Persistent unexplained chest pain and dyspnea in a patient with coronary artery disease: a case report

Abstract

Background: Neurogenic orthostatic hypotension, a sustained decrease in blood pressure upon standing, is caused by autonomic nervous system failure and characterized by an insufficient increase in heart rate needed to maintain blood pressure upon standing. In this case, neurogenic orthostatic hypotension symptoms preceded a diagnosis of Parkinson disease. A diagnosis of underlying neurogenic orthostatic hypotension significantly changed the course of treatment for this patient.

Case presentation: An 84-year-old woman was referred to a cardiologist by her primary care practitioner for evaluation of exertional dyspnea and chest pain upon walking a few feet. Her medical history included hypertension, hypothyroidism, and osteoarthritis. Based on her continued symptoms, the patient underwent 2 cardiac catheterizations for coronary artery stenosis. After the catheterizations, exertional dyspnea and chest pain continued, and subsequently, dysphagia to solid foods and episodic dizziness developed. Orthostatic evaluation showed a supine blood pressure of 150/80 mmHg with a heart rate of 70 beats per min. Upon standing for 3 min, the patient's blood pressure decreased to 110/74 mmHg with a heart rate of 76 beats per min. The diagnostic criteria for orthostatic hypotension were met, and the lack of an adequate compensatory heart rate increase upon standing was consistent with a neurogenic cause (ie, neurogenic orthostatic hypotension), which was supported by tilt-table testing results. Although nonpharmacologic treatments were initially successful, episodes of lightheadedness, chest pain, and dyspnea upon standing became more frequent, and the patient was prescribed droxidopa (200 mg; 3 times daily). Droxidopa significantly improved her symptoms, with the patient reporting resolution of her chest pain and significant improvement of dyspnea and dizziness. She was diagnosed with Parkinson disease approximately 6 months later.

Conclusions: This case highlights the importance of evaluating and identifying potential causes of symptoms of cardiovascular disease when persistent symptoms do not improve after cardiac interventions. This case complements findings demonstrating that signs of autonomic failure, such as neurogenic orthostatic hypotension, may precede the motor symptoms of Parkinson disease. Importantly, this case provides real-world evidence for the efficacy of droxidopa to treat the symptoms of neurogenic orthostatic hypotension, after an appropriate diagnosis.

Keywords: Autonomic nervous system; Cardiac catheterization; Droxidopa; Neurogenic orthostatic hypotension; Parkinson disease.

Fig. 1

Change in heart rate and blood pressure. Heart rate and blood pressure changes upon 60° head-up tilt in a normal individual (top panel) and in a patient with neurogenic orthostatic hypotension (autonomic failure due to pure autonomic failure; bottom panel) [9]. Normally, heart rate increases upon standing to counteract the effects of gravity on blood pressure, while in neurogenic orthostatic hypotension, there is little or no increase in heart rate to compensate for the decrease in blood pressure upon standing. bpm = beats per minute; nOH = neurogenic orthostatic hypotension. Adapted and republished with the permission of Clinical Medicine from Mathias CJ. To stand on one’s own legs. Clin Med 2002;2:237–245; permission conveyed through Copyright Clearance Center, Inc.