Prinzmetal's Angina

[Eydawn]

Figured I'd just throw this out there and see if any of our higher level providers have ever played with this one before. Thoughts on it? Experiences with patients?

I'll give the nutshell version of what happened with me... end of July I worked a night shift after moving all day and ended up with some pretty significant chest pain and took myself down to my own ER. (Damn, I hate when that happens...) EKG had non-specific changes, ER doc decided I wasn't dying after we did a 12-lead and an echo and tossed me out with a scrip for vicodin. "Must be musculoskeletal."

Ok, cool. Not really, but hey, it's all good. I wasn't dying. That's what I needed to know.

Over the next few months I had a lot of palpitations, chest pressure and fatigue. I'm talking ass kicking, feel like I'm dying, can hardly get through a workday fatigue. Did a 2 week king of hearts monitor- some PVC's, PAC's, brady to 48's and tachy to 130's but not consistent or really diagnostic. Chest pressure/pain and that sense of impending doom suck, by the by... apparently, according to my coworkers, I turn grey when it happens...

Go to see first cardiologist. "D'aww! Poor little stressed out new grad. It's just stress. Here's a scrip for propanolol PRN for the palpitations. We'll schedule you for a stress test. We just need reassurance." No, asshat, I need to know what's wrong with me... but thanks...

Helped to push a car. Had crushing chest pain. Freaked out a friend from my SAR team who used to be a pacer/defib device rep. He calls a cardiologist friend to get me in for a second evaluation. Stress echo normal.

Second cardiologist decides that it sounds like a vasospasm issue (oddly, exactly what my boss and charge nurse had said the day after everything started), started me on 2.5mg amlodipine QD, and I've been 90% good to go since. I've had 4-5 episodes of angina now, lasting less than 30 seconds (but holy shit, it hurts) and a few runs of tachycardia in the 140s that self resolves within 4-5 minutes. Someone way smarter than me knew the name for this particular condition, but oddly my cardiologist hasn't used it specifically... just calls it "vasospasm issues."

Doing some research, seems that Prinzmetal's is often cyclical, and it surely would explain some of the episodes of syncope/chest pressure/chest pain that I've had in the past...

So! Anyone have Prinzmetal's other than me? Any thoughts from our doc type folks on the random episodes of angina and the tachycardia? I'm 90% back to normal and I'll sure as heck take it over what I was dealing with.... but I'm curious as to folks' thoughts and ponderances...

--Wendy

[chbare]

I had this happen to a young, male patient in Afghanistan. Presented to our clinic with sudden onset, non-exertional angina. History was significant for smoking and moderate ethanol use. No known past medical issues or familial history. Ran a XII lead and he had some non specific ST changes and a left bundle branch block in addition to runs of sinus tach in the 130-140 range. Worked him up as an ACS. Gave ASA, NTG and loaded him with a Beta blocker. He was evacuated out and worked up in a military hospital. XII lead was normal, enzymes were negative and symptoms had resolved. He was discharged back to full duty. Saw him again a few days later with an identical work up. Again, the military hospital found nothing and told us our ECG machine was probably not calibrated. It occurred again and because it was close for him to return home on leave, he went back home and did a cardiology follow up. Subsequent follow up revealed he was diagnosed with vasospastic angina but well controlled on meds following the diagnosis.

I'm glad you are feeling better.

[scubanurse]

I don't get vasospastic, but I am on 100mg Metoprolol Succ and my HR will still be in the 90's. Doc's have no clue why, but my EDS is likely to blame. I feel your pain wendy and have a wonderful cardiologist if you need her number, she's out of Good Sam.

[mobey]

Yes I have had it (see my old post in burnout & stress forum), and here is my take:

I can tell from the tone of your post that you are defensive about linking psychological factors to the variant angina. Set that aside for a moment and look at it this way: IF you are in an existing anxiety state (which you may not know btw) you may be prone to vaso spasm due to increased release of stress hormones. Stay with me here..... If you are secreting higher than normal stress hormones, simply adding a little more stress, whether it be psychological, smoking a cigarette, or physical exertion, may trigger an angina attack.

Now this may not be what is occurring, but as a diagnostician you should do a thorough job of ruling out whatever you can. My suggestion to you is to entertain the idea that perhaps without knowing it you may be in an "anxious state" and secreting extra catecholamine's that is putting you on the verge of vasospasm, and take some action.

You may be surprised what a massage, meditation, or even a cleanout of your psychological closet can reward you with physically.

If you find my old post about longevity in EMS you will see the steps I took. I am happy to report I am 6mos without angina, horrible nightmares, and have a lower resting heart rate. No drugs, no exercise change, just a change in mentality.

I'm not saying it's all in your head....... I'm just saying some of it may be buried deep within your brain.

[Eydawn]

Hey Mobes! Glad to hear from someone who's experienced it.

I don't doubt there's a deep psych connection. At all. What I found intolerable was being patronized. Dismissed as a stressed out histrionic female. Fuck that doc... this is not all in my head.

It has been a rough year. I'm definitely working on the mental stuff. But if there wasn't a vessel wall issue it wouldn't manifest this way in the first place. Looking at the cyclical nature of this problem my history makes so much more sense now. And yes.... it's shown up more in times of high stress. I think cumulatively I've finally landed in the mess... and I am trying to get better at self care.

I'd kill for a massage, but I can't swing it financially currently. See: student loans, new mortgage and sole breadwinner. I will say that having the energy to get through a work shift has reduced some overt anxiety pretty significantly.

Nightmares... yea, that's been on tap. Had a good recurring one before I started the amlodipine about being coded at work. (It was one of my precognitive type dreams and I actually experienced the day in the dream... that was really eerie.) Other nightmares too. That is also starting to improve.

So... yea I agree with you... and it's a work in progress. Like most illnesses it has both physical and psychological components.

Thanks for the feedback!!

--Wendy