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Forum Name: Cardiology Symptoms

Question: Chest tightness/occasional sharp pain under sternum/etc


 camber - Sun Nov 09, 2008 7:21 pm

34 year old male, no family history of heart disease save one grandfather who was undoubtedly exacerbated by smoking. Don't drink, don't smoke, no recreational drug use, high moderate level of activity (fencing 2x per week for 2+ hours)

About a month ago, I started having episodes where my heart rate elevated from a completely resting position (120-130bpm, sometimes higher). Went to the ER, had EKG/blood work (I don't know the full details but I know it screened for heart damage and thyroid issues) as well as a chest X-ray and CAT scan with and without dye.

There has also been a second ER visit, about a month later with similar symptoms, EKG and bloodwork were done again with no abnormalities.

Was disagnosed with panic disorder (which I do have a history of, but had fully resolved itself a few years back. Started Lorazepam as needed, switched to Clonazepam for a longer duration of help, and have just started on sertraline this past week.

My daily life now consists of a dizzying variety of symptoms, including:

1) Burning sensation in my chest, across both sides of the pectorals; pressing on my chest will make the burning worse when that happens. (This happened to me last night, and I was able to walk down a slope for 2+ miles with no shortness of breath or other symptoms)

2) Pain in my left arm/wrist/fingers sometimes going up to the shoulder (this has been diagnosed by my PCP as the beginnings of carpal tunnel, but it doesn't seem to be dependent on the activity level of that arm, and it doesn't exist on the right side)

3) Feeling of extremely hot skin along my face/neck/shoulders

4) Pain up the left side of my neck sometimes accompanied by a throbbing pulse.

5) Occasional "shooting" pains in my chest, usually at the right side of my sternum.

These all occur when I am completely at rest and have no anxiety triggers to speak of. I don't get anxious UNTIL I feel one or more of these happening for a while.

Shortness of breath is notably absent as a symptom, except when I get super anxious and start breathing faster due to that.

With the anxiety, of course, every one of these when they happen makes me want to run to the ER, but as I am still waiting for new insurance to kick in, that's a spendy proposition. At the same time,

Every single day, I am hitting one or more of these symptoms, and it's having a drastic effect on my daily life. I've spoken to my PCP about all of these symptoms and have been told "your heart is fine, you don't need to be worrying this much".

Should I be trying to push harder for more testing to be done? In particular, I didn't have an electrocardiogram; is there a possibility that something might show on that that hasn't shown on the testing done previously?

It is just difficult to chalk up all of these various symptoms to being "just symptoms of a panic attack", especially when I don't feel panicked until well after they start.
 camber - Tue Nov 18, 2008 11:39 pm

Not sure if bumping is against the rules here, so I'll add some information instead:

I had an "episode" this morning that I couldn't successfully describe to the doctors at the ER today while I was seated on the bus; the symptoms I CAN describe include massive anxiety and feeling very flushed, but there was another feeling that preceded both of those that I still don't know how to describe, aside from "really unpleasant".

EKG looked fine at the ER, and they tested all the usual things for a possible cardiac event as well as doing a CT scan for a possible pulmonary embolism; all came back negative.

Even now, though, I feel nauseous and am having a little trouble breathing, along with feeling flushed. Yet every time I go to the ER, they can't find anything.

I did wear a 48 hour Holter monitor last week as well as a 24 hour urine test to check for a possible tumor overstimulating the adrenal gland. No results back from those tests yet.

Am I going insane? I have a past history of panic attacks but these just feel different and my body just doesn't feel right.
 John Kenyon, CNA - Thu Nov 20, 2008 10:58 pm

User avatar Hello -

While you describe a galaxy of symptoms that most likely are attributable to panic disorder and/or mitral valve prolapse syndrome (MVPS) or both, it is unreasonable for a doctor to "diagnose" you as simply an anxious patient (which you undoubtedly are or have been) when you present with potential cardiac symptoms (even if they are "only" anxiety-related) without having performed an EKG.

While I truly believe, based on your description of your symptoms, that they are likely as above (either anxiety or MVPS or both), if MVP is at the bottom of this it would certainly be helpful to know, as addition of a beta blocker (low dose) might well help and work well with either clonazepam or sertraline to manage the symptoms and help you feel more safe and secure. And of course, if the EKG did show up some other extraneous and unlikely factor, well, we always need to remember that even anxious patients can also get sick. This tends to slip the minds of many healthcare providers. At any rate, taking the little extra time and care just once, to set your mind at ease, could save everyone a lot of worry and time and exense in the long run.

Hopefully this helps put things into perspective for you. Please feel free to follow up with any other questions or to update us. Thanks for using this site to find your answers. Best of luck to you.
 camber - Thu Nov 20, 2008 11:02 pm

Thanks for the followup, Mr. Kenyon.

I think maybe I wasn't as precise in my language as I should've been, though; I've had several EKGs (which all showed as normal) but not the one that is the actual heart imaging.

I've also had a 48 hour Holter monitor (which I'm waiting on the results of).
 John Kenyon, CNA - Fri Nov 21, 2008 11:22 pm

User avatar You're very welcome.

I may have misread your post, also. At any rate, consecutive normal resting EKGs are certainly a plus. The Holter results should be surfacing soon, and they should be interesting even if they show nothing (which would help build a case for anxiety disorder as the underlying cause). So what you haven't had done, then, is an echocardiogram. Well, that certainly wouldn't hurt, again if only to rule out any structural heart problems. Anything that either points to a problem (which then can be addressed) or rules one out (thus setting your mind more at ease) is going to be helpful and this wouldn't be an unreasonable thing to expect.

By all means let us know when you have the Holter monitor results so we can discuss them. Best of luck to you.
 camber - Wed Nov 26, 2008 12:04 am

Mr. Kenyon:

Just to follow up, I got a call from my PCP about my Holter monitor results, and he said that aside from a few rare premature beats that everyone gets from time to time, everything looked normal.

In addition, the urine testing for pheochromocytoma came back negative as well.

However, I am still getting these "episodes" from time to time (once a week or less) that I can't explain, that the Holter didn't capture.

The symptoms, as best I can describe them:
1) Flushed feeling, especially across my shoulders and neck
2) Sudden extreme anxiety/inability to sit still
3) Feeling like I need to sit forward/fidget.

There's no pain or chest tightness associated with them, and I usually feel fine within five minutes after or so (although there's sometimes some residual "what the heck was that" anxiety).

What could be causing something like this to happen? I do know that I was at the ER once and had the feeling I am describing, and the yellow alert light on the bedside heart monitor went off; but no one came rushing in to check on me or anything along those lines.

My PCP is awesome, but his response to my description of these symptoms was "I have no real idea what that might be".

They definitely don't feel like the panic attacks I am used to, but it's not impossible it's just a different "flavor" of them than normal.
 John Kenyon, CNA - Wed Nov 26, 2008 2:05 pm

User avatar Hi there -

This is actually quite helpful, as the triad of "new" symptoms you describe here is another set of things that are classic, at some point or another, for PD, GAD and MVPS. With the latter (and sometimes actually a cause of the former), we sometimes see what's known as dysautonomia, which can either be a result of MVPS/anxiety/PD or, perhaps, causes or triggers it. What dysautonomia means, literally, is "dysfunction of the autonomic nervous system." The autonomic nervous system is that part which controls a lot of normally unnoticed functions, such as heart rate and output regulation, moment-to-moment blood pressure regulation, and even dilation of blood vessels, especially capillaries in the skin. While this can be an essential and physical (though poorly understood) syndrome, it is also definitely a part of various anxiety syndromes. These are all inter-related, including MVPS. In some clinics MVPS is simply called dysautonomia, as there is often no evidence of MVP, yet the same symptoms are present. The symptoms change often, also, which is frustrating as can be, and are either the product of, or the cause of, much anxiety.

The flushed feeling across your neck and shoulders is extremely common in people with any combination of these problems, as is the sudden, spiked level of anxiety; needless to say, the feeling the need to lean forward at these times goes with the triad, and is less well understood, but probably has something to do with a sense of being able to breathe more easily or perhaps is an anticipatory posture poised for "fight or flight", which is where all these feelings become confused in the temporal lobe of the brain. One senses a threat and is prepared to run, although to where and from what is not exactly clear.

Again, this is all classic, it is benign, but since it's new it will command your attention for a while. Once you've become more accustomed to it and perhaps even begin to ignore it, often the process will shift to some other set of equally odd and functionally pointless sensations. It's very difficult to subjectively recognize these things as a rule, because they keep changing their "colors" periodically, or, worse, adding to their "repertoir." Ideally what is most helpful is for the affected individual to learn to maintain the presence of mind to evaluate and dismiss these things as meaningless. unfortunately, the snap responses often elicited by chronic anxiety (and always in the panicky patient) make this nearly impossible, at least in the short run. This is why I so often recommend a referral to a psychotherapist who specializes in cognitive behavioral therapy (CBT), since it is an education and re-training process rather than endless "talk" therapy, and the patient actually has "homework" which helps, along with the sessions, in learning how to recognize and manage the symptoms. Often it results in a dramatic improvement and even if the symptoms persist, the patient no longer reacts to them the same way, but learns to evaluate what is going on calmly and once this is accomplished, the symptoms no longer have the power to control the patient. Anti-anxiety medication sometimes works well in combination with CBT.

Your PCP is technically correct to say he has "no idea" what might be causing these symptoms, since they fit no ordinary medical paradigm for illness. However, many seasoned MDs will recognize these as part of the classic anxiety/dysautonomia picture and refer accordingly. If your doctor doesn't do this you may ask for an appropriate referral or seek effective help independently.

This can be a long, annoying process, but in the end you'll wind up with a lot of valuable self-insights that are gratifying, not to mention the fact that you'll feel in control of your life once again.

Best of luck to you. Please stay in touch.
 camber - Wed Nov 26, 2008 7:13 pm

Mr. Kenyon:

Thank you again for your responses! You've been a great source of information to help me better understand what is happening, since while my PCP is an excellent doctor, he sometimes isn't the best at detailed explanations.

I'm pursuing CBT on my own after talking with my doctor, but I'm already making good strides with short-circuiting my thought processes and getting myself to be less anxious; accepting that I will get these strange feelings from time to time, but that they are not going to hurt me and that they will pass.

The sertraline is definitely starting to have a noticeable effect as well, and I'm already tapering down the benzodiapines and hope to not have to use them at all going forward.

Things are definitely looking up!
 John Kenyon, CNA - Thu Nov 27, 2008 2:07 pm

User avatar You're very welcome. This is all very good news and it sounds as though you're one of the few who have gained a good deal of insight and objectivity regarding the anxiety issue, which makes you much more likely to progress faster and learn to manage, if not entire shut down, the circuit of anticipation and consequent shifting symptoms. I'm sure you'll do really well with this.

My best to you, and please update us from time to time.
 camber - Sat Dec 13, 2008 11:23 pm

Well, things had been going well for a while...but over the last four days, things have taken another interesting turn.

I wake up fine in the morning; in the late morning/early afternoon I start to get a heavy feeling in my chest, with occasional pain near the side of my sternum (usually on the right side though, not the left).

Then in the evenings, I start getting very noticeable palpitations. I can actually, when at rest, see my stomach vibrating in time with my heartbeat.

No shortness of breath still, or anything like that. However, my benzodiapines don't really help much either, so I have to just wait it out.

Does this merit another doctor's visit, or is it just a new tactic for the anxiety attacks?
 John Kenyon, CNA - Sun Dec 14, 2008 1:13 pm

User avatar Hello again-

I think this is probably the anxiety "talking" in a new symptomatic dialect, and certain of the symptoms can be explained as (relatively) normal. Still, given the fact that even an anxious person can have physical problems, and because reassurance of the concrete kind is so helpful in the setting of anxiety, that I think it might be worth a trip to the doctor anyway.

Those symptoms are, to a great extent explainable. For instance, the ability to see your heartbeat by looking at your stomach while lying on your back is actually so normal as to be almost universal. While a very pronounced pulsing may be cause for concern, the problem is interpreting the word "pronounced" against a background of anxiousness. Again, almost anyone can see this pulsing when lying supine, with or without palpitations. Palpitations, by the way, occur most commonly (in otherwise healthy people) in the evening, after the evening meal and close to bedtime, two times when the vagus nerve is active, stimulated, and trying to slow the heartbeat, which always predisposes to premature heartbeats. This phenomenon is normal.

Some palpitations happen to be felt by some people during periods of utterly normal sinus rhythm (NSR), so the word loses a little of its meaning. If they are only felt as distinctly "missed" or "skipped" beats (both are misnomers, but make good descriptors of the sensation) it is more meaningful, but no more serious. These are still normal. And again, they happen most often in healthy people later in the day or evening, especially after dinner and before bedtime.

The heavy feeling in your chest deserves the appropriate attention, in your case perhaps an echocardiogram, as pretty much everything else has already been done. If you were to learn via echo that you have mitral valve prolapse (MVP) it might actually ease your mind, since it is a benign condition that is often accompanied by chronic anxiety and panic disorder, so that could explain a lot. If it doesn't show up, however, then that's one less thing that's not exactly normal, so it would be a win-win. The right-sided sternal-edge pain sounds like it is probably costochondritis, something that responds to simple over-the-counter non-steroidal anti-inflammatories such as ibuprofin (Advil), and if it can be reproduced by manual pressure on the spot, and if it does not radiate to the shoulder, arm, neck or back, then it is probably nothing of concern.

So given this information, I'd still make a doctor appointment and while there explain what's been going on, if only so you can be told you're fine. There's nothing wrong with that kind of news. You might also mention that the benzodiazepines don't seem to be working well and ask if there is something else that might warrant a trial.

That's about it. Hang in there. You'll have better days and worse ones with anxiety as an underlying problem, but on the whole it seems you're doing quite well and just require some occasional reassurance. There's nothing wrong with that.
 camber - Thu Jan 15, 2009 9:24 pm

Doing better these days as far as the anxiety goes, but I do have one new symptom that is puzzling me.

I get tightness (no pain, just tightness/pressure) across my chest, concentrated above the level of my sternum, a couple of times a week. My doctor thinks it's connected with the anxiety issues, even though I don't have any feelings of anxiety that go along with it.

I tried a muscle relaxant (Flexeril) to try to help with it, but didn't get much relief; if anything, my Clonazepam helps more, as does regular aspirin, but neither of them gets me enough relief to be comfortable when it happens.

My doctor prescribed Prednisone to see if it's an inflammatory issue that might be helped by that medication, but I'm leery of Prednisone after reading about some of the potential side effects.

At the same time, it's pretty uncomfortable (I'd describe it as someone tightening a metal band around the upper part of my chest), so I'm willing to try just about anything at this point.

I'm past the point where I think it's anything cardiac-related with all the testing that has been done, but maybe it's worth revisiting? Should I maybe seek a second opinion, or try to self-refer to a cardiologist just incase something got missed?
 John Kenyon, CNA - Fri Jan 16, 2009 11:31 pm

User avatar The sensation is an interesting variation on an anxiety theme, and one thing I do like to stress is that even anxious people can get sick or have physical problems. Sometimes doctors do tend to begin to attribute frequently changing complaints to anxiety (and usually they are right), but there is a certain value in exhausting some of the aresenal of tests to ease the mind of the patient and confirm beyond any reasonable doubt that there's nothing else going on. For that reason I think it would be not unreasonable for you to have both an echocardiogram and stress test, if these haven't already been done by now. I think the current chest symptom does sound like a variation on an established theme (anxiety), and it is telling that Flexeril doesn't help as much as clonazepam. If it is actually inflamatory musculoskeletal in nature, the steroids will probably make it go away; the most likely side-effects would be increased heart rate, increased tension, possible flushing (or sunburned appearance on the face and chest) and slightly increased blood pressure. These effects could last up to a week, but if they relieved the primary complaint that would prove several things: first, that the problem is superficial and physical, and second that you can know what to expect from steroid therapy, and this might actually help you to recognize anxiety symptoms via cause and effect, since if your chest symptom is anxiety-based, again, the anxious person is usually the last to realize this fact. It's a very frustrating feature of anxiety that we tend to deny its presence or totally fail to recognize it. This actually makes sense, since it's a status we live with for such a long time it becomes like "background noise" and we tune it out unless it's punctuated by panic attacks.

I hope this is helpful to you. Please continue to keep us updated. I think the steroid "experiment" might well be worthwhile, at least so long as you're aware of the possible side effects of short-term steroid therapy as outlined above.
 camber - Mon Jan 19, 2009 9:13 pm

Well, the weird (or not so weird depending on your point of view) thing is that I tolerate exercise just fine. I fence recreationally, which is pretty demanding of the cardiovascular system, and I don't have any problems at all.

And my perceived level of anxiety has improved markedly since starting the sertraline; if there's "background noise" anxiety that's causing these symptoms, I just need to figure out how to better manage the symptoms, because they aren't making me feel anxious enough that I'm doing silly things like rushing to the emergency room, anymore.

Still, discomfort is discomfort and I want to get to where I can feel "normal" as much of the time as I can. Hopefully the steroid experiment will get me there, and help me and my doctor figure out how to manage these symptoms long-term.

Thanks again for all of the follow-up!
 camber - Sun Feb 15, 2009 8:05 pm

Mr. Kenyon:

Not sure if you're still watching this thread for comments or not, but I got a copy of my medical records today and there were a few things in there that I want to ask some questions about, and see if you think I should get evaluated additionally.

I'll preface it by saying that we've moved up to 50mg on my sertraline as of the last few days, but I'm still having lots of chest tightness, in addition to severe left arm pain/ache and the occasional palpitation (still no real pain in the chest itself though).

Here's the things I'm curious about:

1) On two of my four ER visits, they did a D-Dimer test on me, and it was "elevated". They did CT scans both times and found nohing there to worry about. There is a part about "tiny exophytic probable small cyst in the left upper pole kidney" noted, but I gather that's a minor thing.

The D-dimer level on the one test was H 0.87 mcg/mL with a "ref range" of 0.22-0.50, so about .30 higher than the top of the ref range.

On the other, it was 0.74, again slightly higher than the norm.

The other two times, it was normal.

2) The EKGs they did on me Show some concerning things:

All of them show sinus tachycardia, but that is to be expected since that was my initial comlaint with all of these visits.

However, they also show things like (on various of the EKGs, these are all the things I see that I don't know what they mean):

[SR] - [Now Absent] Sinus Rhythm
[QT] 328 - [SIGR] Significant Rhythm Changes
[QRSD] 96 - [REPDI] - Nonspecific Repol Abnormality, Diffuse Leads [Remains]
PR 160 - [ETRSR1} - RSR' in V1 or V2, Right VCD or RVH
T -5, T -15 = Abnormal Confirmed under Axis (on two different ones)
T -46 - Abnormal ECG (this was from the time that was probably the worst)

The 48-hour Holter monitor seemed to be pretty normal, with one thing I am wondering about:

There were 55 "brady runs" (I am assuming this is bradycardia), with the longest being 23 beats, and the maximum brady rate being 42.

This is a lot of word salad to me, but the consistent message from my primary doctor and all of the ER personnel has been that "everything is normal, you're fine", and yet I'm seeing a lot of "elevated" and "abnormal" and other disturbing words.

If you're able to take a look through this, it'd be greatly appreciated; I'm contemplating getting a second opinion but at the same time, I have a lot of faith in my doctor and trust that he is looking out for my best interests. At the same time, there's a lot in here that LOOKS out of the scope of normal to a layman's eye.

Appreciate any help you can give!

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