14.Managing Chest Pain
More than half of SCAD patients experience ongoing chest pain* after their SCAD event and this presents a particular challenge for interpretation. While severe and sudden chest pain always requires medical attention, it is common for SCAD patients to visit the ER or be admitted for chest pain after the initial event only to learn that it is benign. One of the greatest challenges for SCAD patients and their cardiologists is learning to differentiate what is problematic pain and what is benign pain.
Most patients will experience at least some chest discomfort in the months following SCAD and it can have a variety of different causes:
- Extension of the original dissection (rare)
- Recurrent SCAD in a new vessel (rare)
- Stent problems (rare)
- Pain or soreness associated with tissue healing
- Pain or sensations associated with vessel healing
- Muscular or skeletal pain from injury or strain in the chest area
- Anxiety-related chest pain
- Benign cardiac sensations magnified by anxiety and interpreted by the brain as pain
*Note: For SCAD patients and women in general, chest pain may not present in the typical way. Refer to the “What is SCAD” module for a list of different types of pain that can occur with a heart event.
Because most SCAD patients experience at least some “false alarms,” it may be best to think of the weeks-to-months after SCAD as a time of relearning how the body feels and behaves post-SCAD. Most patients with ongoing chest pain after SCAD report that these symptoms are different in character and intensity than the symptoms that they had during their event. Also, patients who have experienced recurrence typically report that it is very clear that another event is occurring, and that symptoms are similar to the first event.
One reason why post-SCAD chest pain is so challenging may be due to the way pain and other body sensations are processed in the brain. When a sensation occurs that is unusual or slightly painful, a “warning” or “danger” signal gets sent to the brain. Then different parts of the brain decide how important the signal is and what it means. Based on brain’s response, the person’s experience of pain (severity, intensity, duration) can increase or decrease.
Cognition/Thinking in the Prefrontal Cortex: This part can make pain worse when we are confused or frustrated about the sensation, or when we interpret it as threatening. Once we understand and make sense of the sensation, our brain can begin to quiet the pain.
Emotional Reactions in the Temporal Lobe: This part of the brain can make pain worse with worry or negative stress. Pain can be “turned down” if we can decrease fear and feel more hopeful.
Sensing Pain in the Sensory Cortex: When we choose to restrict movement as a way to feel safe from pain, the body begins to sense pain differently over time. Gradually, the body gets more sensitive and senses danger from more areas. As we begin to move again*, the body has less reason to send danger messages to the brain and this quiets the pain.
Sensing Movement in the Motor Cortex: Avoiding or restricting movement also increases pain because we soon expect movement to hurt. As we slowly return to activities*, this part of the brain can be reset, and this helps decrease the pain.
*There are certain movement and lifting restrictions post-SCAD. Check with your cardiologist about specific movements that you should avoid.
This does not mean that chest pain should be ignored. However, it can be helpful to understand that chest pain or unusual cardiac sensations after SCAD are not always signaling a problem. There are many reasons why SCAD patients may experience ongoing chest pain and behavioral strategies can help to identify and manage the pain. These include relaxation, mindfulness, distraction, and self-soothing (see Managing Stress module and Wellness Exercises).
The good news is that chest pain problems in SCAD patients have been observed to decrease over time. For most patients, the chest pain seems to get much better or resolve completely within 18 months to 2 years post-SCAD.