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Reassure me, dammit!

April 22, 2012

I found the following on a gastroenterology website.  The article was dated 1991, so represents opinion of 20 years ago.  What was amazing about this text was how many concepts from it I and other women I know who struggle with heart disease and chronic angina had encountered in our health care.

Read it and weep.

Microvascular angina: its diagnosis, pathophysiology and treatment

R.O. Cannon (Bethesda)

Claims for etiologies of chest pain in patients with angiographically normal coronary arteries have been reported by cardiology, gastroenterology, and psychiatry investigators. Thus, it appears likely that this represents a heterogenous population.

The usual approach towards such a patient is reassurance of an excellent prognosis, regardless of the cause for that individual’s chest pain syndrome [13]. Unfortunately, many patients are « reassurance resistant», continue to have chest discomfort, and utilize health care resources [45]. Published reports 20 years ago suggested that some of these patients indeed had a cardiac basis for pain [67] although in more recent years emphasis has shifted to noncardiac causes, primarily gastrointestinal [8] (esophageal motility disorders, acid reflux) and psychiatric [910] (psychosomatic disorders, panic attacks, anxiety neurosis). A noncardiac cause for chest pain symptoms in these patients is appealing to cardiologists, because it allows the clinician to direct the patient’s attention away from the heart and towards interested specialists.

On occasion, ischemia may be a consequence of undiagnosed valvular, congenital, or cardiomyopathic (especially hypertrophic or hypertensive) heart disease. Mitral valve prolapse is another etiology that has waxed and waned in credibility over the years. Having excluded these considerations by echocardiography and catheterization hemodynamics, we and others have demonstrated in a subset of patients with anginal chest pain responses to pacing stress and to potent coronary arteriolar vasodilators such as dipyridamole, abnormal coronary vascular responses to exercise and nifedipine, and ischemic-appearing ST segment changes during exercise and daily activities [1121]. On the other hand, other studies have concluded that there is no evidence for myocardial ischemia in these patients [2224]. These studies, however, differed in patient inclusion criteria and study design, as well as in the interpretation of the results. Even the name « Syndrome X » has taken on different meanings to investigators, generally resulting in an unsatisfactory diagnosis for the clinician to make, and for the patient to receive.

Note the highlighted sections above in red.  As a “reassurance resistant” patient who “utilizes health resources,” I have been told by my doctor that my recurrent angina which seems to affect every aspect of my life will not “worsen my prognosis.”  What he failed to take into account is just how debilitating my symptoms are.  You would utilize resources too if you suffered crippling fatigue after minor exertion and had pain in your chest anytime you walk uphill or for more than 10 or 15 minutes.  You might utilize even more when your symptoms occur at rest as mine often do.

I was fortunate to present with huge ST elevation in the anterior leads when I had my first symptoms.  This meant I was recognized as having a cardiac problem from the get-go and taken straight to the cath lab.  Many women I have met were not so lucky.  Some were sent home with Xanax and told they were having panic attacks.  Some were told they had GERD and to take Maalox.  Eventually they were back with heart attacks and some had waited days because of the previous false assurance (and embarrassment at being perceived as a hysterical woman), worsening the damage to their hearts.

One statement in this passage I do agree with its the last sentence, highlighted in green.  I’m glad medicine is moving away from the “Cardiac Syndrome X” nomenclature.

Now, I am not denying that there are causes of chest pain other than cardiac issues.  I just want to see women have as good a chance of getting a proper work up as men.  The consequences of missing a cardiac problem can be life threatening.  I was recently talking with a neighbor whose elderly female relative had a heart attack after being diagnosed with cholecystitis and having her gallbladder removed.  It’s not out of the question that she simply suffered a post-operative MI, however my neighbor is convinced her chest pain was cardiac all along.  This conversation ended with my neighbor declaring she wanted to wear a t-shirt that says, “I’m having a heart attack, dammit!”  Ironically, 45 minutes after this conversation I was being transported to the hospital with chest pain less responsive than usual to nitroglycerin.  At least with my history, I get prompt attention.

2 Comments leave one →
  1. frykwoman permalink
    April 22, 2012 10:48 am

    I seem to be able to rely on you to find pithy and revealing information about what I carry around with me all the time– my chronic condition, heart disease. I am particularly interested in this document– as it is so revealing of the medical mind and culture as they relate to my condition. That medical style that says “never trust the patient to know anything about their condition,” just explains so much about my bad experiences in the medical industrial complex. It is somewhat comforting to know that I’m not just imagining it,
    but disturbing to know that it is the formalized and documented way that many doctors deal with their difficult female patients.
    Time to affect some change, but how?
    I think I can do my part by always telling my truth, by being a fierce self-advocate, and by really vetting the doctors I see, and moving on to a new one if the old one turns out to be a bad one. Part of the process, for me, is to practice the 12 step serenity prayer concepts of having the wisdom to know the difference between things I can change and the things I cannot.
    Thank you so much for another part of the puzzle!

    • April 22, 2012 3:01 pm

      What struck me about the piece, was the way it seemed to take the various frustrating experiences we have had with doctors and codify them into expected behaviors. There is such a cultural divide at times between medicine and nursing, I find it difficult to understand how they think about their patients.

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