CHRONIC CHEST PAIN
A 25-year-old woman is complaining of chest pain. This had been present for 2 years on and off. The pain settled for a period of 6 months but it has returned over the last 10 months. The pain is usually on the left side of the chest, radiating to the left axilla. She describes it as a tight or gripping pain which lasts for anything from 5 to 30 min at a time. It can come on at any time, and is often related to exercise but it has occurred at rest on some occasions, particularly in the evenings. The pain is usually associated with shortness of breath. It makes her stop whatever she is doing and she often feels faint or dizzy with the pain. Occasionally palpitations come on after the start of the pain. Detailed questioning about the palpitations indicates that they are a sensation of a strong but steady heart beat.
In her previous medical history she had her appendix removed at the age of 15 years. At the age of 30 years she was investigated for an irregular bowel habit and abdominal pain but no specific diagnosis was arrived at. These symptoms still trouble her. She has seasonal rhinitis. Two years ago she visited a chemist and had her cholesterol level measured;
the result was 4.1 mmol/L. In her family history her grandfather died of a myocardial infarction, a year previously, aged 77 years. Several members of her family have hay fever or asthma. She works as a medical secretary. She is married and has no children.
On examination, she has a blood pressure of 102/65mmHg and pulse of 78/min which is regular. The heart sounds are normal. There is some tenderness on the left side of the chest, to the left of the sternum and in the left submammary area. The respiratory rate is 22/min. No abnormalities were found on examination of the lungs. She is tender in the left iliac fossa.
The ECG shown is normal. The pain does not have the characteristics of ischaemic heart disease. On the basis of the information given here it would be reasonable to explore her anxieties and to reassure the patient that this is very unlikely to represent coronary artery disease and to assess subsequently the effects of that reassurance. It may well be that she
is anxious about the death of her grandfather from ischaemic heart disease. He may have had symptoms before his death which were related to her anxieties. From a risk point of view her grandfather’s death at the age of 77 with no other affected relatives is not a relevant risk factor. She has expressed anxiety already by having the cholesterol measured
(and found to be normal).
She has a history which is suspicious of irritable bowel syndrome with persistent pain, irregular bowel habit and normal investigations. Ischaemic chest pain is usually central and generally reproducible with the same stimuli. The associated shortness of breath may reflect overventilation coming on with the pain and giving her dizziness and palpitations.
The characteristics of the pain and associated shortness of breath should be explored further. Asthma can sometimes be described as tightness or pain in the chest, and she has seasonal rhinitis and a family history of asthma. Gastrointestinal causes of pain such as reflux oesophagitis are unlikely in view of the site and relationship on occasions to exercise. The
length of the history excludes other causes of acute chest pain such as pericarditis.
The problem of embarking on tests is that there is no simple screening test which can definitively rule out significant coronary artery disease. Too many investigations may reinforce her belief in her illness and false-positive findings do occur and may exacerbate her anxieties. However, if the patient could not be simply reassured it might be appropriate to proceed with an exercise stress test or a thallium scan to look for areas of reversible ischaemia on exercise or other stress. A coronary arteriogram would not be appropriate without other information to indicate a higher degree of risk of coronary artery disease.
• Ischaemic heart disease characteristically causes central rather than left-sided chest pain.
• The resting ECG may show signs of ischaemia or previous infarction but is not a very sensitive test for ischaemic heart disease.