What Is Causing This Older Woman’s Dyspnea?

Author:
Andrew Freeman, MD
National Jewish Health

A 75‑year‑old woman with a medical history significant for hypertension, hypercholesterolemia, and type 2 diabetes mellitus presented to her primary care physician with dyspnea. She is mildly obese and more than 30 years ago had smoked about a pack per day for 15 years. She noted that when walking up a flight of stairs, she would have to stop at the top to rest and catch her breath before continuing.

The primary care physician ordered chest radiography, the results of which showed some mild chronic obstructive pulmonary disease (COPD) or emphysematous changes. The patient was then referred to a pulmonologist for further workup.

After doing a usual workup, the pulmonologist diagnosed the patient’s dyspnea as a symptom of COPD and prescribed an inhaled steroid and long-acting β agonist for her COPD. However, the patient’s symptoms did not significantly improve; in fact, her dyspnea persisted but was subjectively slightly better. Further, the pulmonologist also ordered a computed tomography scan of the patient’s lungs, results of which showed signs of emphysema and coronary artery calcium; The coronary artery calcium was commented on but not scored, as it was an incidental finding.

When the patient’s symptoms did not improve, the patient’s primary care physician referred her to a cardiologist. The cardiologist ordered echocardiography, results of which were significant for mild right ventricular enlargement. This was later felt to be related to sleep apnea, which was diagnosed by the pulmonologist. Her electrocardiogram (ECG) was only notable for sinus rhythm and mild nonspecific ST-T wave abnormalities.

The cardiologist also ordered a cardiac stress test, the results of which showed significant anterior wall reversible defect. This resulted in a cardiac catheterization, which revealed proximal left anterior descending (LAD) coronary artery disease that was easily amenable to a stent. The patient had a stent placed and felt better shortly thereafter.

ANSWER: ANGINAL EQUIVALENT

COPD contributed somewhat to this patient’s dyspnea, but mostly the cause of her symptoms was an anginal equivalent. The treatment for COPD helped the patient slightly but never really eliminated her symptoms, whereas the LAD stent did wonders for her.

Recently, there have been various controversies about whether or not stents do anything for patients, with the rare exception of proximal LAD or left main coronary artery disease, which has prognostic implications. In this case, that is exactly what the patient had—proximal LAD disease. Leaving that untreated raises the risk of morbidity and mortality. Treating it not only helped her symptoms, but also probably afforded her a better overall cardiovascular outcome.

In addition, coronary artery disease is the No. 1 killer of women in the United States.

Many times, health care providers discount coronary artery calcium, which was an incidental finding in this case. Coronary artery calcium that is incidentally found is a marker for people who are at higher risk of coronary disease. Further, this patient—as a 75-year-old woman with hypertension, hypercholesterolemia, type 2 diabetes mellitus, and a history of smoking—is within the high-risk demographic for coronary disease, as well. Age is one of the most important risk factors in characterizing coronary artery disease risk.

When people have symptoms—especially shortness of breath—that come on with activity, these symptoms should be taken seriously. When a patient who has a very high pretest probability is seen in the clinic, such as with this patient, the likelihood of coronary disease is very high. The symptoms should be worked up, particularly if the patient is having ongoing symptoms.

In short, many patients and health care providers discount dyspnea as an anginal equivalent. When patients think about angina, they typically think about someone clutching his or her chest with severe chest pain. But that is only one way in which angina manifests. Particularly in women, particularly in older women, and particularly in people with diabetes, angina symptoms do not always present typically (ie, with chest discomfort).

Heart failure was ruled out because the patient’s echocardiogram was only notable for mild right ventricular enlargement; there was normal left and right ventricular function and normal diastolic function.

Silent myocardial infarction was ruled out because the patient had normal left ventricular function by echocardiogram and no signs of infarct on her resting ECG.

Arrhythmia was ruled out because the patient’s ECG showed normal sinus rhythm, and she did not have palpitations.

Andrew M. Freeman, MD, FACC, FACP, is an associate professor, director of Cardiovascular Prevention and Wellness, and director of Clinical Cardiology & Operations in the Division of Cardiology in the Department of Medicine at National Jewish Health in Denver, Colorado.