Medicine>>>>>Women’s Health
Question 6#

A 50-year-old woman presents with chest discomfort for 2 days. It lasted for 3 hours on the first day and 6 hours the second. Onset was while she was playing cards. She describes it as indigestion. She walks 2 miles a day, and has never smoked. She has a family history of atherosclerosis in her father. Her BMI is 25, blood pressure is 124/74, and heart rate is 72. HDL is 55, LDL is 78, TG 120, and total cholesterol is 188. She is in mild discomfort as you examine her. Her EKG during the discomfort shows 3 mm ST elevation. Troponin I rises to 4.2 µg/L (normal < 0.04). Her treadmill stress test shows mild apical T-wave inversion. Her cardiac catheterization shows no luminal defects.

How do you counsel her for future treatment? 

a. Vasodilators such as nitrates and calcium-channel blockers help prevent micro-vascular vasospasm
b. A statin is not needed since this patient’s cholesterol is at goal already
c. Warfarin has been shown to decrease risk of myocardial infarction in women
d. Proton pump inhibitor and over-the-counter antacid are the most appropriate therapies for her symptoms
e. Benzodiazepines will alleviate this patient’s chest pain from panic attacks

Correct Answer is A


This patient’s laboratory and testing prove she has suffered a myocardial infarction. Women with coronary disease commonly present with vague symptoms, such as shortness of breath, nausea, vomiting, indigestion, fatigue, or upper back pain, as compared with the classic symptoms of chest pain, tightness, or pain radiating to the arms or jaw. Cardiologists recognize that the etiology of women’s ischemia is commonly due to small-vessel vasospasm, not the classic lumen narrowing with plaque that is easily seen on catheterization. Therefore, prevention of further vasospasm with vasodilators, such as nitroglycerin preparations or long-acting calcium-channel blockers (CCB), may provide additional benefit to established secondary prevention treatments, such as statins and aspirin. Secondary prevention according to the American Heart Association guidelines recommend a goal LDL of less than 70, triglycerides less than 150, and HDL greater than 50. Warfarin is not indicated for secondary prevention of myocardial infarction. Treatment of noncardiac chest pain can include proton pump inhibitor trials or benzodiazepines for anxiety or panic disorder. This patient, however, clearly has ischemic heart disease, and treatment should be directed to preventing future cardiac events.