Paying heed to chest pain

Even without serious artery blockage, chest pain is often a harbinger of deadly heart disease.


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Chest pain can be a worrying sign of heart problems. It often prompts a check for cholesterol plaques blocking the arteries that feed the heart. Cardiologists had long assumed that, unless there were plaques causing substantial narrowing of the arteries, chest pain was nothing to worry about. But a new study involving KAIMRC researchers now refutes that idea. 

The findings have sparked a rethink about who should be considered at high risk for the complications of heart disease and might require more significant monitoring and medical treatment. 

The study, known as CONFIRM, included thousands of patients who received an imaging test for a suspected diagnosis of heart disease. Within this larger cohort, around 4,200 people had artery narrowing of less than 50%. Within this subgroup, there were 312 cases of heart attacks, bypass surgeries or other severe heart-related issues. 

KAIMRC cardiologist, Mouaz Al-Mallah and collaborators from across North America, Europe and Asia dug into these numbers, looking for statistically meaningful associations between symptom severity and the risk of major complications in the group without substantial artery issues. Contrary to conventional wisdom, they found that chest pain was linked to worse outcomes. 

Patients with chest pain, men and women alike, were 1.6 times as likely to have serious heart problems than those without it. However, that was only the case among people with at least some degree of plaque build-up and artery narrowing, a condition known as atherosclerosis. For those without any evidence of atherosclerosis whatsoever, chest pain did not seem to portend a worse prognosis. 

Al-Mallah and his colleagues propose several explanations for why patients with chest pain and limited atherosclerosis may have a higher rate of adverse events. It’s possible, they note, that the imaging test may underestimate the extent of narrowing, or that some other feature of clogged arteries — such as the amount of plaque calcification — may be a more important driver of heart disease. 

The authors also speculate that chest pain in those without severe atherosclerosis may be a symptom of some other heart problem unrelated to artery narrowing — such as blood vessel dysfunction.  

Whatever the reasons, the findings from Al-Mallah’s team show that patients complaining of chest pain should be taken seriously by cardiologists, even when sophisticated imaging tests show only partial artery obstruction in the heart.


  1. Lee, J.H., Han, D., Hartaigh, B.Ó., Gransar, H., Lu, Y. et al. Influence of symptom typicality for predicting MACE in patients without obstructive coronary artery disease: From the CONFIRM Registry (Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry). Clinical Cardiology 41, 586–593 (2018). | article

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