Angina, CAD et al.

[Dan-More]

Posted By  CCF CARDIO MD sc on February 23, 1998 at 12:45:43:

In Reply to: Angina, CAD et al. posted by Dan Moore on February 18, 1998 at 06:13:28:

: First angina episode was in 1991 in Atlanta while away from home on business.  I experienced a dull chest pain for hours & assumed indigestion or other cause.  Ultrasound and cath showed no problem, although cardiolite test in late 1997 showed very small damaged area at bottom of heart.
  Started on procardia 30 mg/day at that time.
  Second angina episode was in 1994--pain episodes were more severe but much shorter (2-3 minutes).  Cath showed no problem, doctor took chest xray and prescribed some sort of inhalant under premise this was lung-related rather than heart-related.
  Started pravachol to lower cholesterol.
  Third episode was August 97.  Pain very severe, three nitros did not affect it.  EKG in emergency room showed distress, cardiologist administered TPA. Cath showed serious blockage (90%) in right coronary assumed to be cause of problem and some less serious blockage (40%) in circumflex.
  Note: had been pack-a-day smoker for close to 30 years, approx 20 lb overweight, moderate physical exercise but not sedentary.
  Referred to interventional cardiologist in Indianapolis, who performed atherectomy (rotablator), angioplasty, and inserted two stents in right coronary in early September.
  Unpredictable chest pains started the day I came back from hospital 4 days after procedure and have been constant companion since.  I experienced no pains while in hospital.  Pains are sharp, below sternum, and do not spread to arms or neck, but most painful episodes will cause sweating.  tried numerous combination of drugs -- toprol, posicor, procardia, aspirin, with no real relief.  I had a cath 2 weeks after procedure and doctors found nothing but mentioned "unstable angina."  A month later I had the cardiolite test.  Doctor says I am not at risk of major heart attack but offers no answer to the pain.
  Predictable pains due to exertion, cold, or even heavy meal have gotten worse; it is now difficult to exercise without chest pain starting fairly quickly.
  I am scheduled for another cath in a week by Dr. who performed procedure in September 97.  The cardiologist tells me that there are many cases of chest pains where doctors are unable to diagnose the cause.  He also mentioned that at some point he may refer me to specialists with more experience in dealing with difficult cases (e.g., Mayo or Cleveland).
  The angina is no fun, but nitro makes it go away fairly quickly. On bad days, however, quality of life stinks.  Throughout this ordeal, though, one thought keeps haunting me: these pains started so soon after the procedure that it is difficult not to think that there is some cause and effect relationship.  
  I want to get this fixed -- any opinion / advice will be appreciated.

[CCF Cardio MD sc]

Dear Mr. Moore,
I a very sorry to hear about your predicament. It seems that you have become severely impaired by your condition and I think you should do your utmost to obtain some relief. I agree that there are occasions that a reason for chest pain is not found in some cases but I think that you are far from that stage. I would first of all like to stress that I can only make general comments about your case since I have not examined you and have not been privy to your test results and in no way do I want to come between you and your doctor.
The pain you are describing appears to be very concerning for anginal pain. The fact that there are clear precipitating factors, the relief with nitroglycerin and the associated symptoms all suggest that myocardial ischemia may be cause of your symptomatology. You have said that angiogram was done 2 weeks after your procedure but you did not tell me the status of the right coronary artery. Was the initial improvement maintained or was there some worsening of the blockage. Unfortunately coronary angiography is not the "gold standard" that we cardiologists make it out to be . You have to understand that angiography is a 2 dimensional representation of a three dimensional structure and there are many examples of blockages that look not significant on angiogram that turn out to be critical blockages when evaluated by intravascular ultrasound ( a technique whereby we are able to look at the artery from the inside with sound waves).
We can also assess the limitation to flow a particular blockage may have by means of a wire that we pass through the blockage. This can help to show that even though a blockage may not appear to be very significant on angiography its physiological significance may be much more significant. These are but to of the possible reasons for your pain. There is also the possibility that your blockages may have come back, this is something that will be  determined at the time of your angiogram.
I am not going to go into the other possible cause like small vessel disease and other chest pain syndromes with "normal coronary arteries" on coronary angiography as you have had large vessel disease in the past and until this has been worked up fully the other diagnosis should not be considered. There is also the question of your treatment schedule, you have not told me how well your cholesterol has been taken care of, and what kind of antianginal medications you are on. There are many options available on this front to minimize your symptoms.
I hope you  obtain some answers and possibly some relief in the near future. If you  have any further questions or would like to be seen by one of our interventional cardiologists here at the Cleveland Clinic please feel free to call 1-800-CCF-CARE to set this up. I would  to stress that being are referral center, our interventional cardiologists are very experienced in dealing with problems very similar to yours on a regular basis.
Information in this forum is intended for general purposes only, specific diagnosis and treatment should be reserved  for physicians directly involved in patient care.