Chest Pain in Women -- In the Head or in the Heart?

Chest pain is an extremely common symptom and one of the most common reasons for individuals to visit general practitioners, cardiologists, and emergency rooms. For some people, chest pain is a critical warning that the heart muscle is not getting enough blood and oxygen - a condition known as myocardial ischemia, caused by severe narrowing of a coronary artery. Because chest pain can be the first sign of a number of serious conditions, including heart attack, both doctors and patients take it very seriously (and should). At the same time, most chest pain does not signal an imminent heart attack. In many cases, chest pain isn't directly related to the heart at all. Although it sometimes reflects a lack of oxygen to the heart muscle, more often it originates in the esophagus, in the lining of the lungs, or in the ribs and muscles of the chest wall. Some fleeting pains in the chest are so common that textbooks refer to them as "normal pains." So, chest pain can be anything from "normal" to the first sign of a serious and life-threatening heart problem.

Because chest pain is both common and potentially serious, a great deal of research has focused on how to evaluate patients with new chest pain. Numerous imaging tests and diagnostic procedures have become available for those experiencing symptoms that may signal a heart attack. While a doctor can usually exclude this diagnosis based on exercise and imaging tests, in ambiguous cases, a coronary angiogram may be needed to identify any blocked blood vessels.

Good News

When a coronary angiogram reveals that no arteries are blocked, it's a profound relief to patient and doctor alike. For the doctor, a normal coronary angiogram suggests an excellent prognosis for a patient with chest pain - long-term studies show that for such individuals, a major cardiac event is quite unlikely. The physician may pursue other tests to evaluate the esophagus, which can cause chest pain when it undergoes spasm or has acid reflux. Quite often, however, doctors simply assure such patients that their angiogram results are normal and that they should not worry about the chest pain.

Unfortunately, this reassurance often doesn't diminish the frequency or severity of the pain, and many patients continue to suffer. Although relieved that their long-term cardiac outlook is very good, these people are left to wonder what the problem is and whether it will ever go away.

For reasons that remain unclear, women are more likely than men to have chest pain in conjunction with normal coronary angiograms. Despite their normal angiograms, some of these women undergo further tests (such as exercise or stress tests) that may suggest a blood-flow problem. Contradictory or conflicting test results can leave women feeling frustrated and confused. Even worse, many women are left with the impression that the chest pain is somehow "in their heads." Such notions discourage many women from seeking further medical treatment, an especially unfortunate circumstance when their pain is severe or even disabling.

The syndrome of chest pain with normal coronary arteries is so common that in cardiology it bears the name of syndrome X (not to be confused with the metabolic syndrome also known as syndrome X). Over the past 25 years, numerous reports have suggested that when using sensitive tests for myocardial ischemia, patients with syndrome X (who are usually female) may have evidence of coronary blood-flow problems. Some investigators have questioned whether coronary ischemia had really ...