Small vessel disease or arterial spasm?

[mag40]

40 year old female with chest pain and SOB since pregnancy in 1997: preterm labor at 28 wks, severe pre-eclampsia with HELLP syndrome, placental abruption.

June 2001: Holter: sinus tachycardia with rare supraventricular and ventricular ectopic activity. July 2001: Treadmill stress test to 10 METs. Baseline ECG showed 2 mm inferior, anterior, and lateral ST segment depression, worsening in recovery with T wave inversions and chest pain. Cardiac catherization done; report notes that circumflex artery is co-dominant vessel but appears larger than average. Right coronary artery is co-dominant vessel but appears smaller than average. Estimated ejection fraction of 60%.

June 2003: ECG normal sinus rhythm with short PR (104 ms), ST segment depression in V3 thru V5, T wave abnormalities, QTc = 426 ms. Exercise stress echo (13.5 METs). Additional 1mm ST segment depression at peak stress, continuing into recovery. Worsening T wave inversions and chest pain in recovery. August 2003: ER visit due to disorientation. ECG showed ST and T wave abnormalities, prolonged QT interval (QTc = 463 ms), low voltage QRS. Nuclear stress test performed. Baseline ECG showed poor R wave progression in V1 thru V3 and nonspecific ST segment shifts. Exercised to 10 METs. Additional .5mm ST segment depression in recovery and ejection fraction of 83%. Repeat in 2006 shows pronounced ST dep/T inv.

Taking nitro sublingual as needed and diltiazem 180 mg daily. Dr. says small vessel disease or arterial spasm; thinks no more diagnostic tests would help. SOB and pain increasing. Other thoughts?

[CCF-M.D.-MJM]

Hello,

I am sorry to hear about your struggles.  These can be very difficult cases.  If there is no epicardial coronary blockages to open, small vessel disease or spasm can be culprits.  The typical treatment is with vasodilators (nitrates) and calcium channel blockers.  It may be worth trying a norvasc or nifedipine instead of diltiazem, that is unless diltiazem has helped your significantly.

I hope this helps.  Good luck and thanks for posting.

[Al Dente]

sorry to hear you are having a rought time.  there are a few things that can be done to narrow down and get diagnoses.  small vessel disease can be very difficult to diagnose, as it cannot be readily visualized, even during caths.

calcium channel blockers and nitroglycerin can help coronary artery spasms--sometimes higher doses are needed.  An ergonovine challenge done during a heart catheterization can help diagnose an underlying problem with coronary artery spasm--I have had this done myself, and would only go to the top players (tertiary care centers like CCF) to have this done.  ST segment elevation or depression can be indicative of coronary spasm from what i've been told.

i would find a cardiologist that has more experience and interest in coronary artery spasm and small vessel disease--i've found it very helpful finding the "big docs" that handle difficult to diagnose cases.  by all means talk with your docs that you trust and have confidence in--or find some.

[discobeat]

With small-vessel or spasm being the problem, is there a solution? or do take the knowledge that its not something worse and move along?  I have tried to find more information, and it seems to occur more with rythm disturbances, (I am in A-fib) and my caths have been clear.  Last year I was experiencing chest discomfort with excercise around this time, and the EP doubled my CCB.  Also went on Prilosec.  Now I am getting many of the same symptoms.  Don't know if its the cold air, a progression, or indigestion.  I'm 42, so I'm in the age range for any of it.

Is there a good place to get additional info?

[Al Dente]

Hi,  here are some thoughts and opinions...talk to your doc

This is a very difficult question, and yes there are treatments for both coronary spasm and small vessel disease.  However the most important and vital step is to first actually have a diagnosis.  Docs can speculate on the problem, but you really need a diagnosis of the problem(s) to set a treatment plan.

Some heart disease is presenting differently in people (mostly women in some of the journals that I've been reading).  The entire vessel is thickened, and the docs aren't seeing "traditional" areas of thickend or occluded arteries.  IVUS (intravenous ultrasound) during a cath looks at the vessel itself and can help in diagnosis of a diseased vessel.

A cath is a snapshot in time, and the results are as good as the operator.  You take a cath CD to 5 different docs, and you'll have 5 different opinions.  I had several caths over a 1.5 year period and all had different reports--some occlusions got worse, others got better (with lots of medications).

Endothelial dysfunction can play a large role in both coronary spasm and small vessel disease.  Cholesterol management, particularly statins are showing promise, calcium channel blockers, nitroglycerin, and some diabetes medications are on the leading edge of treatment.  It gets more complex than that.

I have a goofy case of diffuse CAD, small vessel disease, and have had coronary spasm during a cath--we really haven't determined if it occurs in the wild.  Exercise, diet, medications, and really good doctors are important.  I went through some very bad periods lasting months with daily angina--nitro relieved it and it wasn't heartburn (I went to one of the GODS of esophageal disorders to rule out the esophagus as a source of chest pain).  And yes the cold would trigger angina.

The thing with angina & small vessel disease is that you cannot tell whether the event is a small vessel attack (which typically doesn't do damage unless it goes on untreated) or a heart attack.  The only way is to go the ER and have have studies done.  The patient cannot tell and the cardios cannot tell unless the tests are done.  No one's at blame for this.  Once a person is on a treatment plan, things can get better.

Some docs would say it's a panic attack--you could load a person with every anti-anxiety med in the arsenal, and things wouldn't get better (they would worsen).  Placing a person on a regimen to treat these issues, and they respond is proof that it is cardiovascular in nature.  SSRIs and old school anti-depressants don't fix heart problems.  Same thing with "heart burn" diganoses.

Some docs don't understand atypical angina/small vessel disease--this is not garden variety heart disease to which so many are accustomed to.  It takes several disciplines including cardiology and endocrinology to balance to balance this.

I know I've written about alot of stuff--I'm not a doc, just a patient that has gone through a few things.  I would seek help and professional opinions from the medical community.  A quick google search brings up alot of info on these issues but a good medical team is a must.

Good luck.

[mag40]

I appreciate everyone's feedback. I think this is a difficult situation for patients and doctors alike given the current state of diagnostic testing. I have been assured by the EP that future advances in testing should help clarify things, but in the meantime, it seems like the safest thing to do is to play with the meds. He has offered a repeat cath (he did not do the original), but I hate being the youngest person in the cath lab. Plus, my first and only cath was an unpleasant experience (bled out, ended up using a cane to walk for weeks afterwards because of swollen lymph nodes near the incision site). Even if they were to see a spasm or small vessel disease in a repeat cath, it sounds like I would end up in the same place, on the same meds I am now. Given the number of younger (pre-menopausal) women dying of heart disease with perfectly clear arteries, I am hopeful some research is being done to develop better ways to diagnose and treat the problem. If anyone hears of a clinical study along those lines, please post accordingly. Thanks for all the nice wishes.

[momto3girls]

Hi Al,

I was searching through some of the archives regarding angina vs. esophageal spasm and noticed that your posts have been removed.  I found that to be highly annoying as I and many others on this forum truly value and appreciate your insight.  Why would they delete your posts?  I thought it strange.  Anyhow, hope you're doing well and managing your angina bouts!  Take care!

momto3girls

[Al Dente]

Hi, I hope you are doing well momto3girls!

After doing a quick search, I'm finding a limited amount.  I have no idea.

There was a problem a while ago with a spammer that got into the forums, so some posts got deleted.  

I try to offer my thoughts as a patient.

Thanks,
Al.