Despite seeing multiple doctors and underdoing various treatments over the course of a year, an American woman’s hacking, persistent cough was never correctly diagnosed – until a chance intervention from a pupil’s parent nailed it down to a serious cardiac problem.
Music teacher Constance Meyer’s hacking, chronic cough was driving other people crazy. For nearly 18 months, it had been the soundtrack of her life, disrupting the violin lessons she was giving, waking her up at night and irritating family and friends who were baffled by its imperviousness to multiple treatments.
Her doctors couldn’t agree on a cause. One attributed it to asthma, another implicated her age, then 71. A third blamed acid reflux.
It wasn’t until the mother of a new student delved more deeply into her symptoms and medical history that the cause was unmasked – intervention that may have saved Meyer’s life, reports The Washington Post.
Cancer threat
Meyer’s mother died of ovarian cancer at 45. Her maternal grandmother was only 35 when she died of breast cancer. Meyer said her fear was diminished, but not eradicated, when she tested negative for the BRCA genetic mutations that cause hereditary breast and ovarian cancer.
Her health, fitness and diet were priorities. A vegetarian who doesn’t touch junk food and walks at least 5km daily, Meyer was proud of her low cholesterol and blood pressure readings.
So in the spring of 2023 when she developed a dry cough, sometimes accompanied by wheezing, without a precursor cold or other respiratory infection, she assumed it would go away.
Instead, it worsened.
After about three months Meyer consulted her longtime internist who ordered a chest X-ray, which was normal. There was no evidence, her doctor wrote, of pneumonia, scarring or other condition causing her symptoms.
The doctor thought Meyer might have asthmatic bronchitis, although she had never been diagnosed with asthma. She was prescribed an inhaler along with prednisone, the oral corticosteroid that reduces inflammation. The medicines seemed to help, but only briefly.
“The cough got really horrendous,” Meyer recalled. “My husband was going out of his mind.” He was also sceptical. “He has asthma and said, ‘It’s not asthma’.”
But for reasons Meyer now finds difficult to explain, nine months elapsed before she sought treatment again, even though her cough was sometimes so unrelenting it left her doubled over.
Meyer, whose father was a doctor, said she figured the cough was something she had to live with. She felt fine otherwise and had not missed a day of teaching. To ease her symptoms, she took her prescribed medication, guzzled numerous cups of tea with honey and consumed family-size bags of cough drops.
A trio of referrals
In March 2024, Meyer switched doctors and began seeing an internist who specialises in geriatrics. She coughed through the appointment and told the new doctor she was occasionally short of breath. The doctor ordered a standard echocardiogram, which looked “fantastic” and uncovered no abnormalities. She advised Meyer to come back if her symptoms didn’t improve.
When Meyer returned in June, her internist was on leave. The doctor filling in for her referred Meyer to an ear, nose and throat specialist and a pulmonologist.
She also recommended Meyer see a cardiologist after Meyer offhandedly mentioned a fact in her medical records: a family history of heart problems. Her father had the first of three heart attacks at 58, and both of Meyer’s grandfathers died of heart disease, one at 61.
Meyer saw the pulmonologist first who ordered pulmonary function tests, which were normal, and a CT scan of her chest, which was not. It showed possible signs of mild interstitial lung disease, a progressive condition that causes lung scarring and a dry cough. And he added two more inhalers to her asthma regimen.
Meyer’s CT scan also revealed moderate coronary artery calcification, a common finding in people over 70 and a risk factor for heart disease. She began taking a statin, a drug that lowers cholesterol and reduces the risk of heart attack and stroke.
The ENT, whom Meyer saw a few weeks after the pulmonologist, focused on something new. She suspected that acid reflux might be contributing to Meyer’s cough. She added two anti-acid medicines, recommended a low-acid diet and told Meyer to sleep with her head elevated to reduce reflux.
Meyer, who calls herself “a ridiculously compliant patient”, said she did everything she was told. Her cough did not improve.
A pivotal encounter
Megan Kamath met Meyer in 2024 when her five-year-old daughter began violin lessons. Kamath, an advanced heart failure and transplant cardiologist, noticed that the violin teacher coughed when she walked across the room but not while sitting.
Violating her long-standing personal rule against asking acquaintances medical questions in non-medical settings, Kamath asked Meyer a few questions, then arranged a phone call to discuss the matter further.
Meyer, grateful for the assistance, told Kamath that the cough, now in its 16th month, was extremely bothersome, that she was seeing several specialists, and that she had an appointment the next month with a cardiologist at the University of California Los Angeles.
“Do you mind if I try to move this up?” Kamath remembers asking. “I think this needs to be looked at sooner.”
Kamath said her concern was fuelled by her suspicion that Meyer’s cough didn’t stem from asthma or lung disease but was a cardiac cough, the sign of a potentially serious heart problem. Meyer’s CT scan and family history indicated she was at risk.
Kamath spoke to a colleague who agreed to see Meyer sooner. The cardiologist ordered a stress echocardiogram, a test performed while walking or running on a treadmill. Unlike a standard echocardiogram, it assesses how the heart performs during exercise.
Meyer’s test, which was stopped early, was abnormal.
The angiogram revealed a severe blockage – estimated at 90% to 99% – of Meyer’s left anterior descending artery (LAD), which supplies about half of the blood to the heart. Her other arteries were clear.
A severe blockage of the LAD can cause a heart attack known as the “widowmaker” because of its high fatality rate. The survival rate for a widowmaker that occurs outside a hospital or similar facility is only about 12%. And despite its name, widowmakers affect women.
One of the most common symptoms of a blocked artery is angina or chest pain. But Meyer had none.
“Her dry cough was her anginal equivalent,” Kamath said. “Constance was a ticking time bomb. She could have just dropped dead suddenly.”
Meyer was scheduled for an angioplasty, a procedure to open the blocked artery and place inside a tiny metal coil – a stent – to keep it open. The night before the 17 September procedure, Kamath called to wish her well and offer some advice: if Meyer’s cough got worse or if she experienced any symptoms like chest pain, she was to go to the ER immediately.
Findings
The outpatient stent procedure found an 85% blockage of the artery. Doctors determined that her heart function is otherwise normal. She shows no signs of congestive heart failure, a common, chronic and usually irreversible condition that occurs when the heart’s pumping ability is impaired.
Why did multiple doctors fail to suspect a heart problem?
“Women can present very differently than the arm numbness, chest pain, elephant-sitting-on-the-chest feelings described by men,” Kamath noted.
Too often, she added, their symptoms “are dismissed or not even looked into”.
The time pressures under which doctors operate, the cardiologist said, may have been a factor.
Anchoring bias, a common cause of medical errors in which doctors focus on a single piece of information early in the process without considering subsequent data, may have played a role.
Then there’s the possible role of telemedicine, which can impede close observation, an essential clinical tool. The pulmonologist never saw Meyer in person – every appointment was virtual.
“Nothing will replace a good physical exam, and that’s why they have to come in,” Kamath tells patients.
Meyer’s unquestioning acceptance of what doctors told her also seems to have worked against her.
“I think she minimised things,” Kamath said. “I try to encourage patients to be proactive about their care, and I emphasised this to Constance.”
See more from MedicalBrief archives:
Even low levels of air pollution linked to heart damage
AI detects pneumonia through hearing a cough – Korean findings
Drug that eases symptoms of chronic cough may become first new therapy in 50 years
Telemedicine: The end of the physical examination can mean losing touch
New early warning test for coronary artery disease