When pain isn't a heart attack: New research sheds light on an oft-misdiagnosed problem
Patti Hutton spent 15 years dealing with severe stabbing pain in her chest. It would happen whether she was active or not.
"I had really bad chest pain — like an elephant sitting on my chest at times. I was short of breath, stabbing pains. It was really uncomfortable and it would come on any time of the day," the Liberty Township woman explains. "It could be when I was resting or if I was exercising. (It would ) wake me up in the middle of the night."
Despite repeated doctor visits and testing, her doctors couldn't make it stop. She didn't have any arterial blockages — it wasn't a heart attack, they told her. It wasn't indigestion. It kept her from doing the things she loved. She frequently skipped out on going places, like on vacation, because she just didn't feel well. Sometimes she felt like no one believed her pain was real.
"I actually started thinking that maybe it was in my head because nobody was listening to me," she remembers.
Finally, after a doctor recommended open heart surgery to correct something called a myocardial bridge, she went to The Christ Hospital's Women's Heart Center for a second opinion. There she met with Medical Director Dr. Odayme Quesada and other staff members who listened to her list of symptoms and immediately ordered a new set of tests.
"I was very thankful when I saw Dr. Quesada and she assured me that there was actually something wrong with me," says Hutton.
After 15 years of agony, Hutton had an answer in one day.
Quesada recognized the signs immediately and the tests confirmed what she suspected. Hutton had two forms of a heart disease that disproportionately affects women and is frequently misdiagnosed.
Coronary microvascular disease (CMD) affects tiny arteries that supply blood to the heart. Essentially, people have chest or heart pain but don't have any blockages in their heart arteries.
Instead of having open heart surgery — the Christ team determined the myocardial bridge wasn't affecting her at all — Hutton began treating her disease with medication and other therapies.
"I think I cried," she says. "It was really good to know that it wasn't in my head; there was something wrong; and there were options out there for me so I could have a normal life."
When the heart pain isn't a heart attack
When a patient presents with chest pain, the first course of action is to run a traditional stress test, then depending on the results, undergo an invasive coronary angiogram to check for blockages in the heart arteries.
"There are women today that, because they don't have blockage in the larger arteries of the heart, they're being told that their chest pain is in their head, that it's not heart related, etc. But the reality is that these doctors are just missing coronary microvascular disease," explains Quesada.
CMD and similar heart conditions — collectively known as Myocardial Ischaemic Syndromes, including INOCA (ischaemia with no obstructed coronary arteries) and ANOCA (angina with no obstructed coronary arteries) — aren't well known. In fact, doctors only started studying them in women in the 1980s, according to Quesada.
Women are disproportionately affected. When it comes to ANOCA, for example, Quesada points out that if affects 3 to 4 million people, 70% of whom are women. However, that's "likely a huge underestimate because most people are under diagnosed or undiagnosed."
The various diseases are treated with various therapies and medications, but research is ongoing. While some treatments have been shown to be effective, some people continue to have pain or discomfort and doctors like Quesada are still trying to find new treatment options.
Quesada and colleagues from Christ Hospital presented their latest research on the issue, and possible new treatments, this past weekend at the American Hearth Association's Scientific Sessions conference in Philadelphia. Their findings are slated for publication soon in the American Journal of Cardiology.
The goal is to spread knowledge about these heart diseases, especially to people in the medical community.
"I truly believe that men are probably being more misdiagnosed even than women (for ANOCA), because we're starting to recognize this (disease) now. It's more in our conferences — our national conferences, we held our own conference where we're raising awareness about these diseases. We do more in the context of women, but there's a lot of men out there that are having chest pains with no blockage and they're definitely also being told that it's in their head or that it's not cardiac," says Quesada.
Men aren't the only ones likely being under diagnosed. Black and Latino women are likely being missed, too, and they're already at higher risk for coronary artery diseases and cardiovascular risk factors.
"We know less about racial and ethnic differences when it comes to microvascular disease because more research needs to be done in this area."
Quesada adds more research is also needed to determine if there are particular factors that can affect or cause microvascular disease, ANOCA, and INOCA.
"But right now, we do know that the risk factors for obstructive disease, for instance — high blood pressure, hypertension, cholesterol issues, diabetes, inflammatory diseases — we know that those are all going to make you more likely to develop some type of heart disease and microvascular disease is one of those."
Know the signs
Quesada says people generally come in complaining of two types of chest pain. There's the classic stabbing pain in the chest. There's also chest tightness, chest pressure, and shortness of breath. Symptoms can also include jaw discomfort and pain in the epigastric region (the upper abdomen, below the rib cage).
Symptoms may occur while working around the house or out for a walk. She says people may notice they start avoiding hills or doing activities that tend to lead to discomfort. Also, as in Hutton's case, the stabbing pains occur more commonly at rest, and at night and the early morning hours.
"They come out of nowhere. So people get really confused because they're like 'Why am I getting these chest pains, I'm not doing any kind of activity. I'm just sitting watching TV and all of a sudden, something is stabbing me in the chest.' "