ANSWER 28
The ECG shown is normal. The pain does not have the characteristics of ischaemic heart
disease. On the basis of the information given here it would be reasonable to explore her
anxieties and to reassure the patient that this is very unlikely to represent coronary artery
disease and to assess subsequently the effects of that reassurance. It may well be that she
is anxious about the death of her grandfather from ischaemic heart disease. He may have
had symptoms before his death which were related to her anxieties. From a risk point of
view her grandfather’s death at the age of 77 with no other affected relatives is not a rele-
vant risk factor. She has expressed anxiety already by having the cholesterol measured
(and found to be normal).
She has a history which is suspicious of irritable bowel syndrome with persistent pain,
irregular bowel habit and normal investigations. Ischaemic chest pain is usually central
and generally reproducible with the same stimuli. The associated shortness of breath may
reflect overventilation coming on with the pain and giving her dizziness and palpitations.
The characteristics of the pain and associated shortness of breath should be explored fur-
ther. Asthma can sometimes be described as tightness or pain in the chest, and she has sea-
sonal rhinitis and a family history of asthma. Gastrointestinal causes of pain such as reflux
oesophagitis are unlikely in view of the site and relationship on occasions to exercise. The
length of the history excludes other causes of acute chest pain such as pericarditis.
The problem of embarking on tests is that there is no simple screening test which can
definitively rule out significant coronary artery disease. Too many investigations may
reinforce her belief in her illness and false-positive findings do occur and may exacerbate
her anxieties. However, if the patient could not be simply reassured it might be appropri-
ate to proceed with an exercise stress test or a thallium scan to look for areas of reversible
ischaemia on exercise or other stress. A coronary arteriogram would not be appropriate
without other information to indicate a higher degree of risk of coronary artery disease.
- Ischaemic heart disease characteristically causes central rather than left-sided chest pain.
- The resting ECG may show signs of ischaemia or previous infarction but is not a very
sensitive test for ischaemic heart disease.