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- Mon Aug 02, 2004 1:48 pm
I apologize for the length of this message.
My name is Tony and on the morning of Dec. 30, 2003 I had a quick sharp pain in the center of my chest. After this I had tightness in the center of my chest almost like someone pushing hard into the center of my chest and I became very anxious. This occurred around 9:00 am. After dealing with the chest tightness and pressure all day I began to really worry and went to the ER. I was seen between 7:00 and 8:00 P.M. They did blood work: complete bld count, thromboplastin, blood urea, creatinine, glucose, electrolyte and CREATINE PHOSPHOKINASE CPK, CREATINE KINASE MB, TROPININ I. I also had an ekg, and two chest x-rays. Blood pressure at the time was 118/70. Everything was normal I was told and the diagnosis of pluerisy was given. I was told to make an appointment with a cardiologist.
I went to see my new Dr. of Internal Medicine. I had a resting EKG performed followed by a stress test/ekg. Both were normal. I was having symptoms during testing and even had a small panic attack during the stress test. My blood pressure reading at the beginning of my visit was 108/70. My Dr. said the tests were fine and my exercise tolerance was great. He didn't feel it was necessary for further testing to rule out heart problems and asked me to come in for a follow up in two weeks. He was confident that it was not heart related because of the tests performed and because the chest tightness and discomfort was constant for a couple weeks straight.
I had a follow up visit with the Dr. two weeks later after my initial visit on Jan. 6. Between the times of my next visit I continued to lift weights and even use the stair stepper for exercise pretty intensely with no increase in discomfort or other symptoms. On my two week follow up I explained that I was having anxiety over this. No further testing or answers to the problem were given until I told him I was really worried that this was heart related. He mentioned doing a Nuclear Cardiac Sestamibi stress test and told me not to worry but anything was possible (false negative on stress test) and this should clear the air on the heart concern. I opted to wait a while longer for a few reasons, the costs associated even with my insurance, the hope it was just anxiety and the great fear I have of needles and intravenous catheters. The dr. told me to continue my prescription of imipramine 50 mgs and xanax 1mg. and see if that helped with the problem. I had just started ag!
ain after having stopped for about three weeks. These were prescribed by my neurologist for headaches and anxiety. I was actually on tofranil pm 100 but had begun to wean myself off prior to beginning again with imipramine. Because he did not press the issue of further testing and said to try the medication for awhile led me to believe that he might think it was anxiety related.
This is causing great anxiety and panic. I am now having full blown panic attacks because I think I am going to have a heart attack. I used to have these with my migraines because I thought they were tumor or aneurysm related. I have noticed some light aching in my lower teeth and jaw which I have had with migraines before. I also have sharp pains in my upper back which have been present for a couple weeks too. These back pains are very noticeable when my wife pushes on my back. Every little odd feeling causes me great concern. The chest tightness and pressure may be a little better than it was two weeks ago at times. Every time I get on the internet it seems I have all the symptoms of a heart attack.
Brief history and symptoms:
Chest tightness, pressure and occasional sharp pain under left nipple and in center of chest, anxiety, breathlessness, some jaw discomfort with head pains. Pain in upper back.
Male, 35 years old, married with one four year old son
5'8", 210 lbs.
Chest discomfort does not change with exercise or rest.
Blood pressure o.k.
Father is 58 with controlled high blood pressure and cholesterol. Mother has no health issues.
Grandfather had by pass in his late sixties, died in his eighties from cancer.
I used to smoke about two packs cigarettes a week for about 6 years. I have quit for over a year now.
Tightness and discomfort are not brought on by exercise or relieved my rest.
A little tenderness in my ribs under left arm close to my left nipple I believe is new.
I have been severely depressed for sometime and have anxiety problems.
Currently being treated for headaches and anxiety with imipramine and xanax.
I had been on tofranil pm 100 and occasional xanax for five years which helped relieve my chonic headaches and anxiety. Recently stopped tofranil before onset of problems. I thought everything was under control.
My job is very stressful, I trade stock and options from my home.
Some shortness of breath, or I feel like I have to take a deep breath in the middle of sentences but I have been able to do 20 minutes on the stair stepper with no problems.
…….In March of 2004 I went ahead and asked for a Thallium Nuclear cardiac study from my internist. He didn’t think it was necessary and he spoke with my cardiologist who did not think anything would show up but agreed to let me do it for piece of mind. I received the results a few days later and everything was negative and looked fine. I was very happy. About a week later all of my symptoms disappeared, the tightness in my chest, the back pain, the tooth pain and my panic attacks. I resumed my life. I even started working out again weight training four times a week for about 45 minutes followed by aerobic exercise for another 20 minutes. This was my routine four days a week with no problems whatsoever. The stress in my life continued, I am a high stress person and I probably need to learn some coping skills.
This brings me to July of 2004. I began to feel some tightness in my chest when breathing in again. This happened around the time I was having a cold or bad allergies. Not really that bad but I did say to myself I hope this isn’t starting again. A few days later it progressed to constant tightness and pressure, more pronounced with deep breathing. I can do the stair climber for a strenuous 20 minutes and get my heart rate really up with out the symptoms really getting worse but last time I tried to jog it seemed the tightness did get worse. I did get more anxious pushing myself doing some jogging. I was breathing in and out much harder from the jogging and I don’t know whether the heavy breathing made the symptoms worse or not. I went to the dr. and I had an asthma test, check up and chest x-ray, all of which were normal. This constant tightness has been going on now for eight days straight now. It is definitely worse when I take a deep breath but it is not a pain. It is a sensation of tightness and pressure. I have had some aching in my shoulder blades and my upper back too. It’s as if everything has started all over again.
Well this has been constant now for two weeks. My Dr. said angina or symptoms of CAD do not last 24 hours a day. He assured me that after having three to four ekg’s, a stress test, and a thallium nuclear cardiac study, and taking into account all of my symptoms and history that he was very comfortable that this was not heart related at all. He didn’t think an angiogram was warranted at all when I asked about one and he believed that my cardiologist would not perform one based on my history. (They work in the same office and correspond on my treatment) He mentioned again that I might want to see a psychiatrist. I don’t feel like a psychiatrist is necessary. The symptoms set me off. I am worried that it is heart related but I don’t understand how I could have had all these symptoms before, have them go away for four months, exercise as hard as I did with no problems and then it starts again and be heart related. Is it possible? This new chest tightness and pressure did not come on with exercise. I do feel like my stress levels as of late are very high. Is it possible for someone to have chest tightness from stress like someone gets a tension headache? I am beginning to get anxiety because of this. What about the upper back pain? Could the back pain be heart related (angina) or just stress, tension and anxiety? The part that bothers me so much is the symptom I have are exactly like those described as angina, heart attack or CAD on the internet. I am also having what feels like muscle cramping in my upper abdomen and when ever I wake up this awful tickle feeling down my throat when I breathe in. Should I be comfortable with the diagnoses I was given, especially with the addition of the negative nuclear cardiac study? Does any of this sound heart related? Will taking deep breaths cause more discomfort with heart disease? Taking a deep breath causes the tightness and pressure to worsen. Is it possible for angina or CAD, etc to cause chest tightness 24 hours a day for days on end? This lasted about 9 weeks last time and I a scared to death at this point again. Should I have more testing? Thank you in advance for you help.
| Dr. Yasser Mokhtar
- Fri Aug 06, 2004 4:07 pm
Determination of whether chest pain is of cardiac origin or not depends on risk factors that the patient has for coronary disease and the characteristics of the chest pain itself.
The risk factors for coronary disease are
1. Family history of coronary disease in young family members.
4. Being a male.
5. Age. Older people are more prone to heart attacks.
8. Sedentary life style.
9. Some drugs can cause heart attacks in young people such as cocaine.
So, by looking at your profile, you don't have a family history of coronary disease, you don't have hypertension, diabetes, you are young and you don't smoke and you don't use any drugs. So, no risk factors there
You are a male. One risk factor. But you have to put in mind that you are less than 50 years of age.
About your lipid profile, your ldl is high but your hdl is high as well, so these two cancel each other out.
So, when we look at your risk factors, you practically don't really have any except may be for being a male. Your risk factors have not changed since last march since you had the negative thallium study.
About the characteristics of your previous and current chest pain, these are absolutely atypical for chest pain of coronary origin. If someone who has chest pain of coronary origin and he/she climbs stairs or walks or does any kind of exercise, most probably he/she would have developped a heart attack and you did not. So, your chest pain is 100% atypical.
When someone without risk factors comes with atypical chest pain, then there is very low probility that he/she has coronary disease.
Your pretest probability was very low to begin with and you had a negative stress test and a negative thallium just a few months back which means that you did not have coronary disease at that time.
Since your risk factors did not change and your chest pain is still atypical, you still don't have coronary disease.
And the real question is what is the cause of the chest pain you are having and how to treat it so that you stop worrying like this.
Chest pain has many causes. Your chest pain might be related to inflammation of the membranes surrounding the lungs and/or the heart leading to increase in the pain when you swallow. Please, if you have not tried yet, go ahead and use an anti-inflammatory like iboprufen and the like.
Another cause could be acid reflux disease especially with the back pain. Try an antacid and see whether it makes any difference in your symtoms.
Another cause which might also cause chest pain is neck spine problems, so i would recommend at this time to take a look at your neck spine with an x-ray to rule this cause out.
If you are breathing too fast and/or coughing a lot, then your muscles will be strained and believe it or not, they can give rise to severe pain.
Other causes include panic attacks and that is why i think your doctor wants to send you for a psychiatric evaluation.
Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.
Yasser Mokhtar, M.D.
- Fri Aug 06, 2004 4:51 pm
Thank you for your response. I meant to say I had a Myoview cardiac study but i guess they are pretty much the same. Chest tightness/pressure continues but sometimes I don't notice it. The back pain around my shoulder blades continues too, aching for minutes at time and I certainly feel like I might have a panic attack because of my symptoms. My symptoms certainly seem atypical but worrisome none the less. I guess I need to find out what is really causing these symptoms. Thank you again.
- Fri Aug 06, 2004 4:57 pm
Not sure if I was mixed up with someone else but my cholesterol was 290, ldl 210 and hdl in the 60's if that makes much of difference.
| Dr. Yasser Mokhtar
- Fri Aug 06, 2004 5:26 pm
Thank you very much for the updates.
Regarding your lipid profile. These are the numbers that i based my analysis on, your ldl is a just little bit high (-ve risk factor) and your hdl is actually high (+ve risk factor) so both cancel each other out.
Try antacids even though you don't have heart burn because many of chest pain cases that we see nowadays are secondary to heart burn.
Thank you very much for using our website http://doctorslounge.com and i hope that this information helped and if you have any other question or concern, please, don't hesistate to post them.
Yasser Mokhtar, M.D.