A Country Doctor Writes:

Doris Delaney came back to see me a week after her semi-urgent cardiac catheterization. I already knew her coronary arteries were normal. The cardiologist had called from the cath lab immediately after the procedure to let me know. His words on the phone and in his discharge summary were that she had “noncardiac chest pain”.

Doris was obviously not relieved. She comes from a family with a dark cloud of cardiac history hanging over it and she had a markedly abnormal stress-EKG. She was still having crushing, squeezing chest pressure with exertion.

Could this really be esophageal spasm, nerves or chest wall pain, I wondered.

Her symptoms didn’t really fit the definition of vasospastic angina, which tends to occur more at night or with emotional stress than with physical exercise. Women do tend to develop blockages in smaller arteries than men, but in Doris’ case, the cardiologist was adamant that it was not her heart.

I have asked a couple of cardiologists what their thoughts are on patients with classic angina pectoris, positive stress-EKG’s and normal nuclear scans. Everyone has told me the nuclear scan overrides the EKG findings, and no one argues with a catheterization report.

That answer intuitively makes me uncomfortable. The electrical recording of the EKG can pick up changes in potassium levels and inflammation like pericarditis. Why might it not pick up small changes in oxygen supply to parts of the heart muscle that other technologies can’t?

But Doris had “essentially clean coronary arteries”. Why could I not leave it at that?

I prescribed a calcium channel blocker to tighten her blood pressure control, also hoping that it would help what I thought might be some coronary spasm. I made sure she was still taking her new cholesterol medication and her acid reflux pills. We agreed on a follow-up with blood work beforehand within a few weeks.

Less than a week later I saw her name in my schedule again. After her name were the words “still having chest pain”.

My heart sank. I sat down at the computer, logged on to my online database and did a quick search.

There, suddenly, was exactly what I had felt in my own heart was behind Doris Delaney’s chest pain. How many more patients had I seen with the same condition? How many patients were leaving the cath lab at Cityside Hospital without finding out that this is what they have?

I sank deeper into my chair as I kept reading.

Cardiac Syndrome X, not to be confused with the Metabolic Syndrome (previously called Syndrome X), is twice as common in women as in men. Patients have typical, exercise-induced chest pain, positive stress-EKG’s and minimal coronary artery abnormalities on catheterization. They sometimes do worse on the medications we often use for vasospastic angina, do better on beta blockers, tend to have only a moderately increased risk of myocardial infarction and sometimes get better on their own over time.

Searching elsewhere I found that even the New England Journal of Medicine has published a couple of articles on Cardiac Syndrome X in the past decade. I don’t remember seeing them before. I wish I had.

I clicked on “Print”, gathered my thoughts and papers, and knocked on Doris’ exam room door.

“I’ve been thinking a lot about your chest pain, and I’ve found some things I’d like to show you”, I began.