Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
7 September 2006

THEN AND NOW – THE STORY OF ANGINA PECTORIS

            A 54 year old gentleman came to the clinic recently stating that he thought he had heartburn.  He was a very active cattle buyer living from one sale barn to another, buying and selling and cattle.  In this drought year, he was one busy fellow.

            He said that he was in a terrible hurry and he just wanted to have a medicine to stop his heartburn.  He said that he had tried Prilosec OTC and it really didn’t seem to help at all.  He tried Zantac and that didn’t help.

            So I asked him to slow down and give me ten minutes to try and help him. I said that I needed to know the story of his heartburn and what it was like.  I said to pick out a time when this occurred and tell me what happens. 

            He said that the day before he was talking to a rancher who wanted to sell his cattle because of the lack of feed or water on his ranch.  My patient had gone to talk to him about buying the cattle and the rancher had become very distraught at the price that he was being offered. As the negotiations went on, my patient noted that he began to experience a pain in the middle of his chest that grew in intensity.  The pain distracted him from the negotiations and he said that he had to excuse himself and got out to the car.  It was a hot afternoon and when he got the car, the pain actually got slightly worse.  He turned on the air conditioner in the car and went on a brief drive.  He remembers breaking out in a sweat initially as the car cooled off being very nauseated and feeling as if he just couldn’t get a breath.  After his truck air conditioner began to work and he cooled off, the pain began to subside.  He took one of the Prilosec OTC’s but that did not help at all and he came now to say that he needed something better. 

            To make a long story short, he wasn’t having heart burn, he was getting ready to have a heart attack.  The following day, he had an angiogram done to look at the circulation in his heart and that afternoon, he had three stents placed in his coronary arteries to correct major blocks in his coronary arteries.  After a three week enforced vacation, he is back buying cattle again but his wife dragged him back to the clinic for a followup visit.  They both asked how I knew his problem wasn’t “heartburn” and that his condition was so dangerous. 

            It was late in the day and he was my last patient and the conversation was fun.  I explained that William Heberdeen, a doctor in England first described angina pectoris in 1768 and published his findings in 1772.  Dr. Heberdeen described exactly what had happened to my patient although he did not know for sure what the cause was.  It wasn’t until 1778 that a pathologist did an autopsy on someone who had Dr. Heberdeen’s story and found that the coronary arteries were blocked.  It was then speculated that the chest pain my patient was having was coming from coronary artery disease.  I explained to my patient and his wife that the diagnosis of coronary artery disease causing angina pectoris in this gentleman was something know for almost 225 years. 

            His wife then asked how we knew how to treat it.  Real treatment wasn’t available until 1880 when nitroglycerin was found to relieve the symptoms of angina pectoris.  This finding was quite by accident and the nitroglycerin factories in Sweden where men with angina pectoris got better when they came to work. 

            By the 1950’s, it was recognized that the electrocardiogram could be used as a diagnostic help to find patients with heart disease but there was still no effective treatment to prevent the sudden death that often followed patients who had angina pectoris.

            Studies were begun in the 1950’s and believable data available in the 1970’s identifying the causes of heart disease as high blood pressure, diabetes, high blood cholesterol, and smoking cigarettes.  95% of all coronary artery disease in our society comes from these factors.  I pointed out to my patient and his wife that his cholesterol was inordinately high, he had high blood pressure and was a pack a day smoker.  Thus, it was really no trick at all to make the right diagnosis in this gentleman now based upon all the history of medicine that occurred back then. 

            The next question was how to treat this gentleman.  In 1965 when I graduated from medical school, there was no meaningful treatment to prevent the eventual heart attack and then death followed.  But in 1968, coronary artery bypass surgery was started.  In the 1980’s the use of balloons to dilate the coronary arteries and put stents in place to keep them opened was developed.  In the 1990’s, we developed more medications to preserve the work that the surgeons did and thus now, we have very effective surgical procedures to prevent the heart attack that would have occurred in this gentleman.

            The last and most important question we considered that day was what to do now.  He didn’t what to have to take medications and he didn’t know if he could give up the cigarettes.  There aren’t numbers big enough to count the number of times I have heard that story and I have kind of given up on trying to tell South Dakota males what they have to do.  Try to tell a male South Dakotan what he has to do is rather like trying to teach a bull how to sing.  It doesn’t work and it aggravates the bull.  So I just told him he didn’t have to take medicines and he didn’t have to stop smoking as long as he didn’t mind going through all of this again in about 2-3 years. 

            But I told him and his wife who listened a lot better than he did that he didn’t want to go through all of this again in a few years, two blood pressures pills and a cholesterol pill were both critical and stopping his cigarettes abuse was even more critical. At 54 years of age, he is 23 years short of the average life span of men in America today, I made it very clear that he wouldn’t even come close to that normal life expectancy if he didn’t get his hearing defect fixed and listen to what his wife and I were trying to tell him.

            From then in 1772 to now in 2006, there have been miraculous developments which very effectively prevent and treat coronary artery disease.  But we are still working on how to get people to effectively use these miraculous developments.  The healthcare professionals at your local clinics are the most important instrument for prevention of angina pectoris and the heart disease that causes this. Because of what has happened over all the years of “then, they “now” can be a tremendous help.