Hey David , I’ve got a case I’ve been thinking through that’s a little strange. There’s a confirmed angina diagnosis, and he also had acute pancreatitis diagnosed in the ER within the past year ( just the once) What’s throwing me off is that the angina is really food-triggered. Certain meals, especially carb-heavy ones, will reliably set it off. He gets the classic pressurized pain in his left upper quadrant that is so severe, he'll be in tears, and has to sit down in order for it to subside. Nitric oxide also brings improvement. It just doesn’t feel like a straightforward angina pattern to me. Would you think about this more as postprandial demand on the heart, or start looking at pancreatic/hepatobiliary involvement playing a role here?

I am following up on this. I'm wondering if perhaps it was missed?

Response coming shortly!

David said: Pancreatic insufficiency would cause reduced amylase secretion, but I cannot recall ever seeing this cause angina. There is in the literature a rare syndrome where severe pancreatitis can cause angina-like pain with ECG changes, but I have never encountered a case. Pancreatitis can also trigger hyper coagulability which can then reduce blood flow to the heart. Is he having pancreatitis symptoms? If not, I would be surprised if this is directly pancreatic in nature. On the other hand postprandial angina is much more common. The increased blood flow to the digestive tract, decreases cardiac blood flow.

David said: Here is a good review article on the topic: https://www.jacc.org/doi/10.1016/S0735-1097(17)35826-6

He does not have the classic symptoms of nausea, vomiting, fever, etc. they only found the pancreatitis in an ER visit for chest pain. However, since the visit, his amylase has been consistently elevated.