The sensitive heart. A syndrome of abnormal cardiac pain perception

SELECTED CASE A 50-year-old woman was referred to the National Institutes of Health because of a 12-year history of anginalike chest pain despite normal coronary angiograms. She described her symptom as a substernal pressure sensation radiating to the left shoulder and arm, provoked by effort and relieved by rest. Two years prior to admission, she underwent cardiovascular evaluation that included treadmill exercise testing associated with ischemic-appearing electrocardiogram (ECG) changes. Beta-blocker therapy (120 mg of nadolol daily) diminished symptoms somewhat, but because of continued effort-provoked chest pain, she underwent cardiac catheterization, which demonstrated normal-appearing coronary arteries and left ventricle. Nadolol was discontinued, and she was started on 90 mg of diltiazem hydrochloride twice daily, which did not relieve her symptoms. She did find sublingual nitroglycerin to be of help in relieving pain. Her past medical history is significant for a cholecystectomy 3 years prior to admission and cigarette smoking discontinued 10