A Woman With Classic Angina and Two Test Abnormalities: Artifacts, Really??

Hélène described her chest pains as a pressure across her entire upper torso with shortness of breath. It happened with exertion and got better if she sat down. It also made her a little sweaty, even in her air conditioned home.

Her chemical, nuclear stress test report revealed no EKG changes, but “imaging suggested a small inferior and apical reversible perfusion defect not verified by the software” and “mild apical dyskinesia, probably artifactual”.

Stress testing is not as precise as people imagine, just like many other tests. In this case, what percentage of medical providers would trust Hélène’s reassuring report that stated in its summary that her risk of a cardiac event was average?

In many other radiology reports I read caveats like “depending on the clinical presentation, this could…”. But in the stress test reports there is no mention of pre-test probability. Perhaps there should be!

Particularly in women, where a stress echo may be a better test – but only available hundreds of miles away from where I practice – we need to avoid minimizing test abnormalities if our clinical index of suspicion is high.

I prescribed isosorbide and sublingual nitroglycerin the day I saw Hélène for her angina (that’s the diagnosis I used for the stress test order, not “atypical chest pain”) and after the stress test she told me her symptoms were greatly reduced. But she did have some side effects from her isosorbide mononitrate.

She appears to have at least significant microvascular disease, but I often see cardiologists showing little interest in this disease. I told her I wanted to adjust her medications and that we would involve cardiology but that her major coronary arteries were probably okay. She reminds me so much of a handful of other women with angina, like Doris Delaney, whose story I posted 11 years ago:

“But I Still Have Chest Pain!”

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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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