Pseudoangina as an Unusual Presentation of Non-Osseous Arterial Thoracic Outlet Syndrome: A Case Report.
This case report describes a rare instance of non-osseous arterial thoracic outlet syndrome presenting as pseudoangina in a young man, highlighting the critical need for high clinical suspicion and dynamic vascular imaging to diagnose the condition when cardiac causes are excluded and osseous abnormalities are absent.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
The human body is a complex network of tunnels and passageways, designed to let nerves and blood vessels travel safely from the center of the body out to the arms and legs. One such narrow corridor, located where the neck meets the shoulder, is known as the thoracic outlet. It is a tight space bounded by the collarbone, the first rib, and several muscles. Usually, this space is wide enough for everything to pass through without issue. However, in a condition called thoracic outlet syndrome, something narrows this passage, squeezing the structures inside. While this compression most often affects the nerves, causing pain or tingling, or the veins, causing swelling, it can occasionally pinch the main artery that supplies blood to the arm. This specific, rare version is called arterial thoracic outlet syndrome. When the artery is squeezed, blood flow is restricted, which can lead to coldness, color changes in the fingers, or even tissue damage if left untreated. Because the symptoms often involve pain in the chest or arm, doctors frequently mistake this condition for a heart problem, leading to a long and confusing journey for the patient before the true cause is found.
A recent case report from researchers at the Armed Forces Medical College in Pune, India, highlights just how easily this condition can be missed. They describe the story of a 27-year-old man who arrived at the hospital complaining of recurring pain in the left side of his chest. The pain would travel up his neck and down into his left arm, mimicking the classic warning signs of a heart attack. For four weeks, he endured these episodes, which came and went without a clear pattern. Because the symptoms were so convincing, the medical team immediately suspected a cardiac issue. They ran a battery of standard tests designed to catch heart disease: they monitored his heart rhythm, checked his blood for signs of heart muscle damage, performed stress tests to see how his heart handled exercise, and even looked directly inside his heart's arteries using a camera. Every single test came back normal. His heart was healthy, and his arteries were clear. The pain was real, but the heart was not the culprit.
With the heart ruled out, the doctors shifted their focus to the structures surrounding the chest and neck. They asked the patient more detailed questions and noticed a pattern that had been overlooked. Along with the chest pain, the man experienced intermittent tingling in his left arm and a distinct sensitivity to cold in his left hand. When the doctors examined him, they found that simply raising his arm over his head triggered his symptoms. As he lifted his arm, the pulse in his wrist grew faint, and his fingers turned a dusky, bluish color. This physical reaction suggested that raising his arm was physically blocking the flow of blood to his limb. To confirm this, the team used a specialized type of imaging called dynamic computed tomography angiography. Unlike a standard scan, this test took pictures while the patient moved his arm into different positions. The images revealed the problem clearly: when the man held his arm up, the muscles in his shoulder squeezed the left subclavian artery, the main vessel carrying blood to the arm. When he lowered his arm to a neutral position, the artery opened up again, and blood flow returned to normal.
The most striking aspect of this case was that the patient had none of the bony abnormalities that usually cause this type of compression. Typically, arterial thoracic outlet syndrome is linked to an extra rib or an unusually shaped bone that presses on the artery. In this man's case, X-rays showed no extra bones and no skeletal defects. The compression was caused entirely by soft tissue—the muscles themselves—pinching the artery when he moved. This distinction is crucial because it means the condition can hide even when standard skeletal checks are negative. The researchers also noted that the patient's primary complaint was chest pain, which they termed "pseudoangina," a condition that feels exactly like heart pain but originates from a different source. The pain likely traveled from the compressed nerves and blood vessels in the neck, radiating into the chest wall and fooling the initial cardiac evaluation.
The team concluded that this young man was suffering from a rare form of arterial thoracic outlet syndrome caused by soft tissue rather than bone. While the diagnosis was established, the patient chose not to undergo the recommended surgery to decompress the area, and he was monitored without further intervention. The report serves as a vital reminder for medical professionals that chest pain in young, healthy people is not always a heart problem. When standard heart tests are normal, but the patient also has symptoms like cold hands, tingling, or color changes in the arm, the doctors must look beyond the heart. The key to solving this puzzle lies in paying attention to how the body moves and using imaging that captures the body in action, rather than just at rest. By recognizing these subtle clues, physicians can avoid unnecessary heart procedures and guide patients toward the correct treatment for a condition that, while rare, can have serious consequences if ignored.
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