Atypical Chest Pain and Atypical Cardiac Disorders
In atypical cases, the diagnosis of heart disease is not always as straightforward as one would like. For example, patients can have heart disease and ischemic chest pain (angina) in the presence of normal coronary arteries. Or, patients can have atypical chest pain that is erroneously misdiagnosed as "musculoskeletal" pain, when it is actually of "cardiac" origin. This can be especially true in diabetics.
Diabetic patients can develop angina (ischemic chest pain) even if their coronary arteries are normal and do not show any significant narrowing or obstruction. In some studies, this can occur in up to 20-30% of coronary angiograms. [Reference: Proudfit WL, et al. Circulation 1966; 33:901-910.]
Of course, this scenario can be very confusing to a doctor, when his patient complains of chest pain, but the coronary angiogram is normal. A long-term disability insurer, either through Social Security (SSDI) or an employer-sponsored plan (ERISA), may refuse to award long-term disability benefits on the basis that the coronary angiogram is normal.
What may be going on, particularly in diabetic patients, is what has been termed "microvascular angina," where the problem appears to be in the microcirculation of the heart, and not in the coronary arteries per se. That is why a coronary angiogram may look completely normal, but the patient may nonetheless have impaired cardiac circulation and resultant disability related to ischemic chest pain.
Coronary Artery Spasm
Coronary artery spasm is a vascular condition where the coronary arteries on coronary angiography are not obstructed or occluded, but there can occur a temporary tightening or constriction ("spasm") of the wall of one of the coronary arteries, which cuts off the circulation to a part of the heart muscle, and which can cause chest pain, arrhythmia, and even a heart attack.
Diabetes does not appear to be a risk factor for coronary artery spasm, but smoking, exposure to cold, or extreme stress have been associated with this condition.
Prinzmetal's angina, vasospastic angina, and variant angina are different names that have been used over the years for coronary artery spasm.
Atypical Chest Pain
Patients with diabetes mellitus may have atypical chest pain, or they may have no chest pain at all, and still have coronary artery disease and suffer a heart attack. It is well known that diabetes is a risk factor for the development of heart disease. For example, when patients with diabetes are compared to non-diabetics, they have more advanced disease, more affected coronary segments, and more obstructive coronary artery disease than patients without diabetes.
However, what is not as well known is that patients who have diabetes may have either atypical chest pain, or even no chest pain at all, with heart disease and while suffering a "silent" heart attack. It is not exactly known why diabetic patients sometimes do not perceive chest pain, but it may be related to a neuropathy of the autonomic nerves. [Reference: Junghans C, et al. "Atypical chest pain in diabetic patients with suspected stable angina: impact on diagnosis and coronary outcomes." European Heart Journal, 2019; 1:37-43.]
Atypical chest pain in diabetics may go unrecognized as angina (because the chest pain is not characteristic of cardiac pain), and for that reason, the presence of coronary artery disease may go unrecognized and under-diagnosed.
Disability Benefits for Patients with Atypical Chest Pain or Atypical Cardiac Disorders
When applicants apply for disability benefits to the Social Security Administration (SSDI), or to an insurer under an employer-sponsored plan (ERISA), an award of long-term disability benefits may be denied on the basis that the objective evidence in the medical records fails to "support" an applicant's disabling symptoms.
For example, a denial of disability benefits may be based on the fact that the coronary angiogram is normal and fails to show obstruction or coronary occlusion. However,. in "microvascular angina" and in "coronary artery spasm," the coronary angiogram is usually normal and yet, in both conditions, the patient may be suffering from disabling ischemic chest pain (angina) and entirely deserving of long-term disability benefits.
Diabetic patients, who have atypical chest pain, may have underlying coronary artery disease, but their disability claim may be denied on the basis that their chest pain is "musculoskeletal," and not of "cardiac" origin.