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PATTERNS OF ANGINA: DIANE
Diane was forty-one when her coronary disease was discovered—and she had no pain at all. She had had diabetes since she was a child, for which she had to self-inject insulin three times a day. There was a time in her teenage years when she “went a little wild” and let her control slip—a natural reaction at that age to the restrictions of diabetes. However, for the last twenty years she had kept her diabetes under reasonable control.
In the last year or so, though, Diane hadn’t been feeling well, especially when trying to look after her two children. Like many career women today, she started her family late, so that her two boys, aged six and four, are quite a handful.
As with many women with diabetes who become pregnant in their thirties, Diane had a difficult time. Her diabetes was hard to control, particularly near the end of each pregnancy, and the effort of bringing up the two children exhausted her. Her husband shared the work with her, but he eventually convinced her to see her doctor when it was obvious that she couldn’t cope.
The story of exhaustion alerted Diane’s doctors. Most women are protected from the effects of heart disease during their reproductive years by their hormones. The monthly cycle of hormonal changes in some way (we do not yet know how) postpones the onset of heart disease in women, and it is only after menopause that they seem to develop this disease. However, the exception is in women with diabetes. Diabetes appears to neutralize the protective effect of the female hormones, so that women with diabetes are at just as much risk of angina as men of the same age.
There is, however, one striking difference. Angina in women with diabetes is often painless. With diabetes comes a condition called diabetic cardiac neuropathy. The name simply means that, in diabetes, the nerves that convey pain to the brain from the heart are altered. The nerves no longer relay the sensation of pain, so that angina is “silent.”
The lack of oxygen is not perceived as pain, but it may appear instead as a general malaise or simply exhaustion.
This was the case for Diane. An angiogram showed that she, like the first patient, Jim, had several narrowed segments in all three main coronary arteries. She was given a priority waiting-list place for bypass surgery, and was called in for surgery a month later. However, she was also referred to her specialist in diabetes for intensive control of her glucose and insulin levels, so that she would be as fit as possible for the operation.
The surgery was a great success. When coronary artery bypass surgery was first started in the early 1970s, there were doubts about whether people with diabetes would do as well as nondiabetics. These doubts have now been dispelled, following the analysis of the results of large series of patients (in which around one in ten have had diabetes). Through surgery, angina can be considerably improved, whether it is silent or painful, in people with diabetes.
The surgery was not the only change in Diane’s life. She now has a much better lifestyle: She eats smaller meals at shorter intervals than before, and combines them with a different schedule of insulin injections, with the aim of keeping both her insulin and glucose levels as normal as possible throughout the day and night. She also has her blood pressure checked regularly, which is maintained at the lower limit of normal.
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