Assistant Professor PM&R, PM&R Residency Program Director Mayo Clinic Rochester, Minnesota, United States
Case Diagnosis: Coronary Endothelial Dysfunction and Vasospasm
Case Description: A healthy 19-year-old collegiate female athlete was referred to sports medicine physiatry for musculoskeletal chest pain. The patient described a 6–7-year history of intermittent anterior stabbing chest pain adjacent to the sternum that would radiate to her back. There were no consistent provoking factors. The pain could occur with or after activity and at rest. Prior treatments including ice, NSAIDs, and activity modification were not helpful. Evaluation by internal medicine for cardiac and noncardiac (pulmonary, GI, musculoskeletal) causes of chest pain was unremarkable. She was referred to sports medicine with costochondritis as the most likely etiology. Her pain was not reproducible on exam including no tenderness to palpation. Radiographs and bone scan were normal. She was subsequently referred to Cardiology and underwent a coronary angiography and spasm study that showed coronary epicardial and microvascular endothelial dysfunction with acetylcholine challenge and reproduction of her chest pain with prompt resolution with nitroglycerine.
Discussions: Treatment for this patient included low-dose long-acting nitrates and L-arginine supplements. Cardiology recommended continuing exercise activity but to avoid exercise during active or recent chest pain.This case underscores the importance of a comprehensive differential diagnosis for chest pain in athletes. While musculoskeletal issues are common, persistent symptoms unresponsive to typical treatments warrant further investigation. The patient's presentation and results of specialized cardiac testing highlight the need for vigilance in sports physiatry physicians to consider and pursue diagnoses beyond musculoskeletal pain in athletes.
Conclusions: Coronary endothelial dysfunction, including coronary artery vasospasm, can manifest as atypical chest pain in young athletes. This case highlights the sports medicine physiatrist’s need to consider and investigate a broad differential when faced with persistent, atypical chest pain, to ensure accurate diagnosis and effective management.
