Rosemary, at forty-five, is the odd one out of my six angina patient examples. She had symptoms indistinguishable from the others, with pain in the center of her chest when she exerted herself, that subsided quickly when she stopped. However, the angiogram showed she had absolutely smooth coronary arteries, with no sign of a blockage in them.
It transpired that Rosemary’s problem was not in the arteries themselves, but in the blood they carried to the heart. This was because, to my surprise (because she did not look particularly pale), she had very severe anemia. Her hemoglobin level—a measure of how many oxygen-carrying red blood cells are in the bloodstream—was, at 5gm/dl, only a third of normal. The red blood cells were also much larger than normal, a finding that pointed to a disorder called pernicious anemia. This is a condition in which the body is deficient in vitamin B12. Further blood tests confirmed my suspicions, and she was put on injections of the vitamin she lacked.
As is usually the case in pernicious anemia, Rosemary felt much better after the first injection, but it took some weeks before her blood count was back to normal. By that time, her angina had disappeared. Rosemary will need vitamin B12 injections for the rest of her life, but I consider her cured, at least of her angina.
Rosemary did have one thing in common with the other angina sufferers: She was unable to supply enough oxygen to satisfy her heart’s demand for it. In her case, this was because, with her lack of red blood cells, the blood flowing through her normal arteries was simply unable to carry enough oxygen for her needs. In the other cases, there were plenty of red cells to flow through their circulation, but their arteries were narrowed by a disease process that was common to them all—atheroma.