Many patients dismiss ‘pain’ of angina

Dear Dr. Roach: A recent column from a woman with recurrent chest pain and normal stress tests had me wondering: Could this be Prinzmetal angina?

K.O.S.

Answer: That’s an excellent

question.

Vasospastic angina, also called variant angina or Prinzmetal angina, is caused by spasmodic constriction of the artery, often with blockages, but sometimes without any blockages at all. Smoking is one known risk factor for this condition. It was first described in 1959, and it is still underappreciated and underdiagnosed. Only about 2% of hospital admissions for suspected angina are due to vasospastic angina.

“Angina” is usually thought of as chest pain, but it is far more likely to be described as chest discomfort or chest pressure.

Many patients, men and women, think they can’t be having a heart issue because they don’t have “pain,” but they might describe the feeling as “heaviness,” “tightness,” “fullness” or “constriction.” These all are common descriptions of angina pectoris, and need urgent evaluation in people at risk.

A major clue to vasospastic angina is the EKG taken at the time of the symptoms, which shows a finding (called “ST elevation”) that is commonly associated with an acute heart attack, but which goes away quickly once symptoms are gone. However, the findings can be missed and don’t occur in every patient.

Similarly, vasospastic angina may not show on the stress test. When the diagnosis is being considered, a very useful testing tool is ambulatory EKG monitoring, usually for one or two weeks. In combination with a compatible history and EKG findings, the ambulatory EKG monitoring can make the diagnosis.

Cardiac catheterization and angiography may be necessary to confirm the diagnosis. In some cases, experienced cardiologists will inject a small amount of a medication to try to provoke the spasm.

Treatment includes smoking cessation if indicated, and medication to reduce spasm, such as a calcium channel blocker.