PATTERNS OF ANGINA: JIM

Jim is forty-one years old, and a friend of mine. He signed on as a patient in my practice three years ago, when he moved into the district. Jim, a freelance graphic designer, had welcomed the move from the city to our rural idyll in the west of Scotland, seeing it as a haven of peace in which he could get down to his work with little interruption.

When Jim arrived, he decided to take advantage of the country walks to lose the excess weight he’d put on and get in shape. Things went well for a week or two, but then he became a little more adventurous. Few roads in the west of Scotland are flat for any distance, and soon he started to tackle the gentle hills.

It was then that Jim came to the clinic, complaining of indigestion. It seemed that during a walk, he would often get a tight feeling in the center of his chest that would only go away if he rested for a while. Sometimes it was an actual pain—dull and aching—deep within his chest, that traveled as far as his upper left arm or into the left side of his lower jaw. It mostly started when Jim was walking up an incline, but it also affected him on the flats. The pain always went away within a few seconds if he stopped walking, and even faster if he sat down.

The pain didn’t worry Jim: he thought it was probably some form of muscle cramp, and asked if I could prescribe some painkillers for it.

Painkillers were not the first thing on my mind! This story of a pain or tightness in the chest due to exertion, that goes away at rest, must be considered as angina due to coronary heart disease until proved otherwise. And in a man as young as forty-one, any possibility of angina must be taken seriously.

Jim had never been ill in his life, he said, except for a bout of pleurisy at age thirty-six when he was abroad. On further questioning, though, his “pleurisy” had been mainly an illness of severe chest pain and breathlessness. His doctor at that time had told him to stay in bed for two weeks, given him antibiotics, and then let him go back to work. Jim had felt awful for a month or two afterwards, but gradually returned to normal. He had the feeling, though, that he had never been “quite the same man” since this illness.

My colleagues and I were not surprised, since his electrocardiogram (EKG) showed that he had had a heart attack in the past, and that the bout of “pleurisy” had probably been that attack.

We put Jim on a treadmill and tested his EKG again. As we asked him to walk faster, and increased the upward slope of the platform on which he was walking, we saw the changes we expected. There was evidence that his heart was not getting enough oxygen for the amount of work it was being expected to do; shortly after the change in the EKG appeared, so did the pain.

We stopped the test, let Jim rest, then explained that he had angina, which needed treatment. Because he was only forty-one, and there was evidence of a previous heart attack, I referred Jim to the hospital, which had a coronary care unit (CCU) and a catheterization laboratory. There, an angiogram (a picture showing the inside of the arteries) showed that he had narrowed sites in all three main coronary arteries, and he was placed on the waiting list for bypass surgery.

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