Could you be in the ‘silent army’ of women with a hidden heart complaint? One disorder is so hard to spot you can’t even see it on an angiogram
- Sarah Brown’s pain in her chest, shoulders and back was dismissed as muscular
- An ECG, chest X-ray and blood tests came back normal, but the pain continued
- She was diagnosed with microvascular angina which has many different triggers
Doctors initially dismissed Sarah Brown’s pain in her chest, shoulders and upper back as muscular
For years, doctors assured Sarah Brown the pains in her chest, shoulders and upper back were likely to be muscular, and nothing to do with her heart.
As a trim size 10 — she regularly cycled eight miles a day and ran up three flights of stairs at the hospital where she was a midwife — Sarah didn’t think she was an obvious candidate for heart disease.
‘I exercised, was a non-smoker, ate healthily and had no family history of heart disease,’ says Sarah, 57, who lives with her husband and three grown-up children in North London.
‘But since my early 30s I’d suffered random pains in my stomach, back and shoulders. They started as a dull ache, but became more intense as I got older.
‘At first, I dismissed them as indigestion or general aches and pains, but when I suffered a severe attack after my second child was born when I was 36, my doctor sent me for tests.’
An ECG (a test that measures electrical activity and heart rhythm), chest X-ray and blood tests revealed nothing abnormal. But the pains persisted — and painkillers did little to help. ‘I was told I had a musculoskeletal problem,’ says Sarah. ‘As the pain was mainly between my shoulder blades and in my lower left rib, I thought they must be right.’
But in May 2012, Sarah started to get central chest pain when walking upstairs. Her GP referred her for an angiogram, to check for blockages in her arteries — but again, no problem was detected.
A few weeks later, Sarah suffered her worst attack to date after coming in from the garden on a cold Sunday afternoon.
‘I felt nauseous and there was a crushing pain radiating from my chest into my arms, back, shoulders and face,’ she says. ‘My husband called 999.’
An ECG (a test that measures electrical activity and heart rhythm), chest X-ray and blood tests revealed nothing abnormal. But the pains persisted
In hospital, Sarah was given a blood test to measure levels of a protein called troponin. Raised levels can indicate damage to the heart — but the results were below the threshold for a heart attack.
However, she was admitted to a cardiac ward where a doctor, seeing how much pain she was in, put her on a drip with nitrates to widen her blood vessels, as he thought Sarah’s coronary arteries might be going into spasm.
‘His hunch proved right, and the pain disappeared almost immediately,’ says Sarah. Thanks to a more sensitive test, Sarah’s problem was finally diagnosed: microvascular angina.
Like angina that is caused by coronary artery blockages, microvascular angina can cause a tight feeling in the chest, which can spread to the arms, neck, jaw, back or shoulders; shortness of breath; nausea; light-headedness.
Both types of angina can be triggered by cold weather, exertion, eating, stress or exercise.
But with microvascular angina there are no arterial blockages. Instead, the condition is caused by tiny blood vessels less than 1mm in diameter going into spasm or failing to dilate to supply blood to the heart muscle. It significantly raises the risk of a heart attack and symptoms may be worse than standard angina, say experts.
Around 40 per cent of the two million people with coronary artery disease in the UK may actually have microvascular angina, according to Colin Berry, a professor of cardiology and imaging at the University of Glasgow and director of research at Clydebank’s Golden Jubilee National Hospital.
But thousands of people — the problem is more common in women — are not diagnosed because tests to check for blocked arteries are clear. ‘Nearly half of all the UK’s 250,000 angiograms a year do not reveal blockages in the coronary arteries, yet these patients may still have angina symptoms,’ says Professor Berry. ‘So in a lot of cases — as many as four out of five — microvascular angina could be the cause. I call these patients a “lost tribe”; it’s a huge problem affecting as many as a third of people with angina pain.’
Microvascular angina can cause a tight feeling in the chest, which can spread to the arms, neck, jaw, back or shoulders; shortness of breath; nausea; light-headedness (stock image)
Traditionally, microvascular angina is diagnosed using a stress echocardiogram, where the heart is put under stress through exercise or medication to look at how it and other blood vessels are working under pressure; a coronary angiogram, where dye is inserted into the arteries to view them; or an MRI scan.
But in a new, more sensitive, test a thin flexible guidewire is passed into the main heart artery to measure small blood vessel function at the time of the angiogram.
A chemical called acetylcholine is then infused into the artery to measure how the small blood vessels are working.
Sarah underwent the test in hospital and it revealed her blood vessels were going into spasm and constricting, restricting blood flow to the heart.
In a study, called CorMicA and funded by the British Heart Foundation, Professor Berry found patient care guided by the new test makes a ‘significant difference’ to outcomes.
Quality of life and severity of angina symptoms were improved in the group treated with the additional test, compared to those who received standard angiogram-guided care, as their microvascular angina had been diagnosed and treated.
Both microvascular angina (that Sarah was diagnosed with) and angina that is caused by coronary artery blockages can be triggered by cold weather, exertion, eating, stress or exercise
The results were published last year in the Journal Of The American College Of Cardiology. But this test is not widely available on the NHS outside specialist centres, as doctors can only use it off-label (for a purpose for which it is not licensed) — on a pre-planned, named patient basis only.
Professor Berry says there needs to be more research in order for the licence to be changed, which could take up to five years.
Though microvascular angina sounds like a less serious version of angina, the symptoms and health problems it can cause are just as severe, as the blood vessels it affects are too small to treat with stents and bypass surgery.
Attacks typically last between ten and 30 minutes or longer, compared with 15 to 20 minutes with angina, and more commonly occur at random, even when at rest.
Some experts say there may be a hormonal basis for women being affected more, with symptoms flaring up at certain points in the monthly cycle, and during or after the menopause.
Chris Gale, a professor of cardiovascular medicine at Leeds University, says women with microvascular angina are falling through the net because there’s still a focus on coronary artery blockages.
‘If an angiogram or MRI scan doesn’t show blockages there can be this misconception there’s nothing wrong or that nothing can be done — but there are treatments that can help,’ he says.
There also needs to be greater recognition of the problem, says Professor Berry. ‘We need a national NHS strategy, more research and clinicians need to be better informed.’
Following her diagnosis, Sarah was prescribed nitrates and calcium channel blocker drugs, statins and a blood thinner.
‘The drugs and some lifestyle changes have improved my symptoms, although I still get attacks,’ she says. ‘Being believed and having my pain acknowledged makes it easier to deal with.
‘I’m lucky I was diagnosed, but others are not so fortunate. There is a silent army of patients out there, most of them women, who are suffering and cardiologists have turned their backs on them.’
- bhf.org.uk
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