During my cardiology career, I have run into some quite interesting scenarios of patients presenting with angina in rather unusual ways. This is no joke. These are real patient scenarios that I have encountered.
If you read any cardiology textbook, the classic description of angina would be a substernal chest pressure radiating to the arm accompanied by diaphoresis and shortness of breath. The so-called “Levine sign” is when a patient clenches a fist on his or her chest to describe the squeezing sensation of angina. Did Mona Lisa have angina?
Let me share some of the cases with you.
Right Elbow Pain
A 55-year-old man with diabetes type II was having exertional symptoms in his right elbow. He told me “Doc, this is the same elbow that I had three surgeries in when I was playing baseball in the minor leagues as a right-handed pitcher.” He simply thought he was having further orthopedic pain from the abuse that his elbow had taken. Nope. After an abnormal stress test and two stents — one in the left anterior descending and one in in the left circumflex — his right elbow miraculously returned completely to normal.
This next patient I am going to tell you about could have simply been lying to me — but it makes for an interesting story. As an intern on an ED rotation, I went in to interview a patient with the chief complaint “I had a nightmare.” OK. I asked him why a nightmare brought him to the ED. He went on to tell me that he just didn’t feel right. He denied any chest pain, arm pain, jaw pain, shortness of breath or any other symptoms. I was still confused. He looked me in the eye and revealed that it was the exact same nightmare that he had 5 years prior when he had his first heart attack. Oh, come on!! He was right on the money. That little non-specific ST segment change on his ECG tracing was accompanied by a troponin of 12!
This next case is not quite as crazy. A young man in his 30s presented to the ED with the complaint of severe heartburn. Well, it is quite well known that angina can feel like heartburn or “indigestion.” He had actually been taking omeprazole for about a year to manage typical heartburn symptoms — and had great relief. He ran out of his omeprazole about 1 week prior and decided not to refill it. It was about an hour after eating an entire medium pizza when he experienced the onset of symptoms that prompted his ED visit. So I look down at the ECG, and lo and behold: 3 mm of ST segment elevation in the inferior leads with reciprocal ST segment depression in lead I and aVL! I guess taking a history can sometimes be misleading; however, this is of course the exception to the rule.
On a similar note, I met a patient at the VA who had persistent acid reflux symptoms. After taking proton pump inhibitors twice daily and still experiencing symptoms, his primary care physician referred him to a gastroenterologist. An esophagogastroduodenoscopy, or EGD, did indeed show some esophagitis. The patient wound up undergoing a Nissen fundoplication — a surgical procedure that essentially wraps the stomach around the lower esophagus to tighten the lower esophageal sphincter and reduce acid reflux symptoms. You know what I am going to say next. This man’s symptoms did not improve, and eventually we found he was having angina. Coronary revascularization completely relieved his symptoms!
I have seen angina present as only left wrist pain (without chest pains or dyspnea), as gas and “belching,” as upper back pain, as pain in the armpit and, even once, chest pain supposedly reproducible upon palpation.
Just the opposite, I once saw a patient with heart disease risk factors (diabetes) and non-specific ECG changes present with severe left-sided chest pain. Where I trained, it was easy to justify a coronary angiogram, and thus that is what we did. His coronary arteries were normal. His chest pains remained a mystery until he broke out in a nice vesicular rash of shingles on the left side of his chest the next day! They always taught us in medical school, when getting a history from a patient with chest pain, ask if they have a rash on their chest!
Now, I hope after reading this article you don’t initiate a ST segment elevation myocardial infarction, or STEMI, code on every patient that comes to the ER with hiccoughs, hallucinations or an ingrown toenail. But every once in a while, some weird things may cross your path like they have mine.
If any of you readers have had similar unusual experiences, please share with us!
– by Steven Lome, DO, RVT