Angina pectoris or something else?

Angina pectoris is one of the most well-known signs of chronic and acute cardiac issues, both among medical professionals and laypeople, the latter usually deriving such knowledge from works of popular culture. However, pain and tightness in the chest may be symptoms of other medical conditions, some far less dangerous than would otherwise be expected. Standard diagnostic methods can, of course, help differentiate between the causes, but they may be unavailable at the moment a patient presents with such symptoms.

With cardiovascular diseases (CVDs) accounting for 17.9 million deaths in 2016 alone, of which about 9.43 million are due to coronary artery disease (CAD), it is understandable that both the patients themselves and those around them are alarmed by sudden discomfort originating in the chest [1, 2]. In many patients, however, the discomfort may not necessarily be acute, but has a chronic quality and is more likely (though not in all cases) to be connected to actual cardiac issues such as CAD – stable angina. It is estimated that chronic stable angina afflicts up to a third of all patients with CAD, some of them experiencing symptoms on a daily or weekly basis [3]. Studies of those with acute coronary issues like acute myocardial infarction (MI) report far higher numbers symptoms: 78% reported diaphoresis, 64% felt chest pain, 52% experienced nausea, and 47% had trouble breathing (shortness of breath) [4].

Not all patients with acute MI have angina pectoris or other chest-related symptoms – silent MIs may represent from 20% to up to 40% of all cases of MI and are particularly common in women [5]. Females with acute MI are also more likely to report atypical symptoms than men and only half of them experience typical symptoms (i.e. chest pain) [6]. Additionally, women are perceived by many healthcare professionals as being at lower risk of MI (statistically true, but that shouldn’t be an excuse for lack of proper diagnosis), subsequently leading to mischaracterisation of their symptoms, delayed treatment and poor outcomes [7, 8].

Despite the many diagnostic methods for assessing cardiovascular health and detecting cardiac issues that shouldn’t happen, the reality is, of course, often quite different as misdiagnosis is common. A comprehensive cohort study conducted in the UK and encompassing nearly 600,000 patients diagnosed with MI (both STEMI and NSTEMI) found that nearly a third of them (more accurately, 29.9%) were initially given a different diagnosis [9]. Another finding was that women were (again) more likely to be misdiagnosed than men [10]. However, women are not the only group of “troublesome” patients since they share that distinction with older individuals and those with diabetes and/or chronic kidney disease (CKD) [11, 12, 13]. Diagnostic tools such as ECG, cardiac biomarkers, chest X-ray and echocardiography aside, physicians can utilise a handy questionnaire to quickly assess the probability of MI, the likelihood of (non)cardiac causes and the need for subsequent diagnostic procedures.

(Non)cardiac causes

Chest pain can be caused by a number of non-cardiac medical conditions, but which can coexist with actual cardiac issues, leading to possible misdiagnosis and delayed treatment. Examples of said conditions include gastrointestinal issues (the most common cause) such as gastroesophageal reflux disease (GERD), hypercontractile oesophageal motility disorders with nutcracker/jackhammer oesophagus or diffuse oesophageal spasm or achalasia, infectious oesophageal inflammation, oesophageal ulcers, rings, webs and eosinophilic oesophagitis and pulmonary diseases [14, 15]. Other probable non-cardiac causes are musculoskeletal chest wall pain and sickle cell anaemia (SCA) [16, 17]. Lastly, chest pain can be caused by non-organic, mental disorders like anxiety [18].

Accurate diagnosis of the cause of angina pectoris should always be made using modern diagnostic methods for assessing and detecting cardiac issues. However, a well-thought-out questionnaire can be utilised for screening prospective patients with chest pain before committing any diagnostic resources.