What does one do if she experiences major chest pains and medical examinations reveal no heart or BP abnormalities?
This is a particularly good question because it applies to all fields of medicine, and to all people who at some time in their lives will become patients (Yes, even doctors). If a person is experiencing symptoms that are not accompanied by signs of disease, or evidence in the form of an abnormal test, the diagnostic work-up will sometimes cease. Yet the patient still has the symptoms. What should be done?
First, were all the elements of your complaint dealt with? Please see my prior posting about preparing for a visit to a cardiologist. It is appropriate for a visit to any physician.
Second, what constitutes a full work-up for chest pain? This is actually different depending upon the likelihood of different processes causing the discomfort. Arteriosclerotic coronary artery disease is quite unlikely in very young people (but congenital disease may be more frequent). Thus, when the story doesn’t fit with a cardiac diagnosis, a simple exam and electrocardiogram may be sufficient. Sometimes, a cardiology consultation, stress test or echocardiogram is ordered, but this is not always indicated. The more invasive and expensive tests are best avoided if the likelihood of a major problem is low. In cases where the problem is particularly stubborn, repeated, and/or non-responsive to usual measures, and the likelihood of previously undiagnosed coronary arterial disease is higher, further and more invasive studies may be required.
Third, if appropriate testing does not reveal a cardiac cause for your complaint, what next? This is simply common sense. Look elsewhere for the cause. The chest is made up of more than just the heart.
It is not uncommon for women to have discomforts related to their breasts, especially if these vary with the menstrual cycle. Have you checked your breasts or had a mammogram lately?
The chest wall is also made up of muscles, bones (breast bone, ribs and spine) and cartilage that can be injured, or broken. Can you find one spot that hurts when you touch it? Discomfort related to the chest wall is often aggravated by certain motions of the arms or shoulders, by twisting your trunk, and occasionally just by taking a deep breath. The chest often hurts if a muscle in the shoulder is injured. Almost every doctor has seen the patient coming in with “chest pain” that started while throwing a ball or put on a bra, and is associated with trying to lift the arm. In such cases the problem is at the level of the shoulder.
Inside the chest, on both sides of the heart are the lungs. They don’t usually cause pain without shortness of breath unless acutely damaged by caustic substances (inhaled), or victim to blood clots. The area behind the heart however is the most frequent cause of extra cardiac pain. This is where the esophagus lives. The esophagus is the tube that connects our mouth to stomach. The esophagus is not just a simple tube. It has muscle that helps propel food into the stomach when we are lying down and a sphincter at its bottom that keeps food from coming back up when we are asleep or decide to stand on our heads or do somersaults. If this sphincter is not working right or is too lax, the acid from the stomach, as well as the food may go back up the esophagus causing irritation. Since this happens in the region just behind the heart, it can feel exactly like a “heart attack.” Laxity of this sphincter is often a problem related to obesity. When an obese person lies flat, the excess weight against the bowels pushed them up toward the chest gradually straining the lower esophageal sphincter. When the acid from the stomach is repetitively pushed back into the esophagus further damage is done. We call this gastroesophageal reflux disorder (GERD for short). This problem does require some management.
And what we put in our mouth can cause other sorts of problems. For some reason, “middle aged” women are more susceptible to this problem than any other gender or age group. Sharp or caustic objects can scratch the esophagus and cause major damage. The most frequent culprits: corn chips, Fosamax and vitamin C tablets.
While it is nice to be reassured about all of the horrible things that you don’t have, you didn’t go to a doctor for that, you went to find out what you do have, and to get rid of it. Persist in your efforts to find an answer.