Learning Objectives
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Learn the common causes of chest pain.
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Develop an understanding of the etiology of precordial catch syndrome.
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Learn the clinical presentation of precordial catch syndrome.
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Learn how to use physical examination to rule out pathology and other chest pain syndromes that may mimic precordial catch syndrome.
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Develop an understanding of the treatment options for precordial catch syndrome.
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Learn the appropriate testing options to help diagnose precordial catch syndrome.
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Learn to identify red flags in patients who present with chest pain.
Amy Cleaves
Amy Cleaves is a 30-year-old Web designer with the chief complaint of, “I think I am having a heart attack!” Amy started to speak again, and broke out in tears. “Doctor, I am really scared! Who will take care of my kids? How did this happen? What am I going to do?” I did what I could to calm Amy and promised her that together, we would figure this out. I asked Amy to describe her symptoms. Amy said, “Out of nowhere, I get this sharp pain on the left side of my breastbone just over my heart. It really hurts! It’s there and it goes away as quickly as it comes. It really scares me each time it happens!” I asked, “So, Amy, what does the pain feel like, an ache, a stab, an electric shock?” She said, “Doctor, the pain is like a sharp jab that goes right into my heart. One second I am fine, and the next second it hits, it lasts for a second or two, and then it is gone.” “Amy, does it hurt between attacks?” She shook her head and said maybe just a little, but she wondered if that pain was more from her rubbing the painful spot and making it sore rather than coming from her heart. “Amy, what are you doing when the pain comes on?” “That’s the crazy thing, I can be sitting with the kids watching Sesame Street and it hits. The kids can tell it’s happening. I try to hide it, but it just hurts so bad.” At that, Amy started crying again. I again tried to calm her down and then asked if the pain went anywhere, like down her arm, into her jaw, or somewhere else, and she shook her head no. I continued, “Any sweating, palpations, fever, chills, shortness of breath, cough, leg pain, anything else I need to know about?” Amy responded, “Not really, Doctor, but I read on the Internet that heart attacks in women are different than heart attacks in men.” “That’s true,” I said, “and we need to take this very seriously. The first step is to check out your heart and then figure out what the exact cause of this pain is.”
I asked Amy to rate her chest pain on a 1 to 10 scale, with 10 being the worst pain she had ever had, and she said, “This pain is a 20. Doc, this is worse than anything I have ever had. Worse than when my son Jimmie slammed my hand in the car door, worse than having a baby. It’s killing me! I just can’t go on like this!”
I asked Amy if she had any fever or chills since her pain begin, and she shook her head no. She admitted that she quit taking her birth control pills because of the chest pain, as she had read on the Internet that birth control pills cause blood clots. “But honestly, Doctor, with this chest pain, sex is out of the question. I don’t want to have a heart attack and drop dead while I’m having sex with my partner.”
I asked Amy if she ever had anything like this before, and she shook her head no. I asked what she was doing to manage the pain, and she reported, “nothing really works.” She tried a heating pad, but it really didn’t seem to help. She went on to say, “Doctor, I have nobody. I don’t know what will happen to my kids if I have a heart attack. What can I do?” I reassured her that together, we would get this sorted out, and I would do everything I could to get her better.
I asked Amy to point with one finger to show me where it hurt the most. She pointed to an area to the left of her sternum. She said that she kept looking in the mirror expecting to see something there. “Doc, you can’t see anything. There is nothing there. It’s down deep inside. I am afraid it’s something really bad.” I again reassured Amy that we would figure out what was going on and that I would do everything I could to get her better. She gave me a weak smile and said that she hoped so because she was really worn out with the whole thing. “Amy, since this pain has been so hard on you, I have a couple of questions, and I want you to really think before answering because the answers are very important.” She said, “Okay, Doctor, I will do my best.” I said that I knew she would. I then asked her, “Amy, have you ever felt like life just isn’t worth living?” She seemed shocked and then answered, “Doctor, if you are asking me if this pain makes me want to kill myself, the answer is absolutely not. That is a sin, and besides, I have everything to live for, my kids, my partner, my job. I love them all. I would never even think about such a horrible thing. My kids come first, before everyone and everything. They are such good kids.” I responded, “Okay, that’s good, but I want you to know that you can tell me anything, no judgments, no criticism. I’m always here to help.” She smiled and said that she really appreciated my concern, that she always knew that she could count on me. “So, next question. Do you feel like you have an excess of worry or stress? You mentioned that you have been really scared and worried about the pain.” Amy thought for a moment and admitted that she had been pretty stressed out, but quickly went on to say, “Doctor, I am not imagining this or making it up! The pain is not in my head. It’s coming from my heart.” I reassured her, “Okay, Amy, that’s good to know. One last question. Are you being hurt or abused, or have you been hurt or abused in a past relationship or by a stranger or loved one?” Amy shook her head no, and said, “Absolutely not. I have a wonderful partner who is loving and would never hurt me. My kids’ father was a kind man, too. That relationship just wasn’t meant to be. He drifted out of my life when I got pregnant with our youngest, and I have no idea where he is now. With my current partner, I feel very blessed.” I again reassured her, “Amy, this is a place where you can always talk. You can always come for help.” She nodded yes, and said she knew that. She said she appreciated my concern and it meant so much to her. I felt pretty good about that!
On physical examination, Amy was afebrile. Her respirations were 16. Her pulse was 72 and regular. Her blood pressure was normal at 118/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was completely negative. Specifically, her lungs were clear, and there was no mitral valve click suggestive of mitral valve prolapse or cardiac arrythmia. She had mild tenderness over the left costosternal area, but there was no obvious mass, costochondritis, or swelling of the joints suggestive of Tietze syndrome. There were no cutaneous lesions suggestive of herpes zoster or evidence of previous trauma. There was no evidence of infection. Her breast examination was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema or findings suggestive of thrombophlebitis. Her low back examination was unremarkable. Her lower extremity neurologic examination was completely normal.
I told Amy that I had good news. “I didn’t find anything bad on your examination. And more good news. There’s nothing to make me believe your pain is from the heart, but we aren’t going to take any chances.” I had a good idea about what was wrong and how to fix it. For the first time, Amy smiled and said, “Thank you, Doctor. I know I can always count on you.”
Key Clinical Points—What’s Important and What’s Not
The History
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History of sharp, paroxysmal chest pain without a history of antecedent trauma
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Patient’s strong belief that she was having a heart attack
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No classic signs of angina
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Admits to increased anxiety related to the pain
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Pain is localized to the left parasternal area
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No fever or chills
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Denies suicidal ideation
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Denies domestic violence or abuse
The Physical Examination
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Patient is afebrile
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Normal visual inspection of the chest wall
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Normal cardiac examination
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No mitral valve click on auscultation
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No cardiac arrythmia noted
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Normal pulmonary and abdominal exam
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No evidence of thrombophlebitis
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No evidence of Tietze syndrome
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No evidence of costochondritis
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Normal breast examination
Other Findings of Note
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Normal blood pressure
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Normal HEENT examination
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No peripheral edema
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No chest mass or evidence of infection
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No CVA tenderness
What Tests Would You Like to Order?
The following tests were ordered:
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Chest x-ray
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Electrocardiogram (ECG)
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Cardiac stress echocardiography test
Test Results
Chest x-ray is reported as normal.
ECG is completely within normal limits with no evidence of arrythmia or cardiac ischemia.
The cardiac stress test is reported as normal with no evidence of left ventricular wall dysfunction or ischemia on ECG. The ejection fraction is reported as 72%.
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Precordial catch syndrome
The Science Behind the Diagnosis
Anatomy
The cartilage of the true ribs articulates with the sternum via the costosternal joints ( Fig. 8.1 ). The cartilage of the first rib articulates directly with the manubrium of the sternum and is a synarthrodial joint that allows a limited gliding movement. The cartilage of the second through sixth ribs articulates with the body of the sternum via true arthrodial joints. These joints are surrounded by a thin articular capsule. The costosternal joints are strengthened by ligaments. Ribs 8, 9, and 10 attach to the costal cartilage of the rib directly above. The cartilages of ribs 11 and 12 are called floating ribs because they end in the abdominal musculature (see Fig. 8.1 ). The muscles of the anterior chest wall may also serve as a nidus of atypical chest pain ( Fig. 8.2 ).
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