Vangina and Fibromyangia as Common Atypical Causes of Chest Pain.

Chest pain is one of the most common and often concerning symptoms for physicians of all training.  Tell a dermatologist you've got chest pain and they're calling an ambulance before they remove the maximum number of moles they'll get paid for in one visit.   Want to come to the emergency department (ED) to get checked for a pregnancy test?   Call an ambulance and tell them you've got chest pain when you take a deep breath in and that your mother just died of a pulmonary embolism.  You get a free ride through triage to the front of the line.

The ED will always order a pregnancy test before they order your  CT scan to rule out blood clots.  Before they cart you away to the CT scanner ask them for your pregnancy result, then refuse to do the CT scan and sign out from the ER against medical advice.  Don't worry about whether all this nonsense will get paid for.  It will.  You've got Medicaid.

Chest pain is a red flag symptom until proven otherwise.  Missing a life threatening case of acute coronary syndrome or a pulmonary embolism can mean the difference between life and death for the patient and a few million dollars in legal bills for the head doctor in charge.  Tell the ENT doctor you have chest pressure and they'll tell you to hold pressure on your posterior bleed while their nurse calls an ambulance to get you the heck out of their office.   All chest pain goes to the ER these days.  Chest pain is an emergency until proven otherwise.

I'd say everyone at some point in their life has experienced chest discomfort in one way or another.  Classic angina symptoms are described as substernal pressure, usually left sided on the chest with associated jaw or left arm pain.  Often patients can be quite diaphoretic and nauseated.  Depending on which part of the heart is involved and how much heart is involved, patients can present with sudden death, syncope, hypotension and any other assortment of life threatening conditions.  Acute coronary syndrome is a spectrum of disease from stable angina (chest pain that gets better with rest), unstable angina (chest pain at rest), non ST elevation MI (subendocardial infarction with positive cardiace enzyme markers) to ST elevation MI, which is an emergency requiring immediate intervention with thrombolytics, cardiac catheterization or both.

For the hospitalist, getting called at 2 am on their night shift in a patient with chest pain should always be interpreted in the setting of the patients clinical condition.  Unless an obvious alternative explanation is offered, the patient will usually end up with an EKG, cardiac enzymes and possibly aspirin, nitroglycerin and beta clockers depending on the probability of cardiac etiology.   Whether they get a stat cardiology consult depends on how lazy the hospitalist is.

What about pain that does not sound cardiac?  Often referred to as atypical chest pain, common etiologies include costochondritis, musculoskeletal and gastric or esophageal etiologist such as GERD or esophagitis.  The atypical chest pain list is endless and this article is not intended to be a complete reference for atypical causes of chest pain.  However, after ten years of hospitalist medicine, I have discovered a common and under reported cause of atypical chest pain:  pain that has no possible cardiac or pulmonary or gastrointestinal origin.

I say this because these patients have had five negative CT angiograms of their chest to rule out pulmonary embolism, four upper endoscopies to examine the gastrointestinal track, three normal nuclear medicine cardiac stress tests, two heart catheterizations without even a speck of coronary atherosclerosis.  And they've had all this done within the last year.

For these patients, I have petitioned the World Health Organization to include vangina and the chronic variant of fibromyangina as ICD codes for patients who's only possible cause of chest pain is because they are acting like a whiny little girls. All physicians should feel confident diagnosing vangina and fibromyangina in patients who have had an exhaustive work up of chest pain with no resolution of their symptoms.  As an expert in caring for patients with both types of pain, I offer my services up to any ER doctor, hospitalist, internist or family medicine physician who gets sued for documenting vangina or fibromyangina when in fact the patient died suddenly the next day of with a ruptured thoracic aneurysm after  their 7th visit to the ER that month for chest pain.  Who knew?

These medical ecards help explain how vangina and fibromyangina in more detail.

"Sir, your chest pain is called vangina.  The only treatment is to stop coming to the ER."

Sir, your chest pain is called vangina.  The only treatement is to stop coming to the ER ecard humor photo

"If your chronic chest pain makes your doctor cringe at the sound of your name, ask them if fibromyangina is the right diagnosis for you."

If your chronic chest pain makes your doctor cringe at the sound of your name, ask them if fibromyangina is the right diagnosis for you ecard humor photo.

"Ever notice how fibromyalgia jokes are only appreciated by doctors and nurses, especially the ones without fibro?"

Ever notice how fibromyalgia jokes are only appreciated by doctors and nurses, especially the ones without fibro ecard humor photo

This post is for entertainment purposes. I wouldn't wish fibro or chronic pain on anyone.

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