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Forum Name: Cardiology Symptoms

Question: Severe Chest Pain - DES? Strangulated Hiatal Hernia? Angina?


 Dorothy - Sun Mar 07, 2004 9:08 am

I am a 46 year old female, a smoker, and overweight.I have been having severe chest pains for about 4 years which are now increasing in frequency to 3-4 times per week. I'm not sure if they are cardiac or GI in origin. About 6 out of 10 times the pain occurs while eating/swallowing. The pain is located about mid-sternum and is very sudden and severe and is accompanied by dizziness, cold and clammy skin, and most of the time with syncope. My husband witnessed one of these yesterday and said it lasted for about 20 seconds. He said when I passed out my eyes rolled back and my arms bent at the elbows and came in toward my chest as in spasms. When I "came to" I was awake and alert with no post-ictal symptoms. I have a remote history (1998) of post head injury seizures (grand mal and absence). I have been symtom free since 1999. Other medical history is positive for hypothyroidism and HRT for TAH/BSO.

I've been reading about GERD and Hiatal Hernia with Strangulation and also Diffuse Esophageal Spasms. I wonder if one of these could be the cause. I do not have heartburn or other symptoms of GERD. I need to add that I do have a very high tolerance for pain but this pain is absolutely excrutiating. I have a strong family history of cardiac disease (father died at 42 from MI, mother had 2 MI's in her 50's). I have mild MVP and palpitations. As mentioned, a little more than half the time it occurs when I am eating but has frequently happened while driving, walking, sitting, sleeping, etc. I am calm and relaxed when it occurs. Position does not affect the pain. When the pain begins I do of course pull over if I'm driving.

I would appreciate your input very much.

Thank you in advance,
Dorothy
 Dr. Yasser Mokhtar - Sun Mar 14, 2004 11:53 am

User avatar Dear Dorothy,

i assume that you have seen your doctor for those chest pains and/or went to the emergency department. i would like to know what were the things that were done and their results and the opinion of the doctors at those instances. i would also would like to know if you ever had any stress test or echocardiogram. Have you tried any medications like nitro under the tongue for the pain?Have you tried any medication for heart burn? Do you have other risk factors for heart disease besides smoking and obesity like family history of coronary disease, hypertension or diabetes?

It looks that you have severe pain to the extent that you pass out. You have to seek medical attention and find out the reason behind this pain.

Waiting for your reply.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 Dorothy - Mon Mar 15, 2004 7:56 am

Dr. Mokhtar,

Until just a few weeks ago, I had no health insurance so I have not sought medical attention for the chest pains nor have I told my doctor about them. I see my doctor only once per year for med refills (Premarin since 1984, Synthroid since 1998, and Celebrex for arthritis since 2003, and daily low-dose aspirin since 2003 because of long-term HRT). The reason I have not told him is because I knew he would order a variety of tests which at the time were completely out of the question due to the lack of insurance.

I have not tried nitroglycerin for the pain (can it be obtained without prescription?). I have tried antacids which did nothing. After the pain is gone, I do not have any residual pain or other symptoms. I don't have any symptoms of GERD such as indigestion, heartburn, or reflux. I do not have hypertension or diabetes. During a pregnancy in 1982 I did have an echocardiogram, stress test and a 24-hour holter monitor which revealed mild MVP with PVC's. I was not placed on any meds or treatments for this. I do have what I presume are PVC's (frequent palpitations) and my doctor has noted a mid-systolic click on physical exam (MVP). I have occasional swelling of my feet and legs up to my knees with pitting edema for which I take Lasix as needed. This occurs only a few times a year and no other symptoms accompany it.

I do have a strong family history of cardiac disease, however. My father died at 42 from MI (with prior CVA) and my mother had 2 MI's in her 50's and died of MI at 61. My brother has had non-insulin dependent diabetes since the age of 25. Both paternal and maternal grandparents all died from cancer (colon, esophageal, lung CA). There is no other significant medical history.

Again, thank you so much for your reply. I hope this additional information will help. I'm somewhat relieved to hear the passing out may just be from pain. (although I'm surprised since I tolerate pain very well).

Dorothy
 Dr. Yasser Mokhtar - Mon Mar 15, 2004 11:16 am

User avatar Dear Dorothy,

Thank you very much for the update.

With this strong family hisotry of yours, i would advice you to seek medical attention regarding this pain and don't neglect it any further. Patients with mitral valve prolapse are known to experience atypical chest pain especially if they eat large meals. The features of the pain that you are having are somewhat atypical for coronary disease. But still, i would advice you to see your doctor and follow his advice reagarding the approach that he wants to follow to figure out the cause of this chest pain.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 Dorothy - Thu Sep 01, 2005 6:39 pm

After a battery of cardiac tests, all of which were negative, I finally insisted on a referral to a Gastroenterologist. I had an Upper GI study - negative. I then had an esophageal motility study (which measures the pressure in the esophagus). ..... Lo and behold they figured out what was wrong. It turns out that my severe chest pain was due to a relatively rare condition called 'Nutcracker Esophagus'.

Nutcracker Esophagus causes extreme chest pain as severe as angina. In a nutshell (pun intended), and from my layman's understanding of the condition: The normal pressure in the lower 1/3 of the esophagus should be about 40mm. The esophagus contracts and relaxes (peristalsis) in order to move food, liquid, saliva down the esophagus into the stomach. In my case, instead of having a normal pressure in the 40mm neighborhood, mine was at 190mm. And this was at rest with no pain occuring. This high pressure causes the esphagus to contract with extreme force and, subsequently, severe pain.

There is not a definitive treatment for Nutcracker Esophagus but in some cases Procardia has shown some success. Procardia is normally used to decrease the strength of the heart's contractions. Since the heart and esophagus are both muscles, it sometimes helps with Nutcracker Esphagus. In my case, my chest pain symptoms have decreased from 20+ per month to 4-5 per month. Excellent! The drawback is that because the heart's contractions are also affected by the Procardia, edema and hypertension are a problem. This is taken care of by anti-hypertensives (Diovan) and diuretics (Lasix).

While I'm happy the doctors finally figured out what was wrong, I sure wish they had listened to me when I suggested it might be DES - Diffuse Esophageal Spasms. They would have helped me a year ago.

One last sad update. I mentioned in my family history that I had a brother with insulin dependent diabetes. He passed away 6 months ago at the age of 35 of a massive heart attack.

Good luck to all and keep looking until you find a doctor who will listen to you.
Dorothy

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