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Name: Discussion

Donna's EKG shows normal sinus rhythm and normal complex configuration. Thus far Dr. Grey and Suma are unable to establish a diagnosis and therefore must decide whether to order further tests and or treatment. The location of the pain near the chest and the associated diaphoresis and apprehension raise concern about coronary insufficiency.

Does that concern justify a prompt cardiac evaluation, beginning with an exercise stress test? In order to answer this question, the physician must estimate the probability that Donna has significant obstructive coronary artery disease. If the probability is extremely low the exercise stress test is unlikely to be helpful. If, however, the probability is intermediate, a negative stress test can effectively rule out significant coronary disease.

Points to consider in estimating the probability of coronary disease are 1) the tendency of women with coronary ischemia to develop so called "atypical" symptoms and 2) the increased risk of coronary disease associated with surgical menopause. Ischemic pain in women is more likely to occur outside the chest, in areas such as the neck, jaw, shoulders, and abdomen. The pain is also more likely to occur at rest. The risk of coronary disease in post-menopausal women is equal to that of men of the same age.

Donna's risk for coronary disease would be intermediate, in the 20-80% range. An exercise stress test would therefore be useful and appropriate to help rule out the potentially serious diagnosis of coronary insufficiency. Further discussion of these issues will be found in the article referenced below. [1]

Epilogue

After a brief discussion Suma and Dr. Grey recommended that Donna see a cardiologist within 24 hours for a consultation and exercise stress test. Donna agreed and Dr. Grey called the cardiologist, Dr. Lyons, to arrange the appointment. He also prescribed coated aspirin 325 mg daily and omeprozole 20 mg daily, for empiric treatment for esophagitis until the initial tests were completed. He also gave her a prescription for nitroglycerine grains 1/150 to be placed beneath the tongue in the event of recurrent pain and instructed her to call the office if that were to occur. They told her to take the night off from work and rest quietly at home until her stress test.

Concerned that Donna may have unstable angina, Dr. Lyons obtained an exercise stress test with imaging. After five minutes the test was terminated because of shoulder pain associated with marked ST depression both of which resolved 2 minutes later. An echocardiogram immediately after exercise showed transient inferior wall hypokinesis. Dr. Lyons prescribed metoprolol 25 mg BID and admitted Donna for cardiac catheterization the next morning. The coronary angiogram showed a 90% stenosis of the posterior descending artery near its origin. Dr. Lyons was able to dilate the stenotic segment with balloon angioplasty and Donna was discharged uneventfully from the hospital the next day.

Following discharge, Donna returned to see Suma for a follow-up visit. She had not had any pain, and was continuing metoprolol, aspirin, and omeprozole. With Dr. Grey's supervision, Suma recommended a fasting lipid profile which subsequently showed a cholesterol of 260 (optimal less than 200), HDL 45 (low less than 40, high 60 or above), LDL 180(optimal less than 100), and triglyceride 175 (normal less than150). Dr. Grey precribed simvistatin 10 mg daily and referred her to a dietitian for instruction on a low fat diet. Suma also spoke with Donna about hormone replacement therapy (HRT) in view of her surgical menopause at age 44. Donna did not want to begin hormones because of her sister's history of breast cancer.

Suma was comfortable with this decision, having read a recent article from the HERS trial showing that HRT was associated with an increased risk for cardiovascular events in women with established heart disease, during the first two years of treatment. [2] She also read a recent article from EPAT (Estrogen in the Prevention of Atherosclerosis) showing that a statin drug was as effective as unopposed estrogen in preventing progression of atherosclerosis in post-menopausal women with elevated low density lipoprotein levels. [3] [4]

Dr. Grey counseled Donna to enroll in the hospital's cardiac rehabilitation center where she began a supervised graded exercise program. He also gave her instructions to taper omeprazole over the next two weeks and call if symptoms occur.

Donna decided to resign from the Salty Dog and found a job as a hostess at a friend's new smoke-free vegetarian restaurant. She bought a silk blouse and invited Ron to dinner on New Year's eve. On Valentine's day Ron proposed marriage and two weeks later Suma received an invitation to the wedding.

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