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sick man suffering from heart attackA 50-year old Hispanic patient came in last week complaining of daily chest pain for 2 weeks. The pain was described as being on the left, radiating to his left arm and back; however, it only lasted roughly two minutes per episode. It usually hit in the morning. The patient reported no known triggers for this pain; it was not hitting during exercise, going up stairs, lifting heavy objects. In fact, he said he would get up and walk around until the pain subsided. He had no known cardiac history of hypertension, coronary artery disease, or anything else.

There was no trauma. It was not associated with palpitations, shortness of breath, anxiety. The patient took no medications. He was a smoker, but denied drug or alcohol use. In the clinic when I saw him, the patient reported no pain or any other symptoms at that moment. His vital signs were all normal. He was not overweight. Exam, including cardiac and pulses, were normal. An EKG showed a normal sinus rhythm with no abnormalities.

I never saw this patient again, so you tell me…

WHAT WAS THE MOST LIKELY DIAGNOSIS? 

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Coronary artery vasospasm, better known as Prinzmetal angina

Now for this one, I can’t prove it, and is a good example of one of the most common kind of test questions med students get: what is the MOST LIKELY cause of such-and-such? Because in real life, diseases often don’t read the medical textbooks. Not all inflamed appendixes give right lower quadrant abdominal pain, and not all chest pains can be 100% nailed-down without a full cardiac workup first, which is of course far beyond my lowly urgent-care powers. So, I had to refer the patient to a cardiologist; they hopefully hooked him up to a sort of 24-hour EKG recorder known as a Holter monitor that could record changes during one of the patient’s daily attacks, after ruling out other causes of chest pain.

But Prinzmetal was the most likely diagnosis (and the correct test answer, if you got this on the boards), as other common causes of this sort of pain did not really play out. Anxiety was unlikely due to the short duration of the attacks, their daily frequency, and no other signs of stress or panic such as palpitations, SOB, or prior history. An actual heart attack generally wouldn’t last two weeks, have only intermittent pain, and leave a normal EKG. Regular, garden-variety angina produces its chest pain on exertion and is relieved by rest.

What Prinzmetal means is occasional spasm, or contraction, of the blood vessels that feed the heart. Think of that annoying twitch or tic of the eyelid people sometimes get when stressed; now imagine the muscles around an artery to the heart doing that. This temporary blockage produces the usual symptoms in common with any condition that interrupts the bloodflow to the heart’s muscles, including chest pain radiating to the left arm, jaw, and/or back.

But because these episodes are so brief, they usually don’t leave any lasting cardiac damage that can be picked up on EKG. The condition may coexist with some cardiac risk factors such as coronary artery disease, but it can also exist on its own. Many patients, such as mine, have no risk factors — except for smoking, as the nicotine can work to trigger the vasospasm that causes the pain.

Now the key is to distinguish Prinzmetal from the far more dangerous unstable angina. As the latter’s name implies, its presentation can be quite unpredictable, and it can progress to a full-on heart attack. Unstable angina with only two-minute episodes per day, not triggered by anything, would be unusual, but cannot be ruled out 100% with just history, physical, and EKG; hence, the “most likely” phrasing in med school exams.

Prinzmetal is relieved by calcium-channel blocker agents that relieve the vasospasm. Its primary danger is if an artery that is already constricted by cholesterol plaques (artherosclerosis) closes, and is then unable to open again; you can probably guess what we then call it if that happens. This is one reason why Prinzmetal patients require an angiogram or other imaging of the heart’s blood vessels.

But these patients are often completely healthy outside of these brief attacks and can lead a normal life with no lasting complications. And, please, if you’re having chest pain radiating to the left arm, get that checked out right away.

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