One ‘marvellous’ GP’s role in a mystery heart illness

After a series of heart crises with an uncertain diagnosis, you could be forgiven for withdrawing a little from life.
 
But that is not Gwen Brett’s way.
 
A warm, genial resident of Bathurst in regional New South Wales, the retired nurse has made it her mission to raise awareness of a heart condition that bamboozled a succession of health professionals – and which she credits her GP for helping her to get through.
 
It began in spring 2023 with tightness in the chest and shortness of breath when Ms Brett and her new GP, Dr Marcus Hayward, agreed something was not right.
 
From there started a chain of symptoms, events and appointments long enough to cause anyone’s optimism to run thin.
 
There was an inconclusive ECG, a visit to the dentist for jaw pain, followed by a cardiologist appointment and a heart stress test. She was then sent to hospital for an angiogram, which found an 80% blockage in the right artery, and had a stent fitted.
 
Days later, she felt severe pain while talking on the phone and called an ambulance. Another angiogram at the hospital found nothing wrong, with the stent suspected.
 
She went to stay with family in the Blue Mountains, but the ‘absolute excruciating pain’ returned, Ms Brett recalls, and she was in a different hospital for five days. Again, there was no definitive diagnosis, with the stent believed to be stretching an artery, and she was put on beta blockers.
 
They did not have the desired effect. Around this point, she believes her angina became vasospastic.
 
‘That was the big difference. It was just doing it on its own while I was asleep, waking me in the middle of the night when I was just minding my own business sleeping,’ she told newsGP.
 
A further ambulance ride and hospital stay later, she had myocardial perfusion imaging (MIBI scan), and a visiting cardiologist told her she suspected Dressler syndrome, as well as myocardial infarction with non-obstructive coronary arteries (MINOCA).

It did not mean much to Ms Brett (‘I thought it was an island in the Caribbean somewhere’), who continued to feel poorly.
 
The events carried on, including, worryingly, a heart attack in the chemist while picking up a script.
 
During another hospital visit outside of Bathurst, takotsubo cardiomyopathy (broken heart syndrome) was suggested and she was prescribed cognitive behaviour therapy and an antidepressant  – which then induced further angina.
 
It marked a particular low point for Ms Brett, who began to despair and feel her pain was being dismissed.
 
Following every episode of acute care, she relied on Dr Hayward.
 
‘His gentle encouragement and particularly his faith in me when some experts were dismissive … has kept me from giving up altogether,’ she wrote in a letter to the RACGP to express her gratitude.
 
‘After each exhausting event, his kindness has sustained my will to carry on.
 
‘He has helped me navigate a sometimes confusing and contradictory health system and without this support my chances of survival would be greatly compromised.’
 
It was a cardiac arrest, coinciding with the Bathurst 1000 race, that finally led to a definitive diagnosis, with Ms Brett only just calling the ambulance in time.
 
‘I thought, “oh gee, they’ll be busy with all those thousands of people in town”,’ she said.
 
‘I put it off because I didn’t want to bother them. And anyway, I rang, they came pretty quick, got me in the ambulance, and within four minutes I had the arrest.’
 
She was fortunate a highly experienced paramedic came to her aid.
 
‘He captured the torsades pattern on his ECG and flew into action, knowing that a cardiac arrest was imminent,’ Ms Brett recalled.
 
‘Seconds later it hit, and he performed CPR and defibrillation, which saved my life.
 
‘I will never forget him.’
 

Ms Brett had a long wait before she had a clear diagnosis.

Two contrasting angiograms followed, one in Orange showing an 80% artery blockage, another following a transfer to Concord Hospital in Sydney, when the blockage showed at just 30% – a strong clue that her illness was not due to obstructed arteries.
 
After she had an acetylcholine challenge, MINOCA was confirmed as well as ischemia with no obstructive coronary arteries (INOCA), a condition linked to vasospastic angina and other arrhythmias.
 
She was also fitted with an implantable cardioverter-defibrillator (ICD).
 
For Dr Hayward, it has also been a learning experience.
 
‘It was the first time I came across it,’ he told newsGP.
 
‘It’s an under-recognised condition, and I realised just how under-recognised it is.
 
‘GPs being aware of it could absolutely make a difference if they have a patient they know well who seems to be not getting the answers or the outcomes they need.’
 
A 2024 Medicine Today article suggests up to 10% of ischaemic events might be due to INOCA and warns that patients with INOCA/MINOCA may be at risk of major cardiac events.
 
This, the authors write, makes ‘GP awareness of vasomotor disorders crucial for delivering optimal preventive therapy and risk factor management’.
 
While Dr Hayward is a reluctant recipient of public praise, he acknowledges the privilege of a role where ‘people appreciate us going to work and doing what seems like our job’.
 
‘I wasn’t the one that picked up on the vasospasm, or the INOCA/MINOCA,’ he said.
 
‘But validating Gwen’s experiences and helping her communicate with specialists and paramedics through ambulance care plans, just listening and supporting has been just as important and clearly valued by her.
 
‘It’s another one of those lessons that we get regularly: that we can never know everything.
 
‘What worked in her circumstance was persevering and asking questions when she still had symptoms or where we felt like we didn’t have the answers that completely made sense.’
 
He also played another important role, referring Ms Brett to Gosford-based cardiologist Professor Tom Ford – one of the authors of the Medicine Today article, and a specialist in the conditions.
 
It followed yet another traumatic event for Ms Brett, when paramedics did not understand the right response for her condition, which can be worsened with usual emergency heart medications.
 
Later, she learned she had suffered polymorphic ventricular tachycardia leading to anterolateral STEMI during the event – with her ICD preventing it from progressing to a cardiac arrest.
 
Dr Hayward helped with an ambulance care plan, while Professor Ford gave her a protocol for future emergencies, which she says gives her hope.
 
Bit by bit, she has been returning to activities that bring her joy, including Dancemoves – a government-funded rehabilitation program – along with the Bathurst parkrun, yoga, ballet and writing.
 
She is also determined to raise awareness of the condition.
 
‘Now I’m on the way and on a mission to spread the word and help with any research that can be done on it,’ she said.
 
As well as hoping for an easier way to diagnose INOCA/MINOCA, Ms Brett continues her recovery – working closely with Dr Hayward of course.
 
‘In the end, I have gradually built strength and resolve with his genuine interest, sensible cautions and positive response to each small achievement,’ she wrote.  
 
‘He has so lifted my spirits.’
 
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cardiac arrest cardiac disease heart disease INOCA MINOCA polymorphic ventricular tachycardia polymorphic VT torsades de pointes