What is causing my chest pain?

by Carolyn Thomas  ♥   @HeartSisters

First of all, I think even using the word “pain” to describe a common heart attack symptom may be misleading for many women.

It’s important to remember that some women experience NO chest symptoms at all during a heart attack.(1)  And since my own heart attack, I have met countless heart attack survivors who don’t use the word “pain” to describe their chest symptoms. Cardiac researcher Dr. Catherine Kreatsoulas reminds us that words matter when women describe their chest symptoms without using the word “pain” – and can actually influence how they will be treated in the Emergency Department – or not. 

Chest pain is in fact the most common cardiac symptom in both men and women. These are just some of the ways women often describe the chest ‘pain’ of heart attack:

• pressure
• squeezing
• choking
• numbness
• tightness
• heaviness
• fullness
• burning

These symptoms – called angina pectoris –  can appear not only in the chest area but anywhere from neck to navel, such as the jaw, throat, or upper abdomen, and can be associated with discomfort in the shoulders, neck, head, left or right (or both) arms. Angina typically comes on with exertion, and eases up with rest.

Cardiologist Dr. Richard Fogoros reminds us that “these symptoms can last from less than a second to days or weeks, can occur frequently or rarely, and can occur sporadically or predictably. With such a broad definition, you can see why the term ‘chest pain’ is in itself of little help to doctors.”

It’s also important to remember that there are some heart attacks that are accompanied by atypical symptoms – although, to quote paramedic/researcher/film maker Cristina d’Allesandro:

“Women make up over 50% of our population, so why do we call our symptoms ‘atypical’ during a heart attack?”

When I was at Mayo Clinic after my own heart attack, I met a woman there whose only symptom in mid-heart attack had been a persistent cough, and another whose only heart attack symptom was numbness in the lower lip. I think it’s a miracle that either women was referred for more testing after describing those weird symptoms. For more on the variety of actual heart attack symptoms in women, read How Does It Really Feel To Have A Heart Attack? Women Survivors Answer That Question

Study results on the absence of chest pain in women during heart attack vary widely, from 8-42%. For example, as Florida cardiologist Dr. John Canto explained to me a few years ago:

“Chest discomfort is the hallmark symptom for both women and women during myocardial infarction (MI, or heart attack).  But when absent, it is more commonly seen in women than men. On average, in our national study (1.1 million MI patients, 465,000 of them female), 38% of women with STEMI did not did not have this hallmark symptom on presentation.(2) This is because (older) age is a major contributing factor to MI presentation without chest discomfort and more women who present with MI are older than men, on average by almost a decade. ” 

Cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic told me that she now prefers to “focus less on symptom DIFFERENCES (which multiple studies suggest are few and can’t be relied upon for diagnosis) and more on symptom RECOGNITION by both patients and physicians, which continues to contribute to disparities in outcomes.”

Angina can also occur in the absence of any coronary artery disease. Up to 30% of people with angina with a heart valve problem called aortic stenosis, which can cause decreased blood flow to the coronary arteries from the heart, can have angina. People with severe anemia may have angina because their blood doesn’t carry enough oxygen. People with thickened heart muscles need more oxygen and can have angina when they don’t get enough.

When it comes to chest pain, Dr. Fogoros adds that it’s important to keep in mind that chest pain is merely a symptom, not a diagnosis.

And because it can be a symptom of anything from a catastrophic to a trivial medical problem, when a person experiences chest pain it’s important to try to characterize that pain as rapidly as possible as being either completely benign or possibly significant.

Anecdotally, yoga afficianados can also report experiencing chest pain after doing yoga. The poses used in Bikram yoga, for example, can manipulate muscles, including those in the chest region. Overextending them or straining one of them while getting into and out of poses could cause chest pain after a session. Inflammation in the lungs, an embolism, and high blood pressure may be exacerbated by the practice. Injured ribs will likely produce chest pain, particularly after exercise, including yoga.

Heartburn often mimics the chest pain associated with a heart attack, and if you suffer from asthma, trying to get enough air in your lungs could make your chest hurt as well. A common pre-menstrual chest pain symptom called mastalgia occurs occurs in a predictable pattern related to the menstrual cycle.

Dr. Fogoros offers the following list of other causes of chest pain*:

• angina due to coronary artery disease
• angina due to coronary artery spasm (Prinzmetal’s Angina)
• angina due to coronary microvascular disease 
• heart attack
• heartburn (acid reflux, indigestion)
• benign chest wall pain
• costochondritis, an inflammation of the cartilage that connects a rib to the breastbone
• anxiety or panic disorder
• asthma, bronchitis, pneumonia, pleuritis
• mitral valve prolapse
• pericarditis
• thyroid condition
• recent chest trauma
• peptic ulcer
• aortic dissection
• Thoracic Outlet Syndrome

Let’s look at the condition on this list called benign chest wall pain as an example. In young, healthy people presenting with chest pain, this diagnosis is particularly common, according to Dr. Fogoros. He believes that doctors do not understand this condition very well, and consequently neither do their patients.

“Because this condition is completely harmless, the lack of understanding on the part of patients as to what is causing the pain often leads to months or years of needless worry or anxiety.”

*Need a translator?  Visit my patient-friendly, jargon-free glossary of hundreds of complex cardiology terms.

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 (1) S. Dey et al, “GRACE: Acute coronary syndromes: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events”, Heart  2009;95:1 20–26.

(2) J. Canto et al, “Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality,” JAMA. 2012 Feb 22;307(8):813-22.

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NOTE FROM CAROLYN:  I wrote much more about chest pain (heart-related or not) in my book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press). You can ask for this book at your local bookshop (please support your neighbourhood independent booksellers!)  or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from Johns Hopkins University Press (use their code HTWN to save 30% off the list price when you order).

See also:

Hysterical Female? Just Anxious? Or Heart Attack?

How Does It Really Feel To Have A Heart Attack?  Women Survivors Answer That Question

The Myth of the “Hollywood Heart Attack” for Women

The Chest Pain of Angina Comes in Four Flavours

When Chest Pain is “Just” Costochondritis

85% of Hospital Admissions For Chest Pain Are NOT Heart Attack