Angina and Rotary vertigo related or coincidental?

  : : I am a 26 yo female with angina (under shoulder blade, down left arm,  up the neck, exactly over the apex of the heart; brought on by exertion, exposure to cold, eating more than a small portion, and time pressures at work! he he; relieved by rest or nitroglycerin). I also have had multiple abnormal EKG's which state "inferior and anterior ischemia" as well as ST-T depressions in inferior leads and sinus arrythmia (Which is common, I know.) On echo, I have a prolapse of the anterior leaflet of the mitral valve, allowing that leaflet to go straight up into the atrium (the other goes down like it should). At rest the valve closes fairly well and the regurg is "insignificant". No stress echo has been done. I had a treadmill which also showed ST-T depressions in the inferior leads, amazingly enough, at the same time I complained of chest pain. My caridologist called this a "false positive" and says I have MVP syndrome and should read Lynn Fredericksen's book. I did and it doesn't seem to pertain to me. I don't have panic attacks or anxiety or migraines or PMS. I do, now, however, have spider hemorrhages popping up all over, as well as splinter hemorrages in my nail beds. Also, several times a week I getting trendous rotary vertigo, am unable to stand, turn white as a sheet and start sweating and generally end up vomiting, my chest hurts, my BP goes to 150/100, my left side went numb in one episode. So, my question is, could these things all be related? They say you shouldn't look for a zebra when a horse will do. So, when you find black and white hairs all over the place, you say hey, it's a black horse and a white horse. Right? Okay, let me make it easier for you to answer. Do I go back to the GP who says she's sure "It's cardiac, you need a caridologist." and ask for more diag. Or do I try a third cardiologist (the 1st 2 think MVP=no big deal and won't look any further). Thank you for your time. Tracy
  :

[Cleveland Clinic, MD]

  : Dear Tracy,
  : Thank you for your question.  It is possible you are having coronary artery spasm and I would recommend seeking a third opinion from a cardiologist (perhaps at a University Center) about getting a cardiac catheterization.  
  : Coronary artery spasm (also called variant or Prinzmetal's angina) was originally described in 1959 by Prinzmetal and colleagues.  This uncommon syndrome is found in approximately 2% to 3% of patients presenting with chest pain at large referral centers.  The syndrome consists of chest pain at rest.  ST changes during the pain and normal or near normal appearing coronary arteries found on angiogram.  The spasm is usually confined to one vessel but may occur in several vessels at once.  The spasm may be provoked in the cath lab with an injection of ergotamine.  Although the angiogram appears normal there is actually some underlying coronary artery disease at the site of spasm.   Heart attacks have been reported with coronary artery spasm and sudden death due to coronary spasm cannot be ruled out.
  : Multiple etiologies have been proposed for coronary artery spasm and these are outlined below:
  : 1.  The basal release of nitric oxide appears deficient in arteries where spasm occurs leading to the suggestion that basal nitric oxide synthetase may be a culprit.
  : 2.  Low levels of intracellular magnesium and therapeutic response to intravenous magnesium have led to the suggestion that it may be involved.
  : 3.  Low plasma levels of vitamin E in patients with active variant angina and improvement in symptoms when vitamin E is used supplementary to calcium channel blockers has been observed.
  : 4.  Hyperinsulinemia and insulin resistance are thought to be risk factors.
  : 5.  There is an increase of symptoms during sleep and in the early morning hours suggesting certain blood factors that vary with the day.
  : 6. Hyperventilation, cigarette smoking cocaine use and withdrawal and alcohol withdrawal are known to precipitate coronary spasm.
  : Treatment for coronary artery spasm is with calcium channel blockers (nifedipine, diltiazem, verapamil, etc) and nitrates (nitroglycerine).  Potential side effects of calcium channel blockers are constipation, swelling in the legs and in some persons severe swelling in the mouth and throat.  Nitroglycerin may cause headaches and could reduce blood pressure to the point that nausea and vomiting occurs.
  : Also important to treatment is risk factor modification such as cholesterol reduction, weight loss, quiting smoking  and increasing exercise.
  : When symptoms are not responding to calcium channel blockers and nitrates the addition of vitamin E (300 mg a day) significantly reduced recurrent symptoms.  Experimental evidence has shown benefit with cyproheptadine (a nonselective serotonergic antagonist) and this may be available in the future.  Hope this information helps.
  : Information provided here is for general educational purposes only. Only your doctor can provide specific diagnoses and treatments. If you would like to be seen at the Cleveland Clinic, please Call 1 - 800 - CCF - CARE for an appointment at Desk F15 with a cardiologist.
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Dear Tracy,
I am glad to hear you will be seeing someone at Baylor.  This is certainly a fine institution and I am confident you will get the best possible advice.  I kind of doubt vertebrobasilar ischemia but this is a possible cause.  It is possible to get coronary artery spasm at any time.   Let us know what your doctors find at Baylor.  Best wishes and feel free to write back with any additional questions.

Information provided here is for general educational purposes only. Only your doctor can provide specific diagnoses and treatments. If you would like to be seen at the Cleveland Clinic, please Call 1 - 800 - CCF - CARE for an appointment at Desk F15 with a cardiologist