I take a brisk 30-minute walk three times a week and am relatively fit. But when I come to an incline, I feel a dull ache in my right shoulder and the top of my right arm. My GP dismissed the possibility of it being angina, and suggested it may be a muscular issue, and to go back to them if it got worse (I am 72).
John Coleridge, Cheshire.
The symptom you describe is, in my view, highly suggestive of angina.
The textbook description of angina is that it causes chest pain that may radiate into the left arm.
But my experience built up over many decades is that it rarely presents this way. In fact, I’ve rarely seen angina patients with pain in the left shoulder or arm: typically, it leads to central chest pain, though the severity varies.
Angina is caused by a partial narrowing of the arteries. The pain occurs when the heart is working harder (for example, during exercise) and not enough blood is getting through.
You may find that your symptoms worsen if you take your walk after a meal and it may be more likely to happen in colder weather (in both instances the heart has to work harder). In some patients the angina pain is felt in the neck and jaw, while in others it’s the upper abdomen. But the sensation can spread to both arms — or the right arm only.
The textbook description of angina is that it causes chest pain that may radiate into the left arm
In my view… Gut bacteria affect our fitness levels
I don’t often write about mice, but I feel compelled to draw your attention to some exceptional research by the University of Pennsylvania, U.S. — which affects us, too.
Just like humans, some mice enjoy regular exercise (running on their wheel), while others are idle. The researchers failed to find genetic differences between the groups, but what did emerge was a major difference in their microbiome, i.e. the microbes that live in the gut.
The microbiome of the sporty mice created compounds that stimulated the reward centre in their brains after exercise.
When they were given antibiotics to eradicate the microbiome, the mice stopped running. Then, when their microbiome was restored using stool samples, they started running again.
The stage where we need to care for our microbiomes from birth is ever closer.
As well as the pain, you might be slightly breathless. But the chief pattern to watch for is that this pain starts on exertion and stops when you rest.
I think you should see a cardiologist for further investigations.
This might lead to an angiogram, where dye is sent through the blood vessels and a form of x-ray is used to check how it flows through the coronary arteries.
If any blockage is found, you will be treated with medication, such as a nitrate spray for when angina occurs (it works by widening the blood vessels and increasing blood flow), pending a decision about further treatment.
You will almost certainly need medication to reduce raised cholesterol levels or high blood pressure, to reduce any further burden on the heart. You might also be advised to undergo a procedure to address any restriction in the blood flow in the two arteries — this involves having stents (tiny tubes) inserted into any narrowed segments to keep them open.
If there is more widespread narrowing, then a heart bypass may be required. But given — as you say in your longer letter — that you’ve only had the symptoms for six months and they sound relatively mild, I imagine this won’t be necessary. Either technique will mean an end to the angina.
See your GP again and push for an urgent referral.
Narrowed arteries may increase the risk of having a heart attack or stroke. So with your GP’s agreement, while waiting to see the cardiologist, take one baby aspirin (75 mg) a day, provided you have no medical contraindication to doing so.
I’ve had sudden and violent nosebleeds over the past few weeks — mostly in the night and lasting for one to two hours. The blood sometimes comes from the left nostril, sometimes both, and runs down my throat, causing me to cough up large clots. It’s very frightening.
Tests have shown nothing and I’ve had the blood vessels cauterised twice without success. I’ve now been referred to a consultant but, in the interim, what do you suggest if it happens again?
Jenny Cullern, London.
My first thought is that the blood is coming from the back of the nose, rather than just inside the nostrils (the most common site for a nosebleed), not least because the blood sometimes comes down both nostrils.
The tests you’ve had will have excluded any problems with blood clotting (and I assume you’re not taking low-dose aspirin or any other form of blood thinner), and I agree that you need to see an ear, nose and throat specialist.
My first thought is that the blood is coming from the back of the nose because the blood sometimes comes down both nostrils
They’ll want to inspect the back of the nasal airway on each side using a fine fibre-optic inspection scope. It may be that you need further cauterisation.
If you have another bleed before your appointment, pinch your nostrils tightly for at least ten minutes, leaning forwards, breathing through your mouth.
If that fails, continue to hold your nose tightly and take a cab or request someone to drive you to the local hospital.
In order to get the right treatment, ideally you need to be examined at the time of the nosebleed.
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