No, She Did Not Need Prozac!

She was in her late fifties with salt and pepper curly hair and blue eyes. She was dressed in a business suit and she had a great job and the best insurance in town. She was about 25 pounds overweight and most off the excess was in her abdomen. She was bright, engaging, and easily understood everything I said. She was a new patient and she was seeing me for her high blood pressure.

Her hypertension was well-controlled at 138/86. Her LDL or “bad cholesterol” was slightly elevated at 115. Her HDL was a bit low at 38, and her triglycerides were up. She did not smoke. Her fasting glucose was 110, meaning she was prediabetic. She was on lisinopril and hydrochlorthiazide for hypertension and Prozac for depression.

I began to ask about other organ systems and when I got to the heart, I heard something I did not like. She had had more than ten episodes of chest pain and these were severe enough that she had gone to the emergency room, been admitted and had stress tests and heart artery catheterizations three different times. After the first catheterization, they told her she had no blockage in a heart artery greater than 20% and that she was depressed. It was the same story with the other two admissions.

Her chest pains were alarming to her and they were severe. She had this strange sense of doom as they started. They were often brought on by stress and she felt weak with them. I asked if she had taken nitroglycerin under her tongue and she said yes and that it had relieved her pain quickly. OK, now we had what is most likely a life-threatening issue.

She was anxious about these episodes because they were coming every two or three months and nothing seemed to help. I told her that it was very likely that she had serious heart artery disease that could cause a heart attack. There was no easily obtainable test that could reassure us that she did not. She was older, hypertensive, and prediabetic and the probablility was high that her heart was the problem. I told her that it was very likely that she could get rid of the episodes or greatly reduce them and we could reduce her risk dramatically. She agreed that was worth a try.

I changed her treatment in the following ways:

1. Eat real food. Lean meat, eggs, low-fat dairy, fruits, vegetables, beans, peas, nuts. Cut back on sugar and carbs. Try to lose a pound or two a month.

2. Walk thirty minutes five times a week or the equivalent.

3. Change your blood pressure goal to 130/80. Double your lisinopril.

4. Take 40 mg. of atorvastatin daily.

5. Add 500 mg. of metformin ER daily with food. Increase dose after two weeks to two tablets.

6. Add aspirin 81mg daily.

7. Use nitroglycerin under the tongue as needed for chest pain. Refill the prescription if the bottle has been open two months because the pills become ineffective after that.

We moved quickly to assure she had all the elements of optimal medical therapy (OMT) in place. She had one more chest pain two weeks later that was easily relieved by nitroglycerin. She never went to the emergency room or hospital again for chest pain. As she became convinced her heart problem was solved, her anxiety and depression decreased and she was able to taper off Prozac. I have nevery treated a more grateful patient. Too many women are suffering and dying because we have not recognized the differences in their heart artery disease. Women often have repeated chest pain without blockages severe enough to need a stent. They don’t need Prozac, they need OMT. Patients and providers alike should push for the changes that are required to protect our grandmothers, mothers, wives, sisters, aunts, and neighbors. Don’t you agree?