Bridging The Gap (Part 2 of 3)
Published 21st Feb 2022
The Answers?
or do I just have more questions now ?
Since my SCAD 'heart attack'* in March 2021, I had been experiencing ongoing cyclical chest pain.
Acute and severe cardiac 'events', most severe in the 1st week of each month.
In addition, I was having very uncomfortable chest 'tightness' and laboured, difficult breathing when going to sleep at night.
Every night.
My most severe 'event' post SCAD heart attacks happened on the 6th June 2021 - which was similar experience to my SCAD heart attack*, but which felt much more severe, quick and I was within a whisker of losing consciousness.
It was so severe with such sudden onset there was absolutely no doubt in my partner’s mind, this time around, he was on 999 within minutes. Initially, I was saying, “wait, wait, don’t ring them” Luckily he ignored me as the room started swimming and ‘the blackness’ descended all around me.
This particular ‘fun’ event is described in the post - "Shit. It's Happening Again..."
Since then, I have been trying to get the answers to the following questions, questions that I do not think are THAT left field for a cardiologist.
It has taken me until 13th January 2022, to get some limited answers.
* A Spontaneous Coronary Artery Dissection is not a traditional atherosclerotic heart attack, because there is no blockage in any part of the 'plumbing' of the heart.
Below, are the answers to my questions from 3 Cardiology Professionals:
Dr. Bing - Royal Infirmary of Edinburgh
Appt. date - 12/7/21 (in person)
My 1st outpatient appointment after my SCAD on 1/3/21
(Cardiology)
Dr. D. Adlam - University Hospital, Leicester
Appt. date - 1/12/21 (Virtual appt.)
1st appt with SCAD specialist after a very difficult & painful process to gain the referral from Scotland to NHS England. (There were no SCAD specialists in Scotland at the time)
SCAD specialist.
(Cardiology Consultant)
Dr. S Cameron - The Cleveland Clinic, Ohio, USA
13/1/22 (virtual appt.)
A patient of mine, effected an introduction with her brother, who very generously gave me 90 minutes of his valuable time.
For no fee.
I love my patients!
(Head of Vascular Medicine)
Q. 1 - Aspirin
Introduction
If you are having a suspected heart attack, the 999 responder will advise you to chew 4 aspirin - to help to prevent clotting, in case you ARE having an atherosclerotic* heart attack. (*atherosclerotic is your traditional type of heart attack where the patient has blockages etc within the arteries.)
During my 2nd BIG event in June, the 999 call handler advised me to chew 4 aspirins, after which the acute pain dropped from 8-9 out of 10, to 3-4.
I then felt myself 'coming round', coming 'back in to the room' so's to speak and my peripheral vision returned.
Can anybody tell me -
Was the chewing of aspirin & reduction in symptoms totally coincidental?
Did chewing them, avert another SCAD?
As we discovered, I had NOT had another SCAD nor heart attack, so what the hell WAS it?!
It felt the same as before, although it was much more intense, acute, quickIf it WASN'T the aspirin that relieved the symptoms, what might feel the same as a 'heart attack' and resolve on its' own?
If it happens again, can I just chew the aspirin then rest for a few days? Save an NHS bed!
Answers:
Dr Bing
"aspirin won't have done that, it doesn't do that". It will be something else"
Me, "OK. Should I continue to take aspirin long-term?
"well.... you can if you like. I mean, many people do take it".
Dr. Adlam
"aspirin has 2 pharmacological effects; as a painkiller & an *anti-platelet agent [*prolongs bleeding to avoid clots forming]
"it is unlikely that the anti-platelet effect is relevant here.
My best guess, is that it was coincidence or the analgesic effect [painkiller] has had an impact."
"We're becoming more circumspect about giving aspirin to SCAD patients as SCAD is caused by a bruise or bleed in the wall of the artery [ergo] it's unwise to give medications that will prolong bleeding." [I think that he meant giving patients aspirin long-term]
Dr Cameron
"What you've described [in the 2nd severe but non-SCAD event] is classic microvascular dysfunction.
The fact that it resolved on its' own is very positive.
Many cardiologists will prescribe aspirin for anyone with a positive troponin test but aspirin makes it more likely to have a spasm - it accentuates spasm.
Staying OFF aspirin is critical for anyone with vasospasm - as it will make it worse.
Anti-platelet medications are for patients with atherosclerosis heart disease - SCAD is not atherosclerosis."
Q. 2 - Troponin
Introduction
Troponin is the protein produced by the body when there is death or damage to the heart tissue.
A positive troponin result signifies a heart attack, however....
I have now learned that troponin can also be present in the folllowing instances:
some common cold viruses can sometimes lead to inflammation of the sac around the heart = pericarditis, which can feel like a heart attack.
a physical bang to the chest eg. falling off a ladder
elite athletes who work above 85% of their maximum heart rate in order to produce troponin levels
microvascular dysfunction: vasospasm/coronary artery spasm, atrial fibrillation, microvascular angina, which can feel like a heart attack.
(The microvascular system is the network of tiny capillaries that supply most of the blood to the heart muscle. In diagrams of the heart it is the system that resembles a spiders web - teeny, tiny thread-like blood vessels)
I would love to know -
My troponin levels were tiny, during 2nd event in June, BUT they DID show a curve. They increased during the night in hospital but had faded away to nearly nothing 24 hours later.
Is that normal?
Can troponin levels wander about of their own accord?!
If NOT 'normal' what could the curve indicate?
Is there the potential of a microvascular issue?
Medicine LOVES data. You're either within the parameters of diabetes, hypothyroidism, coeliac, etc, or you're not.So what does the data tell us?
NB. I am not worried or anxious, merely curious.
Answers:
Dr. Bing
"your SCAD heart attack was really very small.
The main purpose of this appointment is to reassure you".
Me - " I don't need reassuring but thank you. I have no knowledge of the parameters of troponin levels, could you explain them for me please?"
"well... I mean.. if you have a major heart attack the levels would be up in the 50,000's
and yours were only in the 3000's. And you didn't need resuscitating".
Me - "When I had my 2nd severe 'event', last month, the troponin levels showed a curve 16, 29, 5.
I fully appreciate that my heart is 'beautiful and healthy' - and I have seen the images many times but, can you suggest what those results may mean, if anything at all?"
”let me show you your heart”, and he pulls the images up on the screen -
"as you can see, your heart is very healthy. You have no need to worry"
Dr. Adlam
no definitive answer to the curve in levels.
More discussion on Microvascular angina and Coronary Artery Spasm, which I will go in to shortly.
Dr Cameron
"as previously mentioned many healthy people will return a positive troponin test but, in your case there was a delta curve and that should not happen.
For those with a delta curve (ie it peaks and troughs) this would be the No.1 reason to initiate anatomic investigation. Something has caused it to happen.
What you have described is classic microvascular dysfunction."
Q. 3 - Glyceryl Trinitrate Spray (GTN)
As described in the introduction, after my SCAD event in March 2021, I had been experiencing weird heat/heart palpitations/breathing difficulties, just as I was about to fall asleep at night. Highly frustrating.
And, although my severe heats - no sweating - nearly passing out- during the day episodes had completely disappeared for a month or so post SCAD, they returned about 6-8 weeks after my SCAD. And with a vengeance.
Not great if I was driving.....
However, after my 2nd admittance in June 2021, I was given a GTN spray and, my understanding was that, if the BIG BANG pain happens again, that's when I take it. GTN spray users are told that they can take it 3 times, 5 minutes apart. If the issue does not resolve, then you better be dialling 999
Interestingly, I had noted that:
all of the above symptoms, both day time ones and the falling asleep ones,
completely disappeared whilst ON micronised progesterone
but returned whilst OFF micronised progesterone for the required 2 weeks a month,
And, whilst trialling the GTN spray for my night-time breathing issues,
IT WORKED! I could breathe normally!
Who knew that would happen?!
Nobody had mentioned angina to me and I've not had the Big Bang ?!chest pain! So what do I have that the GTN spray is ‘making better’?!
Can anyone tell me -
Have I been given the GTN Spray as a diagnostic tool?
If the spray alleviates my symptoms, even though they do not include the 'BIG BANG' pain, what condition is being alleviated?
The after effects of the spray are not pleasant. I have to be very ill before I'll take it -
I. Am. Not. Taking. It. On. A. Whim.What is the/is there, a correlation between oestrogen/progesterone levels and cardiac symptoms?
Answers
Dr. Bing
"it has not been given as a diagnostic tool, we don't do that with GTN Spray.
What we do, is give the patient the spray and for the patient, having something, a tool, that they can use, makes them feel better. A placebo if you like".
Dr. Adlam
I didn't ask this specific question. By the time I had my appt with Dr. Adlam (1st December) I had researched microvascular dysfunction, which will be relieved by the GTN Spray, so I was able to ask slightly different questions in the sound knowledge that yes, the GTN spray works for the issues described.
Dr. Cameron
"A GTN Spray works for 2 conditions; spasm of the cardiac blood vessels & spasm of the oesophagus."
"Reproducible reversibility [of a condition] with the GTN spray is, 9 times out of 10, relieving spasm of a small coronary artery".
Q. 4 - Angina/Coronary Artery Spasm/Cyclical Chest Pain/Sex Hormones
Yeah, I know..... catchy heading.... soz.
As already mentioned, I knew that it was the progesterone part of my HRT that was the secret to keeping my heart happy.
You can read more about how I came to this conclusion in Hormones and Heart Health - Research
During my 2 week break per month from progesterone, my cardiac symptoms returned -
excluding another SCAD, thankfully.
{Author Update Summer 2022: due to the shortages of oestrogen in the UK, we discovered that I cannot be off oestrogen for more than 14-17 days, as my heart starts playing up again]
HOLY CRAP, my heart wasn't happy without the progesterone!
Thanks to my menopause specialist's care, Dr. Zoe Hodson -we have now worked out that if I take progesterone for about 23-25 days per month, then come off it for 5-6 days (to have a withdrawal bleed)
both my heart and my womb are happy.
RESULT!
So now, I have loads more questions.....
Why is it that -
S-u-u-u-u-r-e-ly, I'm not the only woman in the entire world, who has experienced these menopausal symptoms?
And I'm not.
I mean, my partner says that I'm 'special', but then he's biased. And I know that I am a little bit.. well... 'out there' sometimes, but I sure as hell don't think that I am unique in my experience.
So cardiology.... can you tell me -
Why is there no conversation about sex hormone levels, within cardiology? (Irrespective of whether the patient has had SCAD or not)
Do known menopausal symptoms of chest pain, breathlessness and heart palpitations, ‘muddy the waters’ of post SCAD treatment?
Why are these very well known and well-documented menopausal symptoms not talked about when a mid-life female, with no known cardiac risk markers, presents in cardiology?
Having researched information from the British Heart Foundation on microvascular issues, do you think that THOSE may be relevant in my case?
Answers
Dr. Bing
"your symptoms will be something else. Don't you worry about what is wrong - you leave that to us. Now. Shall we book another appointment for you in a year or so?"
Dr. Adlam
"We know SCAD patients have a lot of chest pain - the mechanism is not entirely clear.
My instinct is that it is not vasospastic, partly because treatments for vasospasm don't seem to be effect.
[Reader, I think that he was referring to cardiac type treatments - I'm afraid I didn't clarify]
I'm not convinced by microvascular angina - no particularly logical reason that the SCAD patient population would be particularly prone to it.
My hypothesis is that it is to do with the disruption of nerve fibres. And that is does get better over time, 18-24 months.
The way that you have worked through your refinement of your HRT is really very, very, interesting and impressive that you have found a solution by identifying that your symptoms are predominantly driven by that process" [menopause]
"We are very interested in this area.
In fact we had a meeting yesterday with collaborators in France and Austria, where we are looking at progesterone receptors and levels and how that coupling of receptors and hormones
might have an impact on the vulnerabilities of SCAD."
Dr. Adlam
(1/12/2021)
Dr. Cameron
*MINOCA = myocardial infarction with non-obstructive coronary arteries.
To you and me this means having a heart attack when the cause is NOT blockages within the plumbing of the heart, like 'atherosclerotic'/traditional/most common, type of heart attacks.
"changes in oestrogen are independent predictors for *MINOCA
in comparing women who have MINOCA, to women who have 'traditional type' heart attacks, the difference is that, in MINOCA, there is a dysregulation [the mechanism is a bit broken] of the oestrogen receptors
it is not yet clear why some women are more predisposed to this.
the majority of patients with MINOCA ARE women.
most of the blood to the heart arrives via the micro vessels, the microvascular system.
What we sometimes see in SCAD patients [in particular] is a spasming of these little blood vessels.Because you have this issue when your NOT exerting yourself, it is most likely to be spasm of these blood vessels."
So the data IS out there!
The menopause specialists know about cardiac menopausal issues/symptoms.
The cardiologists who know about microvascular dysfunction in mid-life women, totally know about it.
To them, it's obvious, and let's not forget the British Heart Foundation - it's on their website!
Info updated on BHF website 2017
These symptoms can not only drastically affect their quality of life, including the ability to work and drive, but are, in and of themselves, alarming, to say the least.
Especially if these women are like me and who;
have NO cardiac risk factors,
are non-smokers,
are not diabetic
exercise regularly
don't have high blood pressure
and are flummoxed by this brand new 'condition' and lack of answers or explanations.
The information IS out there…….
It can be caused by the fluctuations in sex hormone levels
And the fact that cardiology in general, have no interest in this?.....
Well! This both fascinates AND worries me.
If I had not taken the most dramatic route (!) and subsequently started this research on what the hell was wrong with me,
I would have had
NO IDEA
that menopause symptoms
can include cardiac symptoms.
If cardiology professionals are not aware of the correct information and menopause symptoms can include cardiac issues, then
'Houston, we have a problem'!)
The scientific research IS out there and has been for years.
THIS. IS. NOT. NEW. RESEARCH.
In my next post, I will summarise Part 1 and Part 2.
I will share the links to the data, the NICE guidelines, the British Heart Foundation information, so that you have a 'go to' page. A place where you can read the information that I have found.
(No point in all of us spending the months that I have spent in finding the answers, now is there?!)
And, to the SCAD patients out there, yes I know, MEN can experience SCAD as well.
Remember though,
BOTH men and women produce ALL sex hormones, just in varying amounts.
There is a relationship between progesterone production and the adrenal glands- but that will be in a future post. My brain is getting numb!
