A Tight Squeeze

Laura Schwartz could have hour-long spells of squeezing chest pressure, but she was pretty sure it wasn’t her heart. After all, she was trim, athletic and by her own admission also a “health nut”.

A few years ago she had a stress test with with an abnormal EKG response to exercise but normal nuclear images. The cardiologist we consulted, as most in the cardiac community, felt the normal imaging trumped the abnormal EKG and declared her pain non-cardiac.

Her episodes of chest pressure recurred now and then. We had talked about the possibility of coronary spasm, but she wasn’t sure I was right about that. I had seen women before with “Cardiac Syndrome X”, who had classic exercise induced angina but normal coronary arteries. They tend to have only a mildly increased risk of actually having heart attacks, and sometimes get better over time on their own. In Laura’s case, the chest pain occurred sometimes with exertion like classic angina and sometimes randomly at rest the way Prinzmetal’s, or vasospastic angina usually behaves. She seemed to stand somewhere between the different types of angina, or perhaps she had esophageal spasm.

Laura wanted to leave things alone, and kept up her busy life, attending committees, exercising, gardening and maintaining her big house.

But six months ago, the intensity of Laura’s chest pressure seemed to intensify, and she was on the verge of accepting a referral for another cardiac consultation. Then she cancelled a couple of appointments and disappeared off my radar screen.

Last month Laura came back with a history of three days of on-and-off squeezing chest pressure. Her EKG was normal, but this time she was as concerned as I was. She accepted an ambulance transfer to the hospital where her first troponin blood test was normal, but the second one was dramatically elevated.

She was transferred from our community hospital to Capital Cardiac Center and underwent urgent catheterization. Bob Googan, one of their senior cardiologists, called me from the cath lab. “Hey, this patient of yours, Laura Schwartz, has normal coronaries but she has apical akinesia and must have infarcted because of spasm, so we’ll discharge her on something for spasm.

When I saw Laura in follow-up, she looked and felt great. We talked about how misunderstood women’s heart disease still is, and she sighed and said, “I know I have to pace myself. I’m not forty anymore, and I was pushing too hard”. She accepted a referral for cardiac rehab.

I am waiting to see if her calcium channel blocker will help prevent her angina, as with typical coronary spasm, or if she will need to be switched to a beta blocker, as many women with Cardiac Syndrome X.

This is the art of medicine.

1 Response to “A Tight Squeeze”

  1. 1 Tublu Chatterjee May 20, 2014 at 12:22 am

    I have a patient who is in an identical situation–trim, fit, active 62 yr old who infarcted with normal coronary arteries after weeks do sscp w/o clear etiology.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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