Andrew White had a long history of non-cardiac chest pain, usually fitting the definition of costochondritis, or Tietze’s syndrome. His pain was sharp, localized high up to the left, not far from his collar bone. He was always tender to the touch there and his EKG and bloodwork were always normal.
Between his recurring chest pain and other symptoms, like belly pain and swelling with pain in his legs, Andrew had logged half a dozen emergency room visits in the first 9 months of this year. Each time, he had called the ambulance to get there.
Then one day, during a regular office visit, he told me about a new pain he’d been having. Because he doesn’t drive, he usually walks to the store. For the past two weeks, he had noticed some shortness of breath on the way back up the hill to his apartment. Also, he had felt a pressure more in the middle of his chest.
Was this the power of suggestion after being asked about such symptoms every time he had been to the emergency room? Or was it the real thing this time?
His exam and EKG were normal.
I did not take any chances. I put him on a long acting nitroglycerin plus PRN sublingual tablets with careful instructions on how to use them. I also prescribed atorvastatin and ordered an ASAP nuclear, chemical, stress test and told him under which circumstances to call 911, even though I had discouraged him from doing so for other symptoms before. I didn’t start a betablocker because his blood pressure was on the low side, but I scheduled an early followup.
His stress test was only mildly abnormal, but his cardiac cath showed a near total occlusion of his left anterior descending coronary artery. This is the big one that has been called the “widow maker”.
The lesson here is obvious. Even worriers and hypochondriacs get bad diseases sometimes. We must never dismiss or underestimate that possibility.
A Country Doctor Writes: 
Yes although 99 percent of the time it maybe psychosomatic with a patient like this history history and history will give you the diagnosis . The old adage which although may not be the appropriate term for our time’s nonetheless holds true . “Crazy people get sick and sick people can get crazy “
I too had a 95% stenosis of the LAD. Asked to be scheduled for an angiogram as I was certain it was angina and the Duke cath lab let me send patients direct for cath on the basis of my office exam. I was very careful for the two days required for the protocol medical stress test. You should have seen those eyes bulge as they saw the EKG changes! I smiled until Friday when Joe did the angio; scared him that the lesion might need atherotomy, but I told him OK and not to worry. Angioplasty and stent were 2 years ago and 86 year old just had wonderful sex stress test with Nancy and no pain. Do have some concern about my stoicism and knowing some have asymptomatic infarcts.
My old attending used to say “even a squirrel can fall out of the tree”