I Finally Have the Diagnosis That Explains Years of Chest Pressure. It Wasn't Anxiety. It Was Never "All in My Head."

I was about to agree that this was all in my head. That my ongoing chest discomfort was just anxiety or maybe some referred pain from old sports related musculoskeletal injuries.

For those that have been following along, you will know that almost two years ago now I ended up having to get a stent after having persistent palpitations and minor chest pressure. A CT angiogram found an 80% obstruction that ended up getting stented.

What I haven't spoken about too much is that I've continued to have the same sensation of chest pressure. Earlier this year I had a CT angiogram and an echo repeated. Both were normal and re-assuring that my program was working and my heart was structurally sound and treatment was working as I had no other areas of evident atherosclerosis. I again wore a holter monitor, with normal results. However, the pressure continued. My cardiologist had mentioned the word anxiety and I was starting to go along with that idea. I had been reading about microvascular disorder, and some of that fit my case, so I decided to push on one more appointment and the cardiologist moved me up the ladder to the Mayo Clinic Chest Pain clinic, a specialty clinic.

The doctor at that clinic took a different approach. I was hoping for a special type of MRI or a PET CT scan that can help to rule in or out microvascular disease. However, they recommended I go back to the cath lab. Admittedly, this invoked a lot of anxiety in and of itself. Thinking back to having to get stented. I found myself literally making that argument that maybe this was just anxiety compounded with some disc degeneration. He politely said: "go home and think about it" and left the ball in my court.

After about a week I decided to go ahead with a second visit to the cath lab. I am glad I did, because I found out it was never in my head.

The Bottom Line

I had to stop and admit that for the two years after my stent these ongoing, intermittent, episodes of chest discomfort were taking a real toll. I was to the point of having to take something for anxiety, and lie down until it passed. I missed time with my kids, my wife, my friends, and my job because of it. Every workup said I was fine, and the working theory, from my care team and eventually from me, became anxiety. It made sense. I had to unexpectedly get stented at a young age, despite doing all the right things, with only very minor risk factors. I work in an ER, where I see things turn sideways constantly. The working theory was that even a minor palpitation or referred pain from old back injuries, would get my brain thinking heart attack and the natural result was to spiral when it would happen.

There is only one study in the world that can find what was truly happening the entire time: a specialized study in a cardiac catheterization lab (the cath lab). The same lab I had to get stented in and the same lab where the ED patients having acute heart attacks get rushed to. I will be telling the full details of the types of diagnostic studies that can be done in these labs next week. One of the diagnostics they did on me was called a provocation study, basically trying to stress my coronary arteries to see what happened. When my arteries were challenged with a provoking medication, they clamped down, reproduced my symptoms, and pushed my ECG into the same changes we watch for in the emergency room. One artery was narrowing on its own before the provoking drug was even given, and a dose of nitroglycerin made that narrowing disappear. At first that narrowing was thought by the team to be plaque, but plaque does not vanish in seconds. A coronary artery spasm does.

So, the condition is called exactly that: coronary artery spasm. I had heard of this in school, but had read at the time that it was relatively uncommon. Further, I quickly learned from the team that the blood pressure medication I had chosen after the stent, propranolol, was picked partly because it also blunts the physical symptoms of anxiety. That seemed efficient at the time, one pill helping with both anxiety and my mildly elevated blood pressure. However, propranolol is also one of the drugs that can make coronary spasm worse when it is present. So, the drug being used to help with my anxiety and blood pressure was making the REAL problem worse, because it was never anxiety to begin with.

In this post I am going to be walking through the story and how this discovery, this past Wednesday, has only strengthened my resolve to write. Next week's post is the science: what a diagnostic catheterization can actually find, how spasm testing works, what microvascular testing adds, and why the version of this condition most Westerners have is not the version we were taught in school.

I was the best-case scenario, and it still took two years

I need to establish something first, not to impress anyone, but because it is one of my main points about the difficulties of navigating what it means to be healthy and what exactly you should do if you start to feel like something is just not quite right.

I have been inside the health and wellness world for about 25 years: personal training, diet, supplementation, human optimization, fifteen of those years running companies in the supplement industry itself. I have advanced training in biochemistry, molecular biology, nursing, advanced practice, epidemiology and public health. I work in a Mayo Clinic emergency room and I am friends with many physicians and scientists - all who I spoke personally with about my own case. I read the primary literature for a living as a PhD candidate and as an APRN student focusing on cardiology. I know the wellness world, the biohacking world, the medical world, and the research world from the inside.

However, I was about to accept that my chest pain was "mostly in my head."

It's not that the medical system was doing anything wrong. It was doing what it was intended to. Slowly escalate invasiveness of tests until either the doctor or the patient say 'no more'. I had two cardiologists that already thought enough tests had been performed, so I was sent to a third one. And, even with all my training and background, I was about ready to consent that this was all just in my head. My point is, if even I was at this point, imagine the regular person who would have stopped at the first cardiologist and, after a battery of tests, accepted that he probably just had anxiety.

The two years

The stent went in early 2025, after an 80% blockage was found in my right coronary artery. I went through a period of denial and anger, honestly, I was flat out pissed off that I had to get stented even though I was doing all the right things with diet, exercise, optimization, etc. However, that didn't last too long and I decided I had to admit that my own feelings about diet (I was a keto guy) and LDL (I was convinced that mildly high LDL was ok on keto) were obviously wrong, and I needed to attack the problem. I quickly drove my cholesterol down to numbers you would expect in a baby, with an ApoB of 38. As I mentioned, my repeat imaging looked good, and a couple of very minor areas of plaque in other vessels (atherosclerosis) had actually regressed. In the eyes of the radiologists, three cardiologists, and even in the eyes of my physician friends, the problem was solved. I was fixed. The stent was sound and my cholesterol levels were at the levels all relevant studies said result in regression of coronary artery disease.

Except the discomfort kept coming. Not constantly, just episodes. The first occurring probably four to five months after the stent. It was just a pressure that builds, never feels or looks like a true heart attack, and eventually passes. With my ER training I could work through the logic in real time: I could check an ECG at home, and the episodes always passed, and together those reassured me more than they should have. No ER nurse wants to rush into his own work every time he has some chest discomfort, so I bought the tools and had them at home. I know better than to hand you that logic as a rule: heart-attack pain can come and go, and a normal home tracing between episodes does not rule one out. But, this didn't change the fact that there was no clean answer for what was causing these symptoms, so a familiar story moved into the vacuum: anxiety. A word discussed with every ER patient who comes in with chest pain, has a perfectly normal workup, and heads home. And now I was living it.

So the anxiety explanation hardened, and eventually I started to believe it myself. My rescue plan for the episodes became an anxiety medication and a quiet room. It worked, sort of, in the way that lying down for forty minutes works. Each time, it also deepened the story: see, you took the anxiety pill and it passed.

But, in the back of my head it still just didn't fit right. I had never been an anxious guy my entire life. I have sat in countless tense board room meetings. I run heart-attack codes in an emergency room without my own pulse even moving. My life today, busy as it is with family and work and a doctorate, is genuinely less stressful than my 20s and 30s, when I was in the business world cutting deals, constantly traveling, living in meetings. I went through two category five hurricanes while living in and operating a business in the US Virgin Islands that decimated life as we knew it. If I was prone to anxiety and my chest discomfort was being caused by this, it should have reared its head then. But it never did.

Pushing, and almost quitting at the finish line

I kept pushing, and I want to be honest about what that took, because I had advantages here too. I knew the exact words to use to keep a care team thinking instead of closing the chart. I knew which possibilities there still were and which tests had not been done. After a nuclear stress scan came back partially unreadable, my final ask was to push for a cardiac MRI stress test as the next step. It's eerily ironic that the third cardiologist, instead of saying, yep, this is anxiety, jumped ahead to the most invasive test that even I wasn't pushing for. And that I almost declined it.

As an ER nurse, "cath lab" is a phrase you never want aimed at you; it is where we send the emergencies. I had spent two years fighting for an answer, and when the definitive test was finally offered, my first instinct was that it was too much, too invasive, too far. The procedure has risks. Major ones, like heart attack and stroke. I had been pushing for a less invasive scan, and the irony is that the test I nearly declined was the only one on earth that could see what was wrong with me. It's not something that can show on a CT scan or MRI machine. It has to be provoked, live, with a catheter already in place to watch it happen.

For this testing I was awake on the table, and I felt the exact discomfort I had been describing for two years arrive on command, watched by a team that could finally see its cause: arteries constricting in response to a provoking medication, the ECG shifting into the signature of heart muscle not getting enough blood (ischemia). This is exactly what happens when someone has severe angina caused by atherosclerosis and its also what happens in a heart attack itself. But, the lack of blood flow to my heart was not coming from a heart attack or arteries narrowed from cholesterol deposits, this was something else.

Somebody finally saw "it" and "it" was not anxiety. I cannot fully describe what that did to me. Relief is the wrong word, because the finding is not good news. Vindication is closer, but it misses how much grief came with it. But, that grief quickly cleared as having a diagnosis allowed me to finally move forward with a plan.

My own primary care doctor, who has known me a long time, put it plainly when we talked after the procedure: he had never seen anyone argue for a diagnosis that hard, and the typical guy in my position would never have gotten this answer. He would have just gone on, mislabeled and on a treatment that would continue worsening his condition. His heart disease would have continued to worsen from ongoing periods of low blood flow. And, he would have died prematurely, to be blunt.

What this condition actually is, briefly

Coronary artery spasm is exactly what it sounds like: the muscular wall of a coronary artery clamps down and narrows the vessel, sometimes severely, and sometimes without a speck of cholesterol, let alone a mass amount of it causing a blockage. Blood flow drops, the heart muscle complains, and you get real cardiac chest pain. If the lack of blood flow is bad enough you get ECG changes, and, if it goes on long enough, real damage. However, in most cases the vessel relaxes and everything, including the tests, goes back to normal. It's not something an emergency room can find unless you have such a bad case of it that your ECG changes show up exactly how a heart attack does. Then, you quickly get rushed to the cath lab where they are expecting to have to put in a stent, but sometimes end up seeing no atherosclerosis and nothing to stent at all.

As I will delve into more next week with the full post, most of us in medicine were only taught one version of this in basic classes: Prinzmetal's angina, a dramatic form that announces itself with a specific ECG pattern and tends to get caught because it looks like a heart attack in progress. However, as I am learning, this is not the version most Western patients have. The commoner form is quieter, more diffuse, and much easier to mislabel, which is exactly what happened to me.

Is coronary artery spasm dangerous?

My research on this for the article has just begun, but what I am seeing is that among people with real angina whose arteries look clean on imaging, provocation testing finds a vasomotor problem, spasm of the large vessels or dysfunction of the small ones, in a clear majority. So, this is not as rare as one would first think. It is under-looked-for, probably because you need the most expensive and most invasive test available to cardiology to find it. Untreated, it is not benign: over years it carries a real risk of heart attack and death, and it keeps sending people to emergency rooms that run the standard workup, find nothing, and send them home. Most of these people, myself included, are told that this is anxiety. However, as I learned, the most common BP med that also helps anxiety can worsen the attacks. Meanwhile, the medication used to treat vasospasm works just as well for blood pressure and is cheap and readily available.

Why I write, revisited

I started Calibrated Signal because I was frankly pissed off. I was angry that I had been doing all the right things and spending all the money on a sophisticated longevity routine and I still ended up needing a stent. I'm building a tool as part of my PhD project that systematically grades and weights longevity interventions by mechanism and evidence strength and I will be offering a consumer version of this. I write because I realize that that is the only way to get the word out there. I sit at an interesting intersection of someone that has formulated the supplements and written the marketing copy for longevity and wellness routines. But, now I sit on the other side, as a clinician-scientist and someone angry that I almost died in my 40s yet thought I was optimized. Most of my future writing will be aging biology, grading interventions, exposing conflicts of interest, and helping you make wise decisions. But, intertwined with that will be my personal perspective on patient advocacy. How to argue for yourself when you are being told something that you feel is off. Most people accept the first treatment handed to them. Even I, with all my advantage, almost continued to take a treatment that was actually making the problem worse and accept that anxiety had just gotten the best of me. Trust your gut if you feel like something is off and never be afraid to ask for a second opinion.

So the writing continues, with more resolve than I had last month. The plan does not change: I will take the complex topics apart carefully, one at a time, including the longevity interventions everyone is selling and almost nobody is auditing. What changes is how personally I hold the assignment. Somewhere out there is a reader with episodes their workup cannot explain, halfway talked into a label that does not fit. This post is for them, and if your symptoms involve chest discomfort, so is the more detailed one coming up.

What I changed

• I stopped accepting "anxiety" as a diagnosis of exclusion for a symptom nobody had finished excluding things for.
• My treatment changed to match the actual disease, starting with a medication class that relaxes the spasm instead of one that can aggravate it. The details of that, and why drug choice matters so much in this condition, are next week's post.
• I got my baseline documented, on my own ECG and my own wearables, so every change from here is measured against data instead of memory.

The Final Signal

• Two years of post-stent chest pain, a clean workup, and several satisfied cardiologists still added up to the wrong answer.
• The right answer, coronary artery spasm, could only be seen by provoking it live in a cath lab, a test I nearly declined.
• A mislabel is not neutral: the anxiety story chose my medications, and one of them can make this condition worse.
• Spasm is a clear-majority finding when properly looked for in unexplained angina, and untreated it carries real risk. The details, with the evidence, are in the next post: how coronary spasm is diagnosed in the cath lab, and why the test is rarely run.
• If your symptoms are real and your workup is clean, but your gut tells you something is still off, do not be afraid to get a second opinion (or maybe even a third). Your health is truly in your hands. Not your doctor's.