Case of the Month #19: Refractory Angina by Dr Sonia Pierce

Mrs A is a 59-year-old female who presents with a history of frequent episodes of chest pain radiating midway down her left arm and up to her jaw. She attends her local Emergency Department regularly and has been seen by numerous cardiologists over many years. 

She contacts her GP surgery frequently and her GP has now suggested a referral to the local pain clinic.

If you were the pain clinician seeing her for her first consultation, what questions would you like to ask?

Check the list below to see if you have covered most of the questions:

It would be good to know the following information:

• Description, location, radiation and sequence of pain 
• Frequency and duration of pain
• Triggers, exacerbating, relieving factors, predictability of symptoms, rest and nocturnal pain
• Any changes to the pattern of symptoms; location, sequence, frequency, duration or triggers over the last 12 months (stepwise change may herald a new lesion and prompt further cardiology investigations) 
• Impact of pharmacological and interventional therapy
• Any associated symptoms, nausea, SOB, sweating, malaise, fatigue 
• Medication history- which medication has had the greatest impact, medication that has had no impact and do not confer any prognostic benefit could be stopped
• Investigations and interventions so far
• Occupation, including hobbies and interests
• Impact of pain on life, mood, sleep, relationships, explore fear associated with symptoms
• Past medical history
• How she manages her pain
• Understanding of pain
• Her expectations of the pain service and goals

Mrs A was assessed by the patient’s local pain service’s multidisciplinary team. This was a joint initial assessment with the doctor, psychologist, and clinical nurse specialist. She told the team her story of chest pain, which began approximately 12 years ago, she has no history of a MI. She initially experienced central chest pain described a pressure and gripping sensation on climbing the stairs or walking up hills and associated with a tingling, heavy feeling in her left arm and a gripping sensation up the side of her neck when her pain was severe. Over the past few years, her pains were more frequent and more severe. She would get pains several times a day, usually relieved after a few minutes by her GTN spray. However, she was most troubled by less frequent episodes of severe, central chest pain, which sometimes made it difficult to breathe. These episodes were not responsive to her GTN spray, frightening for her, and she found she sometimes had no choice but to go to A&E. She explained she sometimes felt she was going to die during an episode. These would come on often out of the blue without any obvious triggers. Her son lived next door and would usually be the one to take her to A&E when the pain did not quickly settle. She has been there lots over the years and, most of the time, she sees a different doctor each time. She explained she has to tell the whole story again and again and this is upsetting for her. She often feels not believed. She is usually sent home after a blood test and has to see her cardiology team as an outpatient. She is aware her notes are now several volumes thick, which makes her feel even worse. She has had hundreds of ECGs over the years and a multitude of tests including angiograms, echocardiograms and x-rays. She told the team she was initially treated with some stents to one of her coronary arteries a few years ago but her cardiologist told her there is no further stenting required.