A 69-year-old man with anger and angina.

DR DELBANCO: MR A IS A 69-YEAR-OLD MARRIED, RETIRED government worker with a 27-year history of angina pectoris, often triggered by stress. A father of several children, he lives in Boston and has Medicare and supplementary insurance. He has long received care in Veterans Affairs hospitals, but for the past 2 years, Dr M, a general internist at the Beth Israel Deaconess Medical Center, has been his primary provider. Mr A developed angina in the early 1970s. Despite medical intervention, he has since frequently developed angina with exertion, such as carrying bundles. In the past, Mr A describes “not getting along too well” with his cardiologist, who “yelled at him” about his excessive weight and felt his chest symptoms reflected panic, rather than arterial disease. He also sought help from a psychiatrist who helped him with depression and sleep problems. Mr A reported that, in addition to exertion, certain personal interactions predictably caused angina. Most notably, telephone conversations with his son caused him to “boil up” and develop chest pain, and disagreements with his wife frequently led to similar symptoms. A telephone call from a “difficult cousin,” or even a persistent telemarketer, would result in angina. To minimize such episodes, Mr A reported developing a strategy to remove himself from such calls. In October 1998, he woke with chest pain, which did not subside with sublingual nitroglycerin taken 3 times in short succession. Cardiac catheterization revealed 85% occlusion of the left anterior descending coronary artery, with a second lesion distally exhibiting 80% narrowing. Percutaneous implantation of a stent resulted in marked diminution in his anginal symptoms. Nevertheless, emotionally charged telephone calls continued to provoke angina, although the symptoms are less frequent and milder. Mr A has a long-standing history of peptic ulcer disease and in 1972 had a hemigastrectomy. Symptoms of dumping led to surgical revision, but he remains intermittently symptomatic. He developed diabetes mellitus as an adult and is now insulin-dependent. Mr A experiences painful peripheral neuropathy, which requires narcotics for pain control, and he has developed diabetic retinopathy. In addition, he has a long history of hypertension, moderate obesity, several episodes of gout, symptoms of asthma, and chronic vertigo due to damage to the vestibular system. Colonic polyps have been removed, and osteoarthritis in his legs requires him to use a cane. He has a long history of depression and anxiety, accompanied by episodes that some of his doctors feel represent panic attacks. He has a 15 pack-year smoking history but has not smoked for many years. Current medications include isosorbide dinitrate, diltiazem, lisinopril, aspirin, furosemide, nitroglycerin, insulin, carbidopa/levodopa, oxycodone/acetaminophen, trazodone, denatured tincture of opium, calcium carbonate, loperamide hydrochloride, famotidine, meclizine, and multivitamins. Recent physical examination reveals a mildly obese man who looked quite well, although he was limping and using a cane. The vital signs, including blood pressure, were unremarkable. The cardiac rhythm was regular. There were scattered wheezes, a normal cardiac examination, full peripheral pulses, and findings consistent with degenerative joint disease and peripheral neuropathy. Laboratory findings revealed hemoglobin A1C levels between 6% and 7%, a normal chest film, and an electrocardiogram with diffuse ST-segment and T-wave changes.