To the Editor. Many physicians involved in asthma management have often faced asthmatic patients who complain of chest¹ or epigastric pain which may last for several hours or even a couple of days, and which occurs during or shortly after cessation of heavy attacks of asthma. This pain is usually overlooked because the severity of other symptoms, including dyspnea, shortness of breath, wheezing, etc., masks the transient pain. However, chest pain as the presenting symptom is seldom noted.²

Over a 20-year period, the author encountered three young and active patients whose chief complaints were cramping exertional chest pain, which usually began with heavy exertion, but unlike cardiac pain did not resolve shortly after rest and needed an hour or so to ameliorate. Two of these patients were also noted to have frequent colds and intermittent cough attacks either independently or after exercise. Post-exercise pulmonary function study of the three patients showed a definite obstructive pattern. Anti-asthmatic treatment including disodium cromoglycate (Intal^®) and salbutamol in two patients, and beclo-methazone and salbutamol inhaler in the third case, dramatically resolved all symptoms of the chest pain.

These three cases aroused the author's interest in the possibility of a subpopulation of asthmatics who may present with chest pain. Therefore, cardiologist colleagues were asked to refer all their non-smoking "chest pain patients" for pulmonary evaluation if cardiac origin of the pain had been ruled out.

During a three-year period from August 1993 to October 1996, a total of 232 nonsmoker patients with chest pain were referred for pulmonary evaluation. This group comprised 141 females and 91 men, ranging from 16 to 65 years of age. Before pulmonary consultation, a traditional cardiologic work-up had been performed in all cases, but this failed to confirm a cardiac origin for the chest pain. This work-up included history, physical examination, electrocardiography, treadmill stress test, and coronary angiography in 183 patients who were suspected to have true angina.

Table 1. Profile of the patients and characteristics of their symptoms.

After a pulmonary-oriented medical interview and physical examination, the patients underwent spirometry and either bronchodilator or provocation tests as indicated. The provocation tests used for these patients involved exercise and/or cold air. Methacholine was not used because many patients refused it. Thirty-three patients (14.2%) were found to have asthma, and their chest pain disappeared with asthma treatment. Most of the patients are enjoying good health with disodium cromoglycate and/or beclomethazone inhaler. One 41-year-old woman needs 10 g oral prednisolone per day in addition to 800 μg beclomethazone for optimal control of the disease.

In our series, the diagnosis of asthma was based on an initially obstructive pattern of spirometry, with a 15% or more increment of FEV₁ after inhalation of bronchodilators in 14 cases, and an initially normal spirometry with a decrease of 15% or more increment of FEV₁ after exercise or cold air challenge in the remaining 19 patients. As noted, the major presenting symptom was chest pain, but most patients when questioned admitted to having other symptoms, including shortness of breath and/or mild cough, a history of frequent colds and/or remitted childhood asthma.

Eventually, there were 12 asthmatic patients who denied any symptoms other than the chest pain. The profile of these 12 patients and other characteristics of their chest pain are listed in Table 1.