What are the next steps for a 61-year-old female with left arm pain and right upper jaw pain, and a recent Computed Tomography Angiography (CTA) of the heart and coronary arteries showing no significant stenosis?

Management of Left Arm Pain and Right Upper Jaw Pain in a 61-Year-Old Female with Normal CTA

Despite a normal coronary CTA, this patient with left arm pain and right upper jaw pain requires further evaluation for potential cardiac and non-cardiac causes, with a focus on functional testing to rule out microvascular or vasospastic angina.

Initial Assessment of Symptoms

• Left arm pain combined with jaw pain is concerning for potential cardiac ischemia, even with a normal CTA, as these are common locations for referred cardiac pain 1
• The presence of pain in both left arm and right upper jaw represents a pattern that could be consistent with cardiac ischemia, despite the atypical distribution (right rather than left jaw) 1
• Women often present with more accompanying symptoms beyond classic chest pain, including jaw and arm pain, which increases the risk of underdiagnosis 1
• At age 61, this female patient is in a demographic where atypical presentations of cardiac ischemia are more common and should be taken seriously 1

Significance of Normal CTA Findings

• A normal coronary CTA (no significant stenosis) falls into CAD-RADS 0-2 category, indicating minimal or no obstructive coronary disease 1
• However, a normal CTA does not exclude all causes of cardiac ischemia, particularly:
  • Microvascular coronary disease (common in women) 1
  • Coronary vasospasm 1
  • MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) 1

Next Steps in Evaluation

1. Functional Assessment for Ischemia:

   • Stress testing with imaging (stress echocardiography, nuclear stress test, or stress CMR) to evaluate for ischemia despite normal coronary anatomy 1
   • Consider PET imaging to assess myocardial blood flow reserve (MBFR) which can detect microvascular dysfunction 1

2. Provocative Testing:

   • If symptoms are suggestive of vasospastic angina, consider provocative testing with acetylcholine during coronary angiography 1
   • This is particularly important if symptoms occur at rest or have a circadian pattern 1

3. Cardiovascular Magnetic Resonance (CMR):

   • CMR can help identify other causes of symptoms such as myocarditis or Takotsubo syndrome 1
   • CMR has the ability to identify underlying causes in up to 87% of patients with MINOCA 1

4. Additional Cardiac Evaluation:

   • Echocardiography to assess regional wall motion abnormalities, valvular disease, and diastolic function 1, 2
   • Holter monitoring to detect arrhythmias that may cause symptoms 1

5. Non-Cardiac Evaluation:

   • Evaluation for musculoskeletal causes of left arm pain (cervical radiculopathy, shoulder pathology) 1
   • Dental evaluation for right upper jaw pain 1
   • Consider neurological causes (trigeminal neuralgia, temporomandibular joint disorder) 1
   • Rule out pulmonary embolism if dyspnea is present 1

Management Recommendations

• Initiate empiric anti-anginal therapy if symptoms are highly suspicious for cardiac ischemia, even with normal coronary arteries 1
• Consider calcium channel blockers and/or long-acting nitrates if vasospastic angina is suspected 1
• Address cardiovascular risk factors aggressively (hypertension, diabetes, dyslipidemia) 1
• Low-dose aspirin should be considered for primary prevention if 10-year risk of coronary heart disease is ≥10% 1

When to Consider Referral to Cardiology

• Persistent symptoms despite initial management 1, 2
• Abnormal findings on functional testing 1, 2
• High clinical suspicion for INOCA (Ischemia and No Obstructive Coronary Artery Disease) or MINOCA 1
• Evidence of arrhythmias or structural heart disease on additional testing 1, 2

Key Pitfalls to Avoid

• Dismissing symptoms as non-cardiac based solely on a normal CTA 1
• Failing to recognize that women are at higher risk for underdiagnosis of cardiac conditions 1
• Not considering microvascular dysfunction or vasospasm, which are more common in women and not detected by standard coronary angiography 1
• Overlooking the importance of a detailed symptom assessment, including timing, triggers, and associated symptoms 1