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second opinionepisode 913 angina announcer: major fundingfor "second opinion" is provided by the bluecrossand blueshield association, an association of independent, locally operated,and community-based blue cross and blue shield companies.for more than 80 years, blue cross and blue shield companieshave offered health care coverage in every zip codeacross the country
and supported programsthat improve the health and wellnessof individual members and their communities.the bluecross and blueshield association's mission isto make affordable health care available to all americans.news about our innovations is online at bcbs.com and on twitter@bcbsassociation. "second opinion" is producedin association with the university of rochester medical center,rochester, new york. salgo:
welcome to "second opinion,"where you get to see, firsthand, how some of the country'sleading health care professionals tackle healthissues that are important to you.i'm your host, dr. peter salgo, and today i'm happy to welcomedr. sam sears, from east carolina university.our "second opinion" primary care physician, dr. lou papa.dr. jason pacos from the university of rochestermedical center. and joan and fred jahnke,who are here to share their
personal story -- a story thatour panelists, along with you at home, will be hearing for thevery first time. so time to get to work.we have kind of a tag team here today.well, we do. are you both prepared? j. jahnke: we are prepared. all right, joan, you're aretired nurse. tell me about your nursingcareer.
well, i started off reallywanting to be a cardiac nurse, and that's where i ended up.and ended up to be a charge nurse on a cardiac unit.little bit about your background. did you ever smoke? never. exercise? always -- over the top. okay, and what about yourlifestyle -- food, things like
that? always healthy foods.i've always had that type of healthy lifestyle. all right, so there you are,doing your job until 2005. and what happened then? 2005, actually, i was askedby one of my neighbors to go over and check on somelandscapers that were working in her yard.and all of our homes are on a lake and on a slope, which issignificant to the story.
spoken like a nurse,by the way. yes, so time was going by.i said, i've got to rush over. and i went over, down theback yard, and talked to the landscapers.and at the side of her house, she has steps, which i took twosteps at a time running up. went up to the sloped drivewayand got about two-thirds the way up, and i thought that someonehad taken their fist and hit me right in the gut.right here. you pointed to your gut,right below your breastbone.
right below, yes.i doubled over. not pain? not pain, just lost mybreath. okay, you doubled over? doubled over.i didn't have my cell phone with me, there was no one home on thecul-de-sac i live on. so i just tried to get my breathback and slowly made it home and sat in the chair.and being a nurse, i evaluated. took my blood pressure, took mypulse.
thought that, "okay,my heart" -- listened to my own heart.and everything seemed to be going along fine.and i thought, "i don't know what that was, i don't like it.i didn't feel good, but let's see what happens in an hour."and it passed, and that was the end of it. so you didn't go to thedoctor? i did not go to the doctor. i knew that was coming.[ laughter ]
lou, if she had gone to thedoctor and you were that doctor, what would you have done,what would you have thought? papa: it's a concerning symptom. why? because it's anexercise-induced or an exertional-induced symptom.so when you have something like that, you're kind of increasingyour heart rate, increasing your blood pressure,and putting the increased stress
on your heart.and it could suggest angina or an anginal equivalent. angina meaning heart painor heart discomfort. but what was reallysignificant here, if she didn't point to her chest --i mean, you normally see this thing -- fist in the middleof your chest. it's down here! and that's why we havelearned over time that, you know, disease doesn'tnecessarily play by the rules.
and especially in women, theycan present in a very different way.so any time i hear a patient has an exertion-induced symptom --it can be indigestion, it can be heartburn, it can be shortnessof breath, it could be lightheadedness, it could besweats. i even had a patient who hadexertion-induced headaches that ended up having heartdisease. that's one thing that's at theforefront of my mind. all right, so you didn't goto the doctor.
this, too, shall pass,and it did. it did because i reevaluatedmyself. i felt fine.did not mention it to my husband when he came home.and the next day, he's gone off to work, and i go around thehouse crazy doing housework, and because i love to ride mybike, so i did some weights and did some stretching before i goton the bike. put the helmet on, all my bikegear. and as i said, we live on asloped driveway.
so i always start off with thehighest gear. i start off going up the hill.i make it around the corner of the street that i live --boom! i'm off the bike. oh, my gosh. did you go to the doctor then? then i did. why did you fall offthe bike? what happened exactly?the same thing?
same thing. i mean, that's what knockedyou off the bike? it just took away my breath.there was nothing else i could do.extreme weakness. no particular pain that i couldevaluate with my cardiac knowledge.so i just fell over on the bike, and then walked the bike back home.then i called my primary care doctor, who said,"come in immediately." and when you did,what did -- he or she?
she. what did she do? she did an ekg.and then also did an echocardiogram. did you get a stress testat some point? yes, i did.i did get that later on, but i was told by the results of theekg and the echo that things were probably okay. any radiology studies,cts, x-rays?
eventually,i have had it all. and at the end of the day,what did all those tests show? all of the tests, after twoand a half years of testing, they decided that i hadvasospastic angina. but the tests themselves? jahnke: all of the testing showednothing. here's a woman who has thismajor symptom -- fell off her bike, got -- as we say in thebusiness -- the million-dollar
work-up, nothing.so she's okay, right? pacos: she's not okay. why not? she clearly has angina.what's angina? angina, or chest pain. especially in women, weclassically hear of chest pain, pain that's in the heart,or pressure like an elephant sitting on your chest,that starts in the left chest
and radiates down your left arm.it's the classic interpretation of what angina is.but we know in women, it can be very atypical.it can be jaw pain, it can be epigastric pain or belly pain.it can be just shortness of breath or diaphoresis orsweating. what causes angina? it's pretty simple.it's supply and demand in that not enough blood is getting tothe heart. we've already mentionedvasospasm, which means that the
blood vessels aren't blocked,but they spasm or narrow down, and that causes a problemkeeping supply to the heart. what does angina reallytell you? does it mean that you're aboutto keel over, have a heart attack? no, i think angina is kind ofa warning sign or a kind of a reminder by the heart that it'snot getting enough blood supply and it kind of should tell you,"slow down whatever it is that you're doing.it's too much for your heart."
so you're a cardiacnurse. you know what angina is.you're sitting there with a heart that's hurting.what did you think about that diagnosis? i understood the vasospasticangina portion of it. but the stress tests that theygave me were able to reproduce ekgs that were a puzzlement tothe physicians. they made no sense.they were not normal, but they weren't abnormal.so, for the most part, all of
the testing did lead tovasospastic angina, but the question for my cardiologistlocally in that town was, "why are you having this?" now, before we even go there,you see lots of folks, and it's your job to see folks who haveheart pain, heart trouble, heart failure.with the first premonitory sign, i guess she's a little atypicalbecause she knows what this can impend.what do people think and how do they deal with that?
sears: well, this is the big troublewith this kind of angina, is it can be difficultto pin it down exactly. and ambiguity can equal anxietyin both the patient and their spouse.and, oftentimes, the spouse has even more wear and tear than thepatient while this unknown problem of high-potentialseverity is occurring. and that can certainly then addone more level of fear and arousal over top of thecondition.
and wear and tear on spouses iswell-known and often easy to see. so she's getting all thesetests. you're not. f. jahnke: i'm not. her ticker is at some risk.what are you thinking? i've had experience in thehealth care field, so i'm very confident that the physiciansare working hand-in-glove with
my wife in getting thingsresolved. it's just that it's frustratingbecause there's not a definitive test.no one is looking at an x-ray and saying, "there is thefracture." there's all these tests, andthey're saying things aren't quite right, but they can't tellme definitively what's wrong. when i would be off foranother test -- whether it was in pulmonary or g.i. or anotherstress test, another holter monitor, anothercatheterization, whatever it
was -- and fred would alwaysbe there. and i'd keep having thesesymptoms that got worse. it got beyond the shortness ofbreath on exertion. it got to be no exertion withthese symptoms. so i would look at fred knowingthat he loves me, he wants me healthy.but also there's that feeling that, "gosh, you know, i mustsound like i'm crazy when i'm saying all of this stuff." but you're saying somethingvery worrisome now.
you're getting more and moresymptoms with less and less exertion.and you did mention that you had a cardiac cath. i had two. two of them.they put a catheter into an artery, snake it into yourheart, squirt some dye in there and take an x-ray. mm-hmm. the whole object is tooutline the arteries in your
heart, looking for a big hunkof rock. and they saw? nothing.i was beautiful. beautiful, large coronaryarteries. so they started you onmedication? oh, i've had a list of 30different medications that i've been tried on, and nothinghelped. until my cardiologist said thatbecause of my worsening signs and symptoms, that i better havesome nitro handy.
nitroglycerine. nitroglycerine, sublingual --under the tongue as a rescue drug. now that's an age-old drug.this goes back into the mists of time.it's not a high-tech drug. in fact, it's dirt cheap.are you worried about, "a," the nitro working, and, "b,"that her symptoms were getting worse with less exercise? i think the concerning thingwe heard is that her symptoms
were accelerating, and they wereaccelerating, then happening almost at rest, which is veryconcerning. i think the helpful thingknowing is that, your blood vessels, there are nosignificant blockages, which is very helpful, and that's a goodprognostic sign. that doesn't help you, though.you're still having pain. when you take nitroglycerine,you feel better. i feel great. now, i'm guessing, however,we're back in 2007 now.
it's a little time after yourinitial complaints and this mega work-up.your story isn't over. what happened to your symptoms? my symptoms got progressivelyworse to the point that i was unable to get out of my pajamas.i'd roll from my bed to the couch.my appetite went down tremendously. okay. i had severe pain now24 hours with the spasms.
so it didn't make anydifference -- if i would try to walk to the bathroom,i got chest pain. okay, you're onnitroglycerine, and despite that, you're having morepain 24 hours a day. your appetite's down.you can only get to the couch. something's different.what do you do when something's different? well, you have to kind ofgo back, basically, to the beginning and re-look at it.one of the things that's
reassuring for doctors --not very helpful for patients -- is to know that she doesn't haveany significant large vessel obstructive disease.those are the killers. and, unfortunately, doctors,lots of times, "well, i can tell you what it isn't!"that's true. and that may be, you know,satisfying for the doctor because they know that there'sno big bombs waiting, but your quality of life has gone fromriding uphill on the highest gear to not being able to getoff the couch.
did you have any other symptomsat all? did you have any visual changesor joint complaints, any rashes, anything else that was going on? yeah, i started to have painthat went... from here, underneath here,through to my back. i started getting pain up theside of my neck, into the jaw -- like a toothache, abscessedtooth, an earache. up the side of the head. oh, boy.from the outside looking in,
this couldn't have beeneasy for you. well, you can't do anything.what do you do? okay, she's a nurse --she knows. she's been working with thedoctor, they know. and all you know as the spouseis that she's not able to do the things that she was able to do.she's not getting any better. and i want it fixed.i want an answer, i want it fixed. you went for anothercath?
yes. but we came out of that secondcath, again, i was in pretty bad shape. and the only thing that theycould say was that, "you have vasospastic angina, but we don'tknow why." did they ever inject anythingto show you had the vasospasm at the time of the cath? not that, no.i had that done locally in the town that i lived.i was, again, referred, and i
went out of town for the thirdcath. i had kept a journal of all ofmy symptoms and everything because, at that point in time,i lost my ability to speak. i did not have enough air totalk, okay. tell me about the cathitself, what was it like? the cath was done with mebeing fully awake. i asked not to be sedated.i wanted to know if they were able to reproduce my symptoms.so they did the first injection, and, immediately, theyreproduced.
i got the shortness of breath.i got that tight-chest feeling. i got the pain up the jaw, theside of my head, my back. i remember arching, and mydoctor said to me, "just hang on, joan.we're gonna give you the rescue drug.we'll open you up, we'll get you out of this.just hang on." it was awful, to say the least.but the l.a.d. went into profuse spasm. left anterior descendingartery, the l.a.d.
yes, from what they couldtell from their injection of the lower part of the l.a.d. upthrough the smaller arteries, up through the l.a.d.and i went into v-fib, and i straight-lined, and i had acardiac arrest. now, v-fib is ventricularfibrillation. in common speech, you died. i died.what did they tell you? they came out of the cath laband said, "she died, but she's okay now"?it was --
almost! i'm in the waiting room,it was a very filled waiting room.the doctor comes out into the waiting room and tries to bringme forward out to the hallway to speak privately to him.i have full confidence that she's gone throughthe procedure fine. confidence with the physician.i tell the physician, "go ahead, just sit right here.how's everything going?" "well, your wife is inrecovery, and she's --
we were able to complete part ofthe study, but not all of the study.she did have a cardiac arrest, but after two minutes, we wereable to bring her back." and he does it in the samemonotone, "and you can go back now and see her."and i said, "wait a second. let's go back to 'she hada cardiac arrest' part. is she okay?""yes, she's fine." so that was how the physicianintroduced what had occurred to my wife.so we go into the back, the
waiting room.she is just recovering from the anesthesia, so she's coming up.and i allow myself to have the, to show the feminine side,where you kind of get a little teary-eyed, a little broken up,and look at her. i give her a kiss.i say, "thanks for coming back," you know, type of thing.she looks at me, dead-eye and says, "don't get me upset,fred." [ laughter ]so it's, you know, put on the shield, you know, the manlyshield.
chink, chink, chink, chink.and, you know, then you just deal with the situation. is this common? seasrs: it is.i think couples that are healthy couples find ways ofcommunicating what their needs are and try to get throughthe situation. i think the more challengingaspects are feeling safe again, feeling like you're not introuble after we identify
the problem and start to puta treatment plan in place so then that you feel safe, too.that when you call home and she doesn't answer, that you don'ttake the worst case scenario. so that's part of that recovery. so you had vasospasticangina, heart pain, because the vessels go into spasm.yes? partly correct.the other part of my cath showed that i had very severe cardiacmicrovascular endothelial dysfunction.
that's syndrome x. cardiac syndrome x, whateverthey're calling it. but that's essentially where mymicrovessels will not open up under demand.and through the two and a half years of diagnosing as i wasgetting worse, i had collapse of those microvessels, or infarctsin those microvessels. correct me if i'm wrong,guys. this is not a disease of debrisin the coronary arteries. it's a disease of the arteriesgetting squeezed or being real
small down at their tippy,tippy ends. i think we're kind ofcombining two things a little bit here.there's the vasospastic portion where the blood vessel itself,the large blood vessel, narrows down.and when you think of the heart arteries, the coronary arteries,i kind of use an analogy of a tree, where you have a largetrunk with lots of branches come out and it gets smaller andsmaller as you go out farther. i think what you're havingissues with would be in the leaf
portion of that, the very, verysmall blood vessels which you really can't see in anangiogram, where you can't do anything with them with balloonsor stents. they're just very, very smallblood vessels, and they're not getting good blood flow. again, the overarchingdiagnosis is angina. angina, heart pain, because youdon't have enough oxygen to supply the demand.why the angina is occurring, that's a lot of differentreasons.
all right, we're goingto stop here. we're going to sort of sum upwhat we've discussed so far, and then keep going.angina is a sign that the heart needs more oxygen than it'sgetting. it's often described asa pressure sensation or a tightness or heaviness, pain inthe chest. while angina is common,it's important to determine what's causing it.and it's also important to rule out other conditions.and your docs did a very
complete job of both.if you stop and you think about it, and i'll betyou did -- sam, you can weigh in on this --you're describing a cardiac cripple, someone whose heartwon't let her do anything. absolutely. what's the impact of thatphrase, "cardiac cripple," on somebody? well, really just getsat the diminished quality of life that heart disease canproduce.
and the impact is broad.because, honestly, enjoying life involves being able to elevateyour heart rate. i mean, there is a strongassociation between fun and elevated heart rate, and whenyou're getting continual danger signals back from your heartwhen you try to live life, all you can think about isdanger. and i think it really can setoff an effort to do less and less activities, todisengage in activities, and, ultimately, it's very difficultto keep your mood and your
relationships andthe quality of life high at all. and that's what happenedto me. i had to give up so much. now, you'll forgive me forbroaching a delicate topic, but you volunteered for thisdangerous mission. you said lots of things that arefun in life involve an elevated heart rate.i know what they're thinking. i think i know wherewe're going here. and i know what i'm thinking.so i'm just going to ask.
what happened to your sex life? the sex life was horrible.that was part of something that i always talk about with womenbecause it's something that's integral to a marriage ora relationship. but it takes so much cardiacdemand. so i lost -- when i say i losta lot of my life, i lost a lot, and i gave up the big one.sam, help us out. yeah, this is a tough onebecause, i mean, who feels sexy when you don't feel safe?i mean, the idea that, you know,
you didn't feel safe with yourheart, you didn't feel... like you had the kind of "get upand go" to engage in any physical activity, sex is evenfarther down that line, frankly, when you can't evendo your laundry or whatever, your household work youmentioned earlier. yeah, but who wants totake a chance with having sex if you're afraid you're going tokill her or hurt her? right.it kind of diminishes the whole kit and kaboodle.i mean, you just basically,
that's a part of our life thatis, for all practical purposes, is passed. now, this is still going on,you still have symptoms. oh, yeah. and what are you on?you're on a lot of calcium channel blockers.anything else? that's basically the cardiacmeds. but every day, i wear.016 milligram patches -- three of them.
of nitroglycerine. of nitroglycerine patcheach day. and then i supplement and alwayshave on hand -- which i'm about to use if this keeps up --the nitro spray. that's nitroglycerine? this is nitroglycerine.and i can use up to 20 sprays of this a day. that's a lot.which brings us to this point. she's had the high-tech work-up.she's got every drug known to
woman.this is -- and she's using it now.you feeling okay? a double shot will do it. all right, let us know. mm-hmm.is this the best we have to offer?modern medicine, 21st century? it's sad.unfortunately, it is. she has a problem with themuscles spasming, and she's on, it sounds like, maximal therapyto keep those blood vessels
opened up and dilated.and despite that, those signals to tell the muscles to spasmare still there, and they're still impacting her. how are you feeling aboutall that? it's sad.i'm not depressed about it. you know, this may be the thingthat takes me out. i know i'm at risk fora heart attack. i know i'm at risk for stroke,for blood clotting issues. i know that arrhythmias willprobably get me, but that's the
way it is for me. are you feeling better rightnow, by the way? yes, as i spray again.is it working? i love this.[ laughter ] this works for me allthe time. and i -- if i have to use it -- let's give it a momentto work. let's just give yourselfa moment to work. take a nice, good breath.because i'm going to sum up
where we've been so far. okay, very good. it's your turn to rest.and it's my turn to tell folks that the goal of treatment forangina is to maximize function by helping the heart get theoxygen that it needs. now, a patient needs to learnthe angina pattern the patient has so that any new symptomscan be evaluated right away and then worked up to make surethat the treatment remains effective.how are you feeling?
good. you good enough to goforward? go right ahead. all right.what would be your advice, in the little time we have left,to other folks suffering from angina? i think the number one thingthat i say to women is to get your doctor to believe you.don't go in hysterical. go in with notes, go in withyour questions written down,
and don't ever be dismissed.well, you look great. we hate that comment. no, what i mean specifically,let me explain. i don't know if your tv isgood enough to see this, but since you took the nitro,you pinked up. you were getting a bit pale. i was. i was getting a littleconcerned. i was.i feel the difference.
i do feel the difference. thank you so much for joiningus, and thank you for sharing your story.thank all of you for being here, too.but, unfortunately, we're out of time.i hope you continue the conversation on our website.and there, you're going to find the entire video of this show aswell as the transcript and links to resources.the address is secondopinion-tv.org.again, thanks for watching.
thank you all for being here.i'm dr. peter salgo, and i'll see you next time for another"second opinion."