Her maddening cough had an unexpected cause | Medical Mystery

Constance Meyer’s hacking cough was driving other people crazy.

For more than a year, 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.

“That cough’s going to give me a heart attack!” quipped one father, a doctor who had accompanied his young son to a lesson.

Meyer’s own doctors couldn’t agree on a cause. One attributed her chronic cough 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.

“I often wonder what would have happened” without her involvement, Meyer said.

For decades, the veteran session musician with more than 200 notable performances, including on the soundtracks of the movies Dreamgirls and Ghostbusters and with the Kirov Ballet and Tony Bennett, worried about the illness that had stalked her family.

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 three miles a day, Meyer was proud of her low cholesterol and blood pressure readings. “I’ll walk up seven flights of stairs instead of taking an elevator,” she said.

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 got worse.

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 your symptoms.”

The doctor thought Meyer might have asthmatic bronchitis, although she had never been diagnosed with asthma, a chronic lung disease that results from inflamed and narrowed airways.

Meyer was prescribed an inhaler along with prednisone, an 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 skeptical. “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.

“I’m a squeaky wheel about other people’s problems, but not about me,” Meyer said. “We had a friend here one night for dinner, and I was coughing my head off, and he said, ‘I’m really worried about you.’”

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.

In March 2024, Meyer switched primary care doctors and began seeing an internist who specializes in geriatrics. Meyer said she coughed through the appointment and told the new doctor she was occasionally short of breath. The doctor ordered a standard echocardiogram, an ultrasound test that traces blood flow through the heart and its valves.

The echo, the geriatrician told Meyer, 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 that 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 and by video visit, because he was recovering from the coronavirus.

“He promised to throw everything including the kitchen sink” at her year-long cough, Meyer recalled.

The lung specialist 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.

Megan Y. Kamath met Meyer in the summer of 2024 when her 5-year-old daughter began violin lessons.

“She was very endearing and reminded me of my own violin teacher, whom I adored,” recalled Kamath, an assistant clinical professor of medicine at the UCLA David Geffen School of Medicine. “I just felt this pull.”

Meyer’s hacking was impossible to ignore. 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 nonmedical 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 following month with a cardiologist at the University of California at 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 fueled 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. She was in the middle of a lesson when the cardiologist called with the results and told her to start taking a baby aspirin, double the dose of her statin, and schedule a CT coronary angiogram, an imaging test that provides detailed views of the coronary arteries.

“I was a little bit in shock,” Meyer said. “I didn’t think I’d have a heart condition. I was always waiting for the shoe to drop with cancer.”

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 called a stent to keep it open. The night before the Sept. 17 procedure, Kamath called to wish her well and offer some advice: If Meyer’s cough got worse or if she experienced any symptoms such as chest pain, she was to go to the ER immediately.

“I remember she told me three times,” Meyer said.

Meyer assured Kamath she would. Four decades earlier, a relative died of a massive heart attack in a New York City hospital the night before scheduled heart surgery.

The outpatient stent procedure found an 85% blockage of the artery. Doctors determined that Meyer’s 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.

As Meyer and her husband were driving home hours after the procedure, she realized she hadn’t coughed once. Her cough has not recurred; a subsequent CT scan showed no sign of lung disease.

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.

“It took me sitting down with her for a while to make me think this was cardiac,” Kamath said. “That may not have been the case if somebody had 10 minutes” for an appointment.

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.

“A lot of times, doctors get focused on one particular diagnostic pathway,” Kamath noted.

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.

Kamath said she tells her patients “there’s nothing that will replace a good physical exam, and that’s why they have to come in.”

Meyer’s unquestioning acceptance of what doctors told her also seems to have worked against her.

“I think she minimized things,” Kamath said. “I try to encourage patients to be proactive about their care, and I emphasized this to Constance.”

Meyer said she was rattled by her experience. She said she didn’t know she was at risk for heart disease, which she thought was a male problem. And she remains surprised that doctors didn’t focus on that aspect of her family history until she raised it.

As a result, Meyer said, she is trying to be as assertive in medical encounters as she is in other parts of her life.

In October, a month after her stent placement, she wrestled with whether to keep a previously scheduled appointment with the ENT who had attributed her cough to reflux.

“I didn’t want to hurt her feelings” by calling it off, Meyer said. “My husband said that was absolutely ridiculous. So I canceled it.”