X Doesn’t Always Mark The Spot

An increasingly common occurrence in an emergency room or even in a routine doctor office visit is the diagnosis of chest pain in a woman. An affected female describes quite typical symptoms of angina and significant chest pain, shortness of breath, or central abdominal pain that warrants further investigation. The physician sees a normal or nonspecifically abnormal EKG. The patient may or may not be sent home with reassurance. When it reoccurs, a treadmill is ordered and often positive. A cardiac catheterization is next. No obstructive lesions are seen.

Once, these women would have been lost to follow-up and their next encounter might have been with a heart attack or even sudden death. It is recognized that this condition is now recognized as INOCA (Ischemia and No Obstructive Coronary Artery disease). This is also known as Syndrome X. Here “X” doesn’t mark the spot—in fact the coronary angiogram much more often than not comes up clean. It is estimated that 3-4 million women in the United States have stable INOCA. Knowing what the diagnosis is not only allows treatment of a significant portion of women at risk, but also contributes to a decreased amount of unneeded testing that comes with its own set of complications and adverse effects.

The two most common causes of Syndrome X are coronary microvascular dysfunction and vasospasm of the epicardial arteries. The coronary catheterization shows relatively clean coronary arteries, and the condition may be treated more as an inconvenience than a medical condition of concern. More recent studies of patients with INOCA/Syndrome X however show an elevated risk of cardiac events. These include acute angina and coronary syndrome, stroke, hospitalization, and sudden death. A high percentage show no demonstrable cardiac lesions responsible.

When very small coronary vessels are deprived of blood flow, the occurrence of angina (a heart’s cry for help as it is being inadequately perfused with oxygen) is just as telling as a larger more demonstrable heart attack. Vasospasm (when the arteries go into spasm and do not permit adequate blood flow) show similar signs and symptoms. Either way, whether smaller vessels are affected or even “kinked,” the results are the same. At this point modification of all risk factors becomes necessary to minimize symptoms and to prevent progression into more severe forms of obstructive disease.

There is now more specific testing for coronary microvascular disease and vasospastic coronary symptoms. Called CFT (coronary function testing), it involves the use of vasoactive infusions with chemicals such as adenosine and acetylcholine. Nitroglycerin is also used to diagnose nonepithelial dependent microvascular dysfunction. If the diagnosis is unclear, PET scanning, cardiac magnetic resonance and Doppler echocardiography is also employed. At times, empiric therapy is also used—this is a doctor’s high clinical suspicion of this condition followed by what would be the treatment if that were the case. Those with contraindication or allergies, which prevent full testing, may make the diagnosis if successful response to treatment is observed with therapy.

Underwriters look for as much information as they can get from testing, since the diagnosis and treatment are not always clear-cut. All cardiac testing, successful modifications of risk factors, nature of treatment, and frequency of symptoms are considered. When the diagnosis is clear and the time between events is greater than six months to a year, standard insurance is possible. When poor cardiac follow-up or risk factor modification is not optimal, a policy may be rated to account for this. With Syndrome X, knowing that the disease has been diagnosed even when a catheterization is negative and that “X” doesn’t always mark the spot is more than half the battle.

MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life.

Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World from 1991 to September, 2021.

Goldstone can be reached by ­telephone at 949-943-2310. Emaill: drbobgoldstone@yahoo.com.