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Not all chest pains are related to coronary heart disease

Chest pains strike for several reasons. It is important to know the heart-related causes

Chest pains strike for several reasons, mostly heart-related.

Fig 1 (above): There is marked thickening of the left ventricular septum (red arrows) with the evidence of heart muscle damage (yellow arrows).

Figure 2 (above): Anomalous origin of right coronary artery (red arrow) from left sinus of Valsalva.

APART from coronary heart disease which commonly gives rise to the symptom of chest pain, there are other heart-related conditions that may also cause chest pain. This includes the following conditions.

Hypertrophic cardiomyopathy (HCM)

HCM is an inherited disease of the heart muscle where the heart muscle becomes thickened. Patients may experience chest pain as well as other symptoms such as fatigue, breathlessness, palpitation, near-fainting or fainting. HCM may lead to heart failure, arrhythmia, stroke, left ventricular outflow tract (LVOT) obstruction or sudden cardiac death. This disease is one of the main causes of sudden cardiac death in young athletes.

Echocardiogram and Cardiovascular Magnetic Resonance Imaging (CMR) can be used to assess and monitor the heart function, the severity of LVOT obstruction and the changes of the wall thickness of the heart muscle. CMR has the advantage of being able to detect the heart muscle damage (fibrosis) due to HCM with contrast medium administration (Figure 1). In addition, CMR can reliably assess the regional heart muscle thickening not clearly visualised by echocardiogram.

A patient who failed medical therapy, symptomatic and with severe LVOT obstruction should consider further treatment options such as surgical septal myectomy (removal of part of the heart muscle surgically) or alcohol septal ablation (create a localised heart muscle damage that results in remodelling of heart muscle) to relieve LVOT obstruction.

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Anomalous coronary artery origin

Anomalous coronary artery origin is identified in 13 to 33 per cent of young athletes with sudden cardiac death. Anomalous origin of left main coronary artery from right sinus of Valsalva and right coronary artery from left coronary sinus are the commonest coronary anomalies associated with sudden cardiac death (See figure 2).

Patient may also present with symptoms of chest pain, fainting or near-fainting. High-risk features include anomalous coronary artery that originates with slit-like opening, makes an acute angulation and travels between the aorta and pulmonary artery. The anomalous coronary artery is at risk of being compressed in between ascending aorta and pulmonary artery.

CT Coronary Angiography or Coronary Magnetic Resonance Angiography can be used to assess the origin of the coronary arteries, where the latter has the advantage of not exposing the patient to harmful effects of ionising radiation.

All competitive sports are to be avoided in patients with anomalous coronary artery origin, irrespective of the presence or absence of symptoms. Surgical intervention with reimplantation of the anomalous coronary artery is indicated if it is associated with serious ventricular tachyarrhythmias (a form of life threatening arrhythmia) or myocardial ischemia (heart muscle is starved of oxygen).

Aortic valve stenosis

Aortic valve stenosis is the obstruction of the blood flow across the aortic valve as a result of aortic valve thickening and calcification. This can cause chest pain, shortness of breath, dizziness on exertion, transient loss of consciousness and death.

The common causes of the aortic valve stenosis includes degeneration (especially in the elderly population), bicuspid aortic valve (certain people are born with the aortic valve that has two cusps instead of three) and rheumatic valve disease (damage to one or more heart valves after episode of acute rheumatic fever is resolved).

Echocardiography, Cardiovascular Magnetic Resonance Imaging and Cardiac Computed Tomography can be used for the assessment of the aortic valve stenosis and to plan for the subsequent treatment. Surgical aortic valve replacement or transcatheter aortic valve implantation are the treatment options to be considered in patients with symptomatic severe aortic valve stenosis as they improve symptoms and enhance survival.

Myocardial bridging

Major coronary arteries are normally distributed on the epicardial surface of the heart. When a segment of the coronary artery runs into and underneath the heart muscle and then comes out again, it is called myocardial bridging. This is generally a benign condition. However, myocardial bridging may lead to chest pain and myocardial ischemia (heart muscle is starved of oxygen). Rarely, it may cause acute myocardial infarction (heart muscle damage due to heart attack) and sudden death. It may also be associated with arrhythmia. Myocardial bridging can be detected with CT Coronary Angiography, Coronary Magnetic Resonance Angiography or Invasive Coronary Angiography.

Mitral valve prolapse syndrome

Mitral valve prolapse (MVP) is a condition where mitral valve leaflets do not close smoothly or evenly, but instead bulge into the left atrium. Patient with MVP may experience chest pain. Other associated symptoms include palpitation, shortness of breath, dizziness, fainting, panic and anxiety disorders. Mitral valve prolapse can be diagnosed with Echocardiography or Cardiovascular Magnetic Resonance Imaging.

MVP usually has a benign course but it may lead to significant mitral valve regurgitation (leakage of blood backward through the mitral valve each time the left ventricle contracts), heart failure and sudden cardiac death. The parameters that indicate increased risk include moderate to severe mitral valve regurgitation, flail leaflet (a more serious form of prolapse), impaired left ventricular systolic function with left ventricular ejection fraction less than 50 per cent, increased left atrial and left ventricular cavity size, atrial fibrillation (irregular heart rhythm) and age greater than or equal to 50.

Patients with flail mitral valve leaflet who are in normal sinus rhythm can develop atrial fibrillation at the rate of 5 per cent per year. There is increased risk of stroke among patients with atrial fibrillation. Around 10 per cent of patients with mitral valve prolapse will require mitral valve surgery in their lifetime.

For the proper evaluation of the above-mentioned conditions and coronary heart disease, a cardiologist review is strongly recommended.

This series is produced on alternate Saturdays in collaboration with Singapore Heart, Stroke & Cancer Centre.

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