Health Equity

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.

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"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.

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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."

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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.' "

Covid Hasn't Gone Away And There Is Mounting Evidence Of Link To A Range Of Heart Diseases

Inflammation of the heart can be a complication of Covid-19. Photograph: Kateryna Kon/Science Photo Libra

Covid-19 hasn't gone away. But, almost four years after it was first identified, the infectious disease certainly features less in the zeitgeist. People can be forgiven for placing Covid on the back burner of their psyche.

Most of the population does not qualify for further booster immunisation against the virus, which also diminishes its day-to-day relevance. However, the evidence for long-term health effects as a result of Covid continues to mount.

Probably the most significant finding to emerge recently is a definite link between Covid infection and a range of heart diseases. Even those who had a relatively mild dose and who made a good recovery are developing heart symptoms in the first year after they were initially infected.

For up to a year after a case of Covid-19, people are at increased risk of developing a new heart-related problem – irregular heartbeats, spikes in blood pressure, blood clots and heart attacks. All occur more often, research shows.

Heart attack-caused deaths rose during every Sars-CoV-2 viral surge. This was especially marked among young people, with US research identifying an almost 30 per cent increase in heart-attack deaths among 25- to 44-year-olds in the pandemic's first two years.

A large 2022 study of some 691,455 patients published in The Lancet found that in the year after a Covid infection, people were 1.5 times more likely to have a stroke, nearly twice as likely to have a heart attack, and had between 1.6 and 2.4 times the risk of developing different types of heart rhythm problems.

Researchers... Found that those who had been diagnosed with mild Covid, had stiffer and more dysfunctional arteries than a control group who hadn't contracted Covid

That's a substantial risk and begs the question: how is Covid infection damaging our hearts and our blood vessels?

[ Covid-19 vaccines prevented 16,000 deaths in Ireland, study says ]

Inflammation is one possibility. We have had post-infection links to heart damage before in the form of rheumatic fever. This is an inflammatory reaction to untreated (prior to antibiotic availability) streptococcal throat infection that caused scarring of the heart's valves.

Researchers from the University of Portsmouth and the University of Split found that those who had been diagnosed with mild Covid, had stiffer and more dysfunctional arteries than a control group who hadn't contracted Covid. These changes are often the precursor to the development of cardiovascular disease. The study, while small, suggests we will have an increase in cardiovascular disease in the future as a result of Covid-19 infections.

[ Boris Johnson offered to be injected with coronavirus on TV, inquiry told ]

[ Two-thirds of patients at long Covid neurology clinic yet to return to work fully, seminar told ]

Then, in September came the first evidence that Sars-CoV-2 affects blood vessels directly. A research team, led by Dr Chiara Giannarelli at New York University School of Medicine, analysed coronary artery tissue samples from eight older people who died of Covid-19. The team found Sars-CoV-2 genetic material in coronary artery tissue from all patients. They found more viral RNA in the arterial walls than in the surrounding fat tissue. Many of the infected cells were macrophages, a type of white blood cell that helps remove cholesterol from blood vessels.

Another important question is whether Covid vaccine helps protect our hearts by reducing the inflammatory effects of the virus

The findings suggest that Sars-CoV-2 may increase the risk of heart attacks and stroke by infecting artery wall tissue. This provokes inflammation in atherosclerotic plaques, a known precursor to developing a heart attack or stroke. "It appears that the immune cells most involved in atherosclerosis may serve as a reservoir for the virus, giving it the opportunity to persist in the body over time," said Giannarelli.

This breakthrough offers a likely explanation for the original finding that people who had Covid-19 have an increased risk of cardiovascular disease or stroke up to one year after infection. Obviously the study was limited to the analysis of a small group of older individuals with COVID-19 and pre-existing blocked arteries. So follow-up research will need to look at larger numbers, including younger and previously healthy individuals.

Another important question is whether Covid vaccine helps protect our hearts by reducing the inflammatory effects of the virus.

Until we find out, my strong advice to those of you eligible to get the booster is – go for it.

muiris.Houston@irishtimes.Com

The Experts: Cardiologists On 20 Simple, Successful Steps To A Healthy Heart

Our hearts beat 100,000 times a day, but we tend not to worry about their maintenance unless there is a problem. What should we know about how to keep this vital organ pumping? Four cardiologists give their advice on how to keep our hearts healthy.

Exercise is key

"If you put exercise into a pill, it would probably be better than anything a doctor could give you to improve heart health," says Prof Dan Augustine, a cardiologist at Royal United Hospitals Bath. The NHS recommends 150 minutes a week of moderately intense activity, such as brisk walking "that gets you a bit breathless", says Augustine, or 75 minutes of higher intensity exercise, such as running or cycling. "If you think back to ancient times," says Graham Stuart, medical director of Sports Cardiology UK, "we didn't have cars, we walked everywhere and did manual labour. All the body processes are designed to be active."

Be aware of what your body can do

"If you have done no exercise in the past, you need to build it up," says Augustine. "Older people have more cardiac problems when they are exercising. If you are over 40, you need to have a feel for your own risk factors," for example, if you smoke or have a family history of coronary disease. Augustine advises having regular health checks, which are offered free by the NHS every five years for people aged between 40 and 74, and include monitoring blood pressure, cholesterol level and diabetes risk.

Overdoing it can be bad too

Generally speaking, you can't do too much exercise. "If you're doing really intense stuff like ultramarathons," says Augustine, "there is some evidence that you can cause some heart damage but this probably reverses after three or four days." What is more concerning, he says, is people overexerting themselves without being aware of underlying coronary disease. This can be a reason why otherwise healthy people collapse during marathons, or middle-aged men out cycling have heart attacks.

Avoid a sedentary lifestyle

"You're not going to go from zero to 100% in terms of exercise, but just think about how much you're sitting," Augustine says. "If you're getting your 10,000 steps each day then that is pretty good," says Stuart. Dr Fizzah Choudry, a consultant cardiologist at St Bartholomew's in London, says she walks around her house in the evening until she reaches this target.

High cholesterol can be problematic

"Cholesterol is a type of fat in our bloodstream that is made in the liver and is also found in the food that we eat," says Choudry. "Having too much can lead to furring up of the arteries, particularly the heart arteries and the vessels that supply the brain. This can lead to problems such as heart disease and stroke. The cholesterol-laden plaque that builds up in the heart arteries can reduce blood flow to the heart causing chest pain and angina but it can also cause sudden blockage of the arteries, causing a heart attack."

Inherited risk should be assessed

If you have a family member who has had a heart attack under the age of 60, you should see a doctor, says Augustine. Likewise, "if you have a parent, sibling or relative who has a heart problem that they're told is inherited, then you must get yourself checked," says Stuart. You can see your GP or self-refer. It is important to access information on how to live safely with an inherited condition, especially when participating in sport, Stuart adds.

Diet plays an integral role

"I would recommend a Mediterranean-style diet," says Stuart. "Fruit, vegetables, nuts and pulses are good for blood vessels and good for the heart." "Swap white bread, rice and pasta out for wholegrain versions because they've got more fibre in," says Augustine. "They are more filling and they are digested more slowly. Protein is really important and helps the body to grow and repair. Oily fish is really good for reducing bad cholesterol, inflammation, and lowering blood pressure."

Avoid unhealthy foods …

"I'm from Glasgow," says Stuart, "and there is a lot of evidence to suggest that deep-fried Mars bars are not so good for the heart." "What I say to patients," says Choudry, who has a specialism in cardiovascular disease prevention, "is try to cut down on fats – particularly saturated fat – and the amount of oil you put into food. Also cut down on carbohydrates. Mostly when people eat, they have a whole plate of rice or pasta and then a bit of meat and a bit of veg. Cut the carbs in half and fill the rest of your plate with white meat, fish and vegetables, and then you will start to lose weight and reduce your cardiovascular risk."

… and other no-brainers

"Stopping smoking can significantly improve your life expectancy on its own," says Tharusha Gunawardena, a cardiologist who works in coronary intervention at the Royal Papworth hospital in Cambridge, and describes himself as a "glorified plumber". Choudry explains how her heart attack patients often "have a sudden wake-up call, and say: 'there's no way I'm ever going to smoke again', which is great." She also sees a lot of younger patients who have used cocaine, which can cause a sudden heart attack straight after taking it, or heart disease in the longer term. "From a cardiac perspective, alcohol in moderation is OK," she says, as long as you stick to safe amounts, which UK guidelines state should be no more than 14 units over three days or more. "The key thing is not to binge," says Augustine.

Prioritise sleep

Gunawardena has just come off the night shift. Working nights, he says, has been shown to cause inflammation and worse cardiac outcomes, but he has done a Brazilian jiu-jitsu session to feel "less awful". "There are a lot of regeneration processes that occur while we sleep and trying to get eight hours of sleep a day is important," he says. Better sleep can be achieved through positive sleep hygiene, he says, avoiding screens and prioritising rest before bedtime. "Your heart is a muscle, an engine," says Augustine. "It needs fuelling and resting."

'If you could put exercise into a pill, it would be better than anything else for heart health …' cardiologist Dan Augustine. Illustration: Thomas Hedger/The Guardian Stress leads to unhealthy habits

"Do I have evidence to say that if you are emotionally stressed, that is bad for your heart? I can't say that," says Augustine, "but if you are under a lot of stress and your body clock is all over the place … you aren't going to be as physically active." "We know that if you're running on adrenaline, you're more likely to get abnormal beats," says Stuart. "If you're in a constant high-adrenaline environment, you're more likely to develop problems. How you deal with stress in the modern world is more difficult. I tell the teenagers I see to make sure they get time for rest, whether it's meditation or a walk."

Hearts can sometimes race

We become more aware of our heartbeat when we are anxious or nervous, as blood is pumped faster, like when we exercise. Gunawardena explains: "Generally we don't notice our heartbeat but sometimes people do. This can be because something peculiar is happening, like their heart is racing or beating irregularly. It can sometimes be a normal phenomenon – often contemplating your heartbeat suddenly makes one aware of it, but palpitations, as a symptom, is the unusual awareness of them, where it feels odd." If someone is concerned about palpitations, especially if they are also breathless and experiencing chest pain, they should see a doctor. "It is hard to be too prescriptive," says Gunawardena. "It can be a very individual experience. Some people can have abnormal heart rhythms and experience very few symptoms and there are others who find more common, non-life limiting phenomena much more intrusive."

What is a heart attack?

"A heart attack is when you have a blocked artery," says Choudry. "And because of the blocked artery, you don't get blood supply to a certain part of the heart. That is what causes the pain." Choudry's team deals with almost 1,000 heart attacks a year and makes about 3,000 coronary interventions, which involve putting stents into people's arteries when they become blocked, to prevent heart attacks.

A heart attack can feel like a heaviness in the chest

Symptoms vary, says Augustine, but a chest pain "that feels like a weight or heaviness" is common. Some patients describe it as "radiating up to their throat or down their left arm." This can be accompanied by feeling sweaty or sick. If you think you are having a heart attack you should seek medical advice immediately.

A heart attack can lead to cardiac arrest

"When a person is having a heart attack, the arteries are blocked and the muscles are starved of oxygen," says Gunawardena. "It sets off this abnormal heart rhythm and that makes the heart beat very fast and irregularly. Your heart should pump in a rhythmic, regular fashion, but when it goes into one of these abnormal heart rhythms, it pumps in a very uncoordinated fashion. And so people pass out and that is when they have what is called a cardiac arrest."

We should all learn how to do CPR …

"I can't say how important it is that people know how to do CPR [cardiopulmonary resuscitation]," says Gunawardena. "If you don't know how to perform CPR then learn how to do it so you are prepared if there is a serious complication of a heart attack."

… and how to use an electric defibrillator

"Ideally they should be everywhere where there is sport," says Augustine. He recommends looking at the Resuscitation Council website for information on where to find them and how to use them.

After a heart attack, driving and sex should be avoided for a month

Heart attacks "can really upset a person's confidence," says Gunawardena, because you can "suddenly become acutely aware of any sensation in the chest." With sex, "most people tend to feel nervous about it," says Gunawardena, "and want to have engaged with all the cardiac rehab and exercises first. Like with anything, it's a case of starting slowly." Sex, like any form of aerobic exercise, is obviously very good for the heart too.

Statins can be life-savers

"In the last 20 years or more, reducing cholesterol with medications such as statins has led to a dramatic reduction in mortality related to heart disease," says Choudry. "Statins are usually prescribed for all patients who have had heart disease and also those felt to be at increased risk, whether that is down to raised cholesterol or other factors."

A pacemaker isn't as life-altering as it sounds

Stuart gives the example of the Danish footballer Christian Eriksen who had an implantable cardioverter defibrillator, a type of pacemaker, fitted after a cardiac arrest at the European Championships in 2021, but is still playing professionally for Manchester United. There are minor inconveniences, like setting off security at the airport but "people can live really normal lives with them," says Gunawardena.

This article was amended on 14 November 2023. Christian Eriksen's cardiac arrest ocurred at the 2021 European Championships, not the World Cup, as an earlier version said. It was also amended on 16 November 2023 to correct the pronouns used to refer to Dr Fizzah Choudry

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