Angina for the Unexcited

The nagging chest pains of angina pectoris are a common symptom of coronary artery disease and may serve as early warning of an impending heart attack. They usually mean that the heart muscle, because of exertion or excitement, is demanding more blood than the disease-narrowed coronary arteries can supply. But angina can also come to the most relaxed and unexcited person. Last week, in the A.M.A. Journal, Los Angeles' Dr. Myron Prinzmetal reported that he and five colleagues have identified 23 cases of a strange angina that holds off while its victims shovel snow from their driveways or play 36 holes of golf but attacks when they are quietly resting.

The maverick angina, says Dr. Prinzmetal, is often accompanied by palpitation, faintness and fear of death and may be even more severe than classic angina. Seizures last from 45 seconds to more than 20 minutes, and often occur in remarkably regular cycles, perhaps at the same time each day. The condition is extremely difficult to diagnose. A physical examination reveals no abnormalities. An exercise tolerance test causes no pain. Results of laboratory tests are normal. Chest X rays and routine electrocardiograms give no indication of the disorder. Eventually, says Dr. Prinzmetal, "on repeated visits the suspicion grows that the patient's symptoms are of psychoneurotic origin." But since emotional distress does not provoke the viselike pains, tranquilizers and sedatives do not relieve them. Bewildered, the doctor may tell his patient to go home and rest, only to have him stricken again there.

Sometimes the victim" may convince his doctor that his ailment is painfully real by having an attack in the doctor's office. Then an electrocardiogram taken during the course of his pain will register telltale changes in the electrical activity of the heart. The ailment is often progressive; eleven of Dr. Prinzmetal's patients eventually suffered major heart attacks. In all these cases, says Dr. Prinzmetal, the attacks struck the exact area of the heart in which the gripping pains of angina had earlier occurred.

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