Chronic Chest Pain? 5 Steps to Alleviate It

Many women who have angina need more testing and treatment than they're getting, a new study says.


Every so often, I read a new study and think, "Wow! This new finding could really save women's lives." I came across such a study in yesterday's Archives of Internal Medicine concerning chest pain. It showed that many women with angina aren't getting the necessary work-up and treatments—and may be dying of heart disease as a result.

An estimated 3 million women in this country fit this scenario: They report chest pain and have an abnormal exercise stress test, a common screening test for heart disease. They are then referred for a cardiac angiogram, an invasive imaging test that reveals whether there are artery blockages. If the angiogram shows clear, unblocked arteries, most women are sent on their way with no further testing and no treatment beyond painkillers for their chest pain. (Men also sometimes fit this scenario, but far less commonly than women.)

Yet, these very same women have about double the likelihood of suffering a heart attack or stroke or needing a major heart procedure within the next five years, according to the study. And they have a greater risk of dying: Women with chest pain and unblocked arteries, who were on average in their 50s, had a 1.5 percent chance of dying from heart-related causes over five years, compared with a 0.6 percent chance for those with no heart symptoms. Those with chest pain and blocked arteries had a 4.4 percent chance of dying.

"I was taught in medical school that women who had chest pain with an abnormal stress test and clear arteries didn't really have a heart problem, but this study suggests otherwise," says C. Noel Bairey Merz, a coauthor of the study and director of the Women's Heart Center at the Cedars-Sinai Heart Institute in Los Angeles. These women may have malfunctioning endothelial cells lining the inner artery, which prevent the artery from constricting and dilating when appropriate. As a result, arteries can constrict too tightly, cutting off blood flow to the heart and potentially causing a heart attack even in the absence of plaque. Detecting this condition requires more testing than an angiogram.

Bairey Merz suggests the following if you're experiencing chronic chest pain. (But seek immediate medical attention if you're experiencing a sudden onset of chest pain or other symptoms of a heart attack.)

[Here's a list of 7 heart attack warning signs.]

1. Get checked out by your primary-care physician. You'll be evaluated for noncardiac causes of chest pain like heartburn, panic attacks, or a pulled muscle. Once those have been ruled out, you might be referred for a stress test.

2. Get a stress test. It's a good, noninvasive screening test. If the results are normal and you have no other cardiac risk factors like high blood pressure or high cholesterol, your doctor will probably recommend pain medication to relieve your symptoms, says Bairey Merz.

3. Consider a coronary reactivity test along with an angiogram. An angiogram may be warranted if your stress test is abnormal. But cardiologists, says Bairey Merz, should perform coronary reactivity testing along with the angiogram to measure endothelial cell function. This test, which has been around for years, involves injecting a drug into the artery to see whether it dilates appropriately. Many doctors fail to use it to evaluate chest pain, she says.

4. Get medical treatment if testing is abnormal. If the coronary reactivity test is abnormal but you have a normal angiogram, you could probably benefit from a heart medication like a statin or a beta blocker to improve endothelial cell function, says Bairey Merz. A newer medication called ranolazine (Ranexa) that specifically treats chronic chest pain or angina may be the treatment of choice.

5. Make those necessary lifestyle changes. Increasing your activity level and switching to a more healthful diet can also help alleviate chest pain. In fact, a study published yesterday in the same issue of the Archives of Internal Medicine found that women who followed the blood-pressure-lowering DASH diet, which is rich in fruits, vegetables, and low-fat dairy products and low in red meat, salt, and saturated fat, had a lower likelihood of developing heart failure.

[See more details on the DASH diet.]

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