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Forum Name: Valvular Heart Diseases

Question: Chest pain


 arowland25 - Thu Apr 05, 2007 6:07 pm

Hello. I am a 28 year old female. My health history includes endometriosis (2 surgeries) and gallbladder removal last year.

About 1 month or so ago I started having sharp stabbing chest pains. The pains were near and around the heart. My family physician diagnosed me with reflux....after treatment, we concluded it was an incorrect diagnosis. I have been to the ER 3 times for this chest pain. The day that the first pains came about I was just sitting on the couch watching tv and the pain radiated from my back shoulder blade to my chest, along with shortness of breath. I've had blood work, EKG's, ABG, CT w/dye of my heart at the ER's all came back fine. Next stop was the cardiologist. He did an EKG, echocardiogram & a Stress Echocardiogram. The echo showed that I have mild tricuspid regurgitation and mild mitral valve regurgitation. I could not get my heart rate up as high as he wanted me to during my stress echo. So when they tried to do the ultrasound of my heart, my heart rate dropped quickly. He put me on 25 mg of toprol-xl 1x daily. My blood pressure has always been around 120/80 and now with the toprol it has lowered greatly. I start on 1/2 of the 25 mg toprol tomorrow.

The toprol seems to work ok, but I still have mild chest pains. And of course all chest pains are scary...which is what I don't like!

My question is does the pain sound like tricuspid & mitral valve regurgitation? And is there any other drug out there that will not lower my blood pressure, but help my chest pain?

I am thinking about having children and am also worried about the effects of my heart on the pregnancy.

Sorry to make this so long! I appreciate your help!

Mandy
 John Kenyon, CNA - Fri Apr 06, 2007 12:22 pm

User avatar Hello Mandy - While your symptoms are a mixed bag, the likelihood is that they are not due to coronary artery disease both because of your age and gender and because of your description of the pains.

One possible structural cause could be mitral valve prolapse (MVP) which can often be difficult to diagnose definitively because the "gold standard" requires an echocardiogram which shows one or both leaflets prolapsed or redundant; a "click" murmur, and non-specific ST-T wave changes on a resting EKG. With those requirements it is very difficult to nail the thing down. Many doctors, however, will go with a presumptive diagnosis of MVP if the symptoms are consistent with the syndrome. Having sharp, stabbing chest pains, especially at rest, is one from the long list. Shortness of breath (paradoxically with reasonable exercise tolerance) is another. Fatigue and palpitations are also common. MVP is reported most often among young, otherwise healthy females. So that is one possibility. The fact that your symptoms seem to have responded to the Toprol also would help support a presumptive diagnosis of MVP since there is mild mitral regurgitation also.

Given the likelihood of MVP syndrome (if not a concrete diagnosis of MVP) a beta blocker would be the first line medication to be used (and often the only one). Toprol is an excellent choice as far as that family of drugs go, usually having the least side effects.

Sometims MVP frustrates the doctor because it is difficult to meet all the criteria for a definite diagnosis, and the symptoms can be quite diverse. Sometimes people with this syndrome will also have occasional migraine headaches or optical migraine (visual disturbances without the headaches). Anxiety is often prominent as well. Has any of this ever happened to you?

My best guess, given the information you've supplied, is either MVP syndrome or possibly something irritating the diaphragm (hiatal hernia?). It seems at least that there is nothing life-threatening going on, but you should continue to follow up as needed, or if the symptoms increase or change.

Best of luck to you and do keep us updated.
 arowland25 - Fri Apr 06, 2007 2:39 pm

Thank you for your reply! I greatly appreciate it! When all of the chest pains started, I did have the palpitations, shortness of breath and anxiety. We tried to treat the anxiety by itself...but had no luck. With MVP, would toprol stop the chest pain?

I've had a lot of chest pain last night and today and it has caused a lot of anxiety. We're supposed to be travelling this weekend, but I just can't do it with the chest pain.

How is coronary artery disease diagnosed? I just want to make sure that was ruled out. I've had just about every test done! EKG, Echo, Stress Echo, blood work, Ct scan, so I can't imagine they could have missed something! lol!

Also can mitral & tricuspid regurgitation cause the chest pain I described?

Thanks!!

Mandy
 John Kenyon, CNA - Fri Apr 06, 2007 3:23 pm

User avatar Hi again, Mandy - You are very welcome. The additional information you've provided convinces me more than before that you likely are experiencing one of the common variations on the theme of MVP Syndrome (which can be diagnosed without a diagnosis of actual MVP - although this remains controversial in some quarters). Results are what matters, really, so long as there is no life-threatening problem, and I don't believe there is.

Generally what helps the pain and other symptoms is a combination of a beta blocker (Toprol is my personal favorite because of generally fewer annoying side effects), a guided fitness program and management of anxiety and/or panic. Usually this will bring MVPS-related pain under control, and the Toprol should have some fairly immediate benefit. It doesn't do it in every case, but many people have benefitted from just the beta blocker therapy.

Coronary artery disease is usually diagnosed via a series of tests, starting with a simple 12-lead EKG. If that shows nothing specific then a stress test either with echocardiogram or nuclear scan comes next. If this yields no positive findings then for most people that's where the search for CAD ends and the hunt for a resolution of the symptoms begins. That's where you appear to be now. If, for some reason, the stress echo exam had yielded some positive results (and remember, in diagnostic medicine "positive" is what we don't want to see), the next step and gold standard for diagnosing CAD would be to move to an angiogram, where a catheter is intruduced through the femoral artery and up into the heart, contrast dye is injected, and real-time pictures of the coronary vessels can be made and studied. This is (so far) the last, best way to rule CAD in or out, but only if there is some good reason to take that step. There has been nothing turned up in your workup that would warrant this, so MVPS seems by far the most likely cause.

It is worth noting that people often say "But I didn't have this before!" Often the symptoms of MVPS don't show up until young adulthood, and often they are associated with some emotional or physical stressor that is out of the ordinary for the individual. Other times it just starts up for no apparent reason. Either way it's treated first with a beta blocker, and sometimes also with one of the benzodiazapine family of drugs, like Xanax or Klonopin, at least temporarily, to ease the anxiety that often accompanies the symptoms.

To answer your final question, mild mitral or pulmonary regurge should not, by itself, cause chest pain. The connection between apparent MVP and most of the symptoms is extremely unclear, as most of the symptoms involve not the heart itself, but the autonomic nervous system (which in turn can affect the heart's behavior). What has been established is that there is some sort of statistical corelation between the two (although not all people with MVP have symptoms). Also, chest pain characterized as sharp and/or stabbing is rarely associated with CAD, which usally will produce fairly insidious, longer-lasting, constricting pressure, deep aching, or crushing sub-sternal pain. "Sharp and stabbing" is very often reported with MVPS. It also often is located in the left chest instead of beneath the breastbone as in most cases of symptomatic CAD.

I hope this helps clarify the picture for you. You've had a very comprehensive cardiac workup, so it is very unlikely that anything was missed. On the other hand, something telling, although essentailly innocent, was uncovered. The symptoms strongly suggest MVP syndrome. No one can declare this with certainty at a distance, but, given the excellent workup and your description of the symptoms, it is pretty much a textbook description of MVP syndrome, which is definitely not life-threatening, although it can be, as one authority on the subject has put it, "lifestyle threatening", mainly because of the anxiety and uncertainty it causes, the unnecessary worry and consequent fear of doing a lot of the things one would normally do.

It's hard when you've got a very literal pain going on, to tell yourself it's unimportant. We are wired to react to pain as though something is wrong. In the case of MVP, though, the thing that is "wrong" is actually the pain itself. Toprol hopefully will put a major dent in the pain and other symptoms as well.

Good luck to you and pleae keep us updated.
 arowland25 - Fri Apr 06, 2007 3:36 pm

Thank you so much! I appreciate your detailed answers. They've put my mind at ease.
 John Kenyon, CNA - Fri Apr 06, 2007 3:38 pm

User avatar You're very welcome. Good! I'm glad all those words were helpful. I hope you have a wonderful weekend. :)
 arowland25 - Fri Apr 06, 2007 3:42 pm

Hi again! I'm sorry I forgot to ask something!! Last time I promise! haha!

Can the pain associated with MVP be on either side of the chest? I get pain on the left side and then sometimes on the right side. I also at times have pain that radiates to the shoulder & back.

Mandy
 John Kenyon, CNA - Fri Apr 06, 2007 3:59 pm

User avatar No problem! While the pain associated with MVP can occur on either side of the chest, most people tend to point to the left breast. However, I have encountered people whose pain was more random and some whose pain followed the typical cardiac pain route (center to left, then down the arm). Since yours occurs in different places at different times there is also the possibility (I think I mentioned this early on) that it is referred pain from something irritating the diaphragm. I still think MVPS the most likely explanation though.

I should ask you: is any of this pain worsened by breathing or upper body movement? (This would disqualify it as any sort of heart-related pain and lead toward an orthopedic cause). Just curious.
 arowland25 - Fri Apr 06, 2007 4:08 pm

Hi! I don't think the pain comes with movement. Usually the pain comes and goes as it pleases.
 John Kenyon, CNA - Fri Apr 06, 2007 4:40 pm

User avatar Got'cha. At least you won't have to branch out into those areas. It's just a question I should have asked but didn't. :)
 Leanlife - Thu Jan 08, 2009 10:40 am

I was riding a stationary bike at the gym after i finished i walked down the stairs and twords the front door when an electric shock type feeling went through my center chest twords my arms it only lasted like a heartbeat and was gone? It felt like someone hit me with a sledgehammer.
 John Kenyon, CNA - Thu Jan 08, 2009 9:03 pm

User avatar The sensation you describe would not be cardiac pain, but may have been a premature heartbeat, probably a PVC, which was more pronounced in your perception of it because you had been exercising. Often these will occur during cooldown, and when the cardiac output is higher. This could account for the odd "eletrical" sensation. It was most likely an errant PVC felt acutely. Let us know if this happens any more, and if so, if it feels the same way. I think this was an innocent event.

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