
treated with proton pump inhibitors such as Prilosec.
Hiatal hernia.
A hiatal hernia, also called a diaphragmatic hernia, is an abnormally large
opening in the diaphragm where the esophagus connects to the stomach. As a
result, the upper end of the stomach may herniate into the chest cavity. This is
not likely to occur while someone is sitting or standing. Consequently, chest
pain, when it appears, does so only when the subject is either lying down or
leaning forward after a heavy meal. The chest pain that develops is a
constricting or burning discomfort that appears in the mid and left chest
regions, and may last for 30 minutes or longer. On occasion it may radiate to
the left arm. It may be temporarily relieved by belching or assumption of the
upright position. Sublingual nitroglycerine does not relieve the pain.
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CHEST PAIN FROM OTHER AREAS WITHIN THE CHEST
Lungs:
A variety of disorders involving the lung may be associated with chest pain.
Pneumonia is one of the most common, particularly when it involves the lining of
the surface of the lung known as the pleura. Inflammation of the pleura is
called pleurisy. Pleuritic pain tend to be sharp, and of brief duration when it
is present. Typically it may come and go over a period of hours, and tends to
occur only during inspiration. When associated with pneumonia, it is usually
accompanied by a cough and fever. It also may be a symptom of a pulmonary
embolism (see below), the site of metastasis of a malignant tumor, or a sign of
one of the autoimmune diseases such as lupus erythematosus. Although pleurisy
tends to be localized to a relatively small area of the chest, at times, with
the more infectious type, the chest pain may be generalized and cause shortness
of breath.
Pulmonary Embolism:
Another major cause of chest pain is a pulmonary embolism. An embolism is a
mobile blood clot that usually occurs after a surgical procedure, particularly
if the patient has been lying immobile in bed for several days. Immobility and
the stress of surgery are associated with stasis of blood in the lower
extremities and pelvis. This encourages the formation of blood clots in these
areas. An injury to the lower extremities also may result in the formation of a
clot, days or even weeks later. Whatever the origin, portions of the clot may
break off and migrate to the lungs. This is most likely to occur when attempts
are made to ambulate a patient in the post-operative period. Usually such a clot
lodges in the small blood vessels in the lung. If the clot is a large one, it
may be associated with coughing up of blood, shortness of breath, pain
intensified by deep breathing, and even sudden death. The pain associated with a
pulmonary embolism may be indistinguishable from both cardiac ischemia and the
pain of an acute heart attack. Chest pain may be the first clue that a clot is
present in the legs or thighs. In general, prolonged bed rest for any reason
encourages the formation of blood clots in the lower half of the body followed
by a pulmonary embolus. Usually the diagnosis of an embolism can be made by
chest x-ray, however, special tests and procedures may be required in more
obscure cases.
Pneumothorax:
A pneumothorax is an important cause of chest pain. It occurs when air
perforates the outer surface of the lung forcing ambient air into the chest
cavity. When this happens, the victim suffers chest pain followed by collapse of
the perforated lung and shortness of breath. Usually the pain is in the lateral
chest rather than the center of the chest, and it may be aggravated by
breathing. The diagnosis of pneumothorax can readily be made with a chest x-ray.
It also may be identified on physical examination, if the doctor takes the
trouble to listen to both lungs.
Mediastinal emphysema
refers to the presence of air in the central portion of the chest cavity that
contains the heart. Because the air may create pressure and stretching of the
structures and nerves within the mediastinum, severe chest pain may result. In
addition, because the stretched nerves involve the same nerve roots as the
nerves coming from the heart, it may be very similar to cardiac pain. Usually
the pain is more superficial and tends to be modified by respiration and body
position. This disorder can be diagnosed by a chest x-ray.
Pulmonary Hypertension
is a rare cause of chest pain. As you might infer, this is an elevation of the
pressure in the pulmonary arteries. The pulmonary artery is the artery that
exits from the right ventricle. Before it enters the lungs and branches into
tiny blood vessels, it contains unoxygenated, venous blood. A number of diseases
may cause the pressure in the pulmonary artery to become elevated including
various forms of congenital heart disease, mitral stenosis (obstruction of the
mitral valve), chronic lung disease, and primary pulmonary hypertension.
Although primary pulmonary hypertension is an extremely rare disease, it has
recently been found to be a side effect of certain medications used for weight
loss. The chest pain associated with pulmonary hypertension occurs with exertion
and is relieved by rest, and may be indistinguishable from the chest pain
associated with cardiac ischemia. Indeed, it is thought that the pain seen in
this condition is due to ischemia of the right ventricle. Except for chronic
lung disease, the various conditions giving rise to pulmonary hypertension occur
in a much younger group of people, and the chest pain that develops does not
respond to the usual cardiac medications. The diagnosis of all these disorders
can be made from a careful physical examination, chest x-ray, and even the
electrocardiogram.
Aortic Valve Disease:
The aortic valve is the exit valve of the heart and all blood must leave the
heart through this opening. Immediately after the aorta exits from the heart,
the coronary arteries arise and supply the heart muscle with blood. If the
aortic valve is diseased and obstructed, the blood flow exiting from the heart
eventually will be reduced, even though the pressure within the left ventricular
chamber becomes markedly elevated. At the same time, the pressure within the
aorta beyond the valve will be reduced, and the amount it is reduced depends
upon how obstructed the aortic valve becomes. If pre-existing coronary artery
disease is present, a previously insignificant degree of narrowing in a coronary
artery may now become very significant. The result will be a reduction in blood
flow and chest pain. Usually, if significant aortic stenosis is present, the
murmur associated with it is readily heard. Unfortunately, the modern
cardiologist has become so technology oriented that frequently he does not even
bother to listen to a patient's heart with a low technology instrument such as
the stethoscope. Even if he does so conscientiously, the blood flow through the
valve may be so reduced that no murmur can be heard.
Mitral Valve Prolapse
has been claimed to cause chest pain. There is no anatomical reason why mitral
valve prolapse should cause chest pain. Because both this disorder and recurring
chest patient pain are so common, mitral valve prolapse is often discovered
coincidentally in the evaluation of a patient with chest pain symptoms. Also,
mitral valve prolapse may accompany obstructive coronary artery disease; however
it is the coronary artery disease that produces the chest pain and not the
mitral valve prolapse.
Pericarditis:
This is due to an inflammation of the membrane surrounding the heart called the
pericardium, and is accompanied by unique changes in the electrocardiogram.
Viral and bacterial infections may sometimes involve the pericardium and will
produce chest pain very similar to that seen with cardiac pain. The pain of
pericarditis, however, is aggravated by deep breathing and influenced by changes
in body position. It may cease when the breath is held or if the victim leans
forward. Pericarditis is not a common disorder. Because of its similarity to
cardiac pain, and the unique changes seen on the electrocardiogram, it easily
can be mistaken for an impending heart attack. If coincidental coronary artery
disease is found on an angiogram, and if the doctor seeing the patient is an
aggressive cardiologist, potentially dangerous coronary artery bypass surgery
may be performed that not only is unnecessary, but possibly harmful to the
patient.
Dissecting aneurysm of the aorta
is enlargement and separation of the wall of the aorta, the main artery exiting
from the heart. When present, it may cause chest pain and be mistaken for an
acute heart attack. When chest pain is present, it usually is severe, may
involve the back and even the abdomen, and is a medical emergency. If the artery
ruptures through the weakened portion of the aortic wall, death is immediate.
Milder forms of dissection may be confused with a heart attack but can usually
be diagnosed by a simple chest x-ray. However, if an x-ray is not taken, and the
patient is made to undergo angiograms, there will be prolonged delay during
which the aneurysm may rupture.
Syphilis:
While syphilis is rarely seen today, it occasionally does occur, particularly in
individuals who spent their earlier years in undeveloped countries where this
disease is still prevalent. The lesions of syphilis have a predilection for the
ostia of the coronary arteries; that is, where the coronary arteries exit from
the aorta just above the aortic valves. By causing marked narrowing of the ostia,
blood flow is markedly reduced in the coronary arteries. This will cause chest
pain that is identical to that caused by obstructive coronary artery disease.
Surgical intervention as well as antibiotic treatment of the syphilis are the
recommended forms of therapy.
Premature Beats
may be accompanied by a sharp, stabbing pain over the heart area, and
occasionally may be associated with a fleeting choking sensation. Usually such
symptoms occur at rest and decrease during physical activity, but may reoccur
when activity ceases.
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CHEST WALL PAIN
Cervical Disk:
A cervical disk may irritate the nerve roots going to the chest wall and produce
chronic chest pain that is aggravated by walking and certain body positions. The
pain tends to be more superficial than that seen with obstructive coronary
artery disease and is more likely to be present at rest.
Thoracic Outlet Syndrome:
The nerves and blood vessels that enter the arm often have to go through a
bottleneck of muscles. If a blood vessel or a nerve is kinked by a muscle or a
rib, arm and chest pain may develop that is associated with walking. Since
exertional chest pain is a hallmark of coronary artery disease, it is easy to
see why confusion may arise. The pain is induced by swinging of the arms, and
can be reproduced by elevating the arm and rotating it.
Tietze's Syndrome:
Inflammation and swelling of the cartilage between the rib and breastbone (costochondral
or chondrosternal joints is known as Tietze's syndrome. Such chest pain tends to
be superficial rather than deep, is aggravated by breathing, and is very tender
if the area is pressed.
Tenderness of the muscles of the chest wall:
A variety of factors may be responsible for tenderness of chest wall muscles
including injury from direct trauma (usually several days before the onset of
pain), coughing, and weight lifting causing a pulled muscle. Usually the chest
pain is localized to a small area, is brief while it lasts, is aggravated by
chest wall movements, turning, twisting and deep breathing, and may last many
hours.
Herpes Zoster:
A severe skin rash that does not spread beyond the midline, may cause extreme
chest pain in the pre-eruptive stage. Typically the skin is extremely sensitive
over the involved area. Herpes may not be suspected until the skin eruption
actually occurs.
Hyperventilation Syndrome:
An extremely common cause of chest pain is the hyperventilation syndrome.
Hyperventilation is simply over breathing as a result of anxiety or fear. It
also has been called panic attacks. Typically the subject unconsciously starts
to breath more rapidly and deeply when under stress. The over breathing is often
interspersed with deep sighs. In its acute form it will quickly produce a
variety of symptoms including lightheadedness, dizziness, a far away feeling,
numbness, palpitations, blurred visions, flushing, and tingling of the hands and
around the mouth. Sometimes the victim will even faint. In its milder form, the
subject may be constantly over breathing throughout the day. In so doing there
is increased use of the chest muscles. If there is enough overuse of these
muscles, they will become painful producing chest pain. Usually the victim is
not consciously aware that he is over breathing, but rather feels short of
breath. When this is associated with pounding of one's heart, dizziness, blurred
vision and the other symptoms of hyperventilation, it is not hard to understand
the panic that may accompany this disorder. Because the symptoms are due to over
breathing and blowing off of carbon dioxide from the lungs, the chest pain and
shortness of breath do not occur during exertion but rather at rest. Indeed,
physical exertion, which will produce carbon dioxide, makes the victim feel
better.
Primary Muscle Pain:
This includes some poorly understood disorders that have been called fibrositis,
fibromyalgia, myalgia and neuralgia. The pain of these disorders tend to be
chronic and ill-defined by the patient, are usually not related to exertion, and
are confined to localized areas of the chest in locations that are different
than what is seen with cardiac pain. The patient is usually more concerned about
the significance of the symptoms, and whether it is a sign of heart disease
rather than the intensity of the pain.
Cancer
may originate or spread to any structure in the chest including the heart and
cause chest pain. Such pain tends to be continuous and not related to physical
exertion. The diagnosis often may be made by a chest x-ray. Cancer also may
spread to the spine and vertebrae with irritation of the nerve roots that go to
the chest. Such pain may be quite severe and will not respond to the usual
cardiac medications.
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ABDOMINAL CAUSES OF CHEST PAIN
Perforation of a peptic ulcer:
Bleeding from a peptic ulcer may cause lower chest pain, a rapid heart rate, low
blood pressure, and even electrocardiographic changes. Thus, it erroneously
might be interpreted as a heart attack. Massive bleeding from such an ulcer will
be accompanied by black, tarry stools and be readily evident. However, if there
is low grade, chronic bleeding, the presence of blood in the stools will not be
obvious. The only symptoms might be discomfort that is mistakenly thought to be
coming from the chest. The fact that the pain is related to food ingestion
rather than exertion usually differentiates the two, but that distinction is not
always clear.
Pancreatitis:
Acute inflammation of the pancreas may cause severe chest pain that although
predominantly in the epigastrium, also radiates to the chest. Such pain is often
accompanied by changes in the electrocardiogram. However, patients with
pancreatitis usually have a history of alcoholism and gall bladder disease. In
addition, unlike the pain of a heart attack, the pain of pancreatitis radiates
to the back and can be partially relieved by leaning forward.
Gallbladder disease:
In the acute stage of a gallbladder attack, pain may be referred to the lower
chest. The pain is often severe, steady in character, and may show changes in
the electrocardiogram. Gallbladder colic may also trigger chest pain in someone
with silent coronary artery disease. Chronic gallbladder disease may produce
recurring lower chest and upper abdominal chest pain. Gallstones are readily
identified with an abdominal ultrasound examination.
Splenic Flexure Syndrome:
This is the term given to distension with gas of that part of the large
intestine in the region of the spleen. Because the colon makes a 90 degree turn
at this location, gas may get trapped causing the colon to distend. Since this
location is just beneath the diaphragm, the location of the pain appears to be
coming from the lower left chest. It may be distinguished from cardiac pain by
its intermittent, colicky behavior, and fluctuations in intensity of the pain.
Also passage of flatus gives temporary relief.
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MISCELLANEOUS CONDITIONS CAUSING CHEST PAIN
Abnormal fluid retention:
A variety of conditions may cause abnormal retention of fluid. This may increase
the blood pressure and cause a secondary reduction of blood flow to the heart
muscle by compression of the microcirculation within the muscle. This is due to
an increase in pressure within the cavity of the left ventricle that is
transmitted to the muscular walls of the heart, or it may result from an
increase in fluid within the muscle itself causing an increase in tissue
pressure (similar to the swelling that accompanies a local inflammation). One of
the most common causes of such fluid retention is the use of anti-inflammatory
drugs containing ibuprophen or a similar acting compound. They are popularly
called NSAID drugs for non-steroidal, anti-inflammatory drugs. Such drugs may
cause profound fluid retention and interfere with the flow of urine. The excess
fluid usually lodges in the tissues of the body, and can cause a weight gain of
several pounds. Because this fluid must enter the blood stream to reach the
kidney, it can result in fluid overload and chest pain. I recall one patient who
came to see me for a second opinion because he had been advised to undergo
coronary artery bypass surgery. Although his coronary artery disease had been
stable for several years, in recent months his chest pain had become more
frequent. The findings of his noninvasive examination suggested fluid overload.
When asked if were taking any medication for pain or for arthritis, his eyes lit
up and he replied, "Yes, I take six Advils a day". I told him to stop his Advil
and to substitute plain aspirin. This he did with prompt disappearance of his
symptoms.
Prostatitis:
In addition to NSAIDs, fluid retention may occur with a variety of urinary tract
problems which interfere with the formation and excretion of urine. These
include kidney or bladder infections, prostate infections in men and kidney
failure. Many is the patient who has undergone unnecessary angiograms for chest
pain with subsequent coronary artery bypass surgery or angioplasty for
coincidental coronary artery disease, when all they really needed were
antibiotics for their prostatitis.
Stress:
Fluid retention as a result of stress also may cause chest pain. A victim of
stress induced fluid retention may put on as much as 5-10 lbs. in 24 hours. Such
fluid retention can be eliminated and prevented with diuretics.
Anemia
is another unsuspected cause of chest pain. An anemia may have a variety of
origins, and a discussion of these is beyond the scope of this book. A few of
the more common causes, however, are bleeding from a peptic ulcer, a tumor or
polyp in the colon, bleeding hemorrhoids, inadequate nutrition with lack of iron
in the diet, pernicious anemia and chronic kidney disease. If the blood count is
low enough, it will produce such cardiac symptoms as palpitations and shortness
of breath with exertion, chest pain and fatigue. A simple blood count can
readily determine whether anemia is or is not present.
Thyroid Disease:
Either an under or over active thyroid can cause previously silent coronary
artery disease to become symptomatic. An overactive thyroid, or hyperthyroidism,
may result in chest pain because the heart is simply overworking. Typically the
heart rate is in the nineties or low one-hundreds even at rest or while the
victim is asleep. Silent coronary artery disease is usually present in such
individuals, but is not symptomatic at normal heart rates. If there is enough
narrowing of the coronary arteries, blood will not be able to get through at
higher rates and chest pain will result. With hypothyroidism or an under active
thyroid, the heart rate will be very slow, and the function of the heart will be
impaired enough so that pain may occur during exertion. In both of these thyroid
disorders, the disease is easily corrected with appropriate medication.
Cigarette Smoking:
There is hardly anyone who is not aware that smoking has serious side effects.
That it can produce heart disease and cancer is now common knowledge. Many are
not aware that smoking also may produce chest pain. Smoking increases the heart
rate, blood pressure and work load upon the heart. If there is pre-existing
coronary artery disease, but with adequate blood flow at rest, the increased
work produced by smoking, as well as the increase in concentration of carbon
monoxide carried by the blood in place of oxygen, may be enough to produce chest
pain.
Medications:
Chest pain related to miscellaneous problems with medications: Many patients
with coronary artery disease can live a normal life on a medical program. They
have little or no chest pain, and are not considered as subjects for angioplasty
or coronary artery bypass surgery until their chest pain returns, or becomes
more frequent or severe. The immediate concern voiced by the cardiologist is
that their coronary artery disease is getting worse, and that an obstructed
artery is getting ready to close off. Often the patient is literally frightened
into having surgery. In fact, in the majority of instances, the recurrence or
change in symptoms is rarely due to progression of the patient's underlying
disease, but is often due to a problem with the patient's medication. A common
cause is that the pharmacy where the patient purchases his medication has
substituted a different generic preparation for one of his prescriptions, and
this form may not be as readily absorbed from the gastrointestinal tract. Or,
the patient may have been taking a brand name drug and the pharmacist
substituted a generic form of the drug. At other times the patient may have
developed a tolerance to the medication he has been taking so that the drug is
no longer effective. Some patients will arbitrarily reduce the dose of a given
drug merely because they think they are taking too much medication. An extremely
common problem is seen with diuretics. Often, when diuretics are initially used,
the subject will have to void a great deal. This is a real problem with many
women who have had several children, and no longer have the bladder capacity
they once did. Going shopping and running errands are particularly difficult.
Accordingly, they will only take their diuretic when they are overloaded with
fluid. This result is running to the bathroom all day long.
It is necessary to explain to such patients that the body takes up fluid like a
sponge. If a sponge is filled with water, it doesn't take much squeezing to get
a lot of water out of it; however, if it is dry, additional squeezing wont have
an effect. The body works the same way. If overloaded, even one diuretic pill
will get rid of a great deal of fluid. If they continue to take the diuretic,
its effect will be diminished and be more tolerable.
Another reason why patients may arbitrarily reduce the amount of medication they
are taking is when they develop a coincidental flu infection or gastrointestinal
problem with diarrhea, and wrongly blame it on their medication. When they get
better, they are convinced that it was the reduction in their medication that
did it, rather than the coincidental and spontaneous improvement in their
illness.
Finally, some patients take their medication too close to meals, and it
interferes with the absorption of the drug. Accordingly, it is important that
someone examine the medical program of a patient to be sure it is correct.
Deconditioning and weight gain:
Other factors that can produce symptoms, and be misinterpreted as progression of
the underlying coronary artery disease, are weight gain, deconditioning,
inappropriate timing of exercise, and change in the weather. At times, for a
variety of reasons, patients with stable and silent coronary artery disease will
cease to exercise, and gain a significant amount of weight. Perhaps it is
because they are too busy, they might have sustained an injury to their back or
leg, or they merely may have been on a vacation. Whatever the reason, weight
gain invariably follows along with some deconditioning. When the patient finally
decides to resume exercising, chest pain returns. Only through careful
questioning and weighing of the patient at each visit can these explanations be
uncovered. Another reason for the flair up of chest pain is a change in the
weather. Patients with coronary artery disease are much more apt to have pain in
cold weather than warm. Merely dressing warmly or avoiding cold wind may be
enough to eliminate the occurrence of chest pain if it is present.
Exercise after eating:
Another cause of recurring chest pain is when patients decide to embark upon an
exercise program, but do so not long after eating a meal. While few people would
be foolish enough to vigorously exercise, many patients think a walk after
dinner is acceptable. When they begin to have pain they become frightened.
Merely having them walk before dinner is usually effective in stopping the pain.
Alcohol:
Finally, some patients drink to much. Often it is thought to be harmless, but
close questioning reveals that the patient is drinking as much as a half a
bottle of wine with evening meals. Alcohol is toxic to the heart making it beat
faster and harder. The alcohol may even produce irregular and ineffective heart
beats. The increased need of such a heart for oxygen may be sufficient to
produce chest pain. Cessation of the alcohol is all that is needed to eliminate
chest pain.
It is apparent that patients with coronary artery disease may develop symptoms
for many reasons. While patient and doctor alike become concerned that the new
onset of symptoms, or a change in previous symptoms means an impending
catastrophe, numerous observations and studies have established that emergency
action is rarely necessary, or even indicated. In the author's personal
experience, a recent increase in the degree of coronary artery narrowing is
hardly ever responsible for a change in the patient's symptoms. Consequently,
the common practice of many cardiologists of rushing a patient in for
angiograms, followed by angioplasty or coronary artery bypass surgery is totally
unwarranted. Most of the time, the cause of a flair up in patient's symptoms can
be determined by carefully asking the appropriate questions, and performing an
adequate examination. Too often that is not done, and the patient is scheduled
for an array of high tech tests. Even when those tests are abnormal, typically
there are no prior tests to compare with. Accordingly, the cardiologist has no
way of knowing whether the abnormality found on an echocardiogram, radioactive
imaging study or angiogram is the direct cause of the patient's symptoms, or is
merely coincidental, and there is some other reason for the patient's
complaints. In our modern, hurry-up world where both patient and doctor expects
immediate relief, the outcome is one in which the doctor urges the patient to
undergo immediate surgery. Oftentimes the reason for such recommendations are
more for the benefit of the doctor than the patient. At times such patients
actually may have some temporary improvement in their symptoms after a surgical
intervention. As will be discussed in later chapters, there are many reasons why
a symptomatic patient may obtain relief that have nothing to do with the surgery
or procedure performed. Thus, merely the fact that the patient feels better does
not mean their surgery or angioplasty was needed.
It takes a great deal of time to sort out all the possible reasons why someone
may develop chest pain. It can take months of treatment to eliminate other
diseases that may result in similar symptoms, or other diseases that cause
previously silent coronary artery disease to become symptomatic. Even when
obstructive coronary artery disease is the source of the patient's symptoms, it
may take many weeks and even months to eliminate their chest pain. Accordingly,
it cannot be emphasized strongly enough that you should never allow yourself to
be rushed into the cardiac laboratory for emergency angiograms as a prelude for
surgery. Nor should you ever accept the explanation that coronary angiograms are
needed to determine the cause of your chest pain, or whether a heart attack is
occurring, or how you should be treated. Angiograms cannot provide answers to
these questions. In contrast, a variety of noninvasive tests will readily
provide such information. This will discussed more fully in later chapters.
Rarely, a patient may require emergency surgery because of a vascular accident.
Examples are rupture of a muscular wall of the heart, massive leakage of one of
the valves of the heart, rupture of an artery and shock. Such catastrophic
accidents can be readily diagnosed without angiograms. Knowledge of your
disease, what tests are indicated, what tests are not indicated, and what your
various options are for treatment will greatly increase your chances of
receiving the best and safest treatment possible.