Noncardiac causes of angina-like chest pain☆

S INCE 1910, WHEN OSLER described a young man with a history of angina pectoris who was found not to have coronary artery disease (CAD) at autopsy, it has been recognized that angina1 chest pain may occur in the absence of significant atherosclerotic CAD.’ Angiographic studies have confirmed that the probability of CAD is higher in patients with chest pain typical of angina pectoris than in patients with less typical pain patterns.’ However, the prevalence of CAD among patients with atypical angina has varied considerably among different studies, and physicians demonstrate considerable variation in their classification of individual patients as having either typical or atypical patterns of angina-like pain.’ One reason for variations in the clinical presentation of CAD might be that common physiologic factors variably influence the development of angina in individual patients. These influential factors need to be appreciated lest a patient’s history of chest pain be inappropriately viewed as being inconsistent with myocardial ischemia. To be considered are the adequacy of warm-up,“ the relationship of physical activities to eating or exposure to cold,S-‘o smoking,“-‘6 variable thresholds to exertional angina,“-19 and the frequency of myocardial ischemic events that cannot be accounted for by increases in myocardial oxygen demand.20~2’ Nevertheless, CAD can be reliably excluded in most patients with chest pain, and therefore, clinicians must systematically consider noncardiac conditions when evaluating patients with chest pain in whom CAD has been excluded. There have been many recent published series of patients diagnosed as having angina pectoris but having minimally or nonobstructed coronary arteries by coronary arteriography (Table 1).2245 Typically, these reports have included minimal discussion of the means by which other noncardisc disorders capable of producing angina1 chest pain were excluded. It is apparent from these studies, however, that the exclusion of CAD in patients with angina1 pain is associated with a low risk of subsequent myocardial infarction or sudden death when compared with similar patients with CAD.23~25*28*3033”3934’45 Nevertheless, defining the absence of CAD without identification and appropriate treatment of the specific condition causing the chest pain does not adequately address a patient’s needs. Such patients often continue to have chest pain and repeatedly seek medical attention for it, resulting in recurrent outpatient visits and subsequent hospitalizations. They often continue to live in fear, believing that they have CAD despite negative diagnostic tests.34 Finally, physicians often treat these patients indefinitely with antianginal drugs despite telling them that they do not have CAD. 23V28734*35*36,4’,43 Although some of these individuals may have a myocardial ischemic disorder which, as yet, remains to be clearly defined, 26327*2973’~40*4648 others have noncardiac disorders capable of producing chest pain mimicking that caused by myocardial ischemia. Because recurrent angina1 pain can be caused by many different disorders, with prognoses ranging from benign to severe, it is essential that both cardiologists and primary care physicians have a strategy for further evaluation and management of patients in whom significant CAD and other causes of myocardial ischemia have been excluded. It is the purpose of this paper to review those disorders that might cause recurrent angina-like chest pain and substantial disabilities relating to employment and everyday living.