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Forum Name: Cardiology Symptoms

Question: Extreme Chest Pain (left side) and Left Arm Tightness


 cjn - Wed Dec 31, 2008 9:12 am

Hello. I hope you can provide me some insight for my situation.

For about 3 months now, I have been experiencing anxiety problems and chest and left arm pain. This first began to manifest itself when I contracted mono from my 6 month old nephew (end of September). I would have small bouts of extreme nervousness and anxeity which I read online can be caused by mono, so I just passed it off as a symptom and thought it would pass once the mono had ran its course. However, I never really had any other symptoms from the mono...I would get tired but I could still manage to do all my daily activities, which included exercising and full 8 hour work day. My doctor gave me xanax to help wih the anxiety and I went on my way.

Well, during the month of November, I noticed that these panic attacks became more frequent (daily) and always seemd to revolove around when I would eat (when I would get hungry or after I eat a large meal). The "attacks" aslo seemed to change from just feelings of anxeity to total exhaustion, EXTREME dizziness and lightheadedness, a "flushing" or adrenaline rush feeling over my body for 30 to 45 mintues at a time, difficulty remembering and speaking at times and chest pain and left arm tightness began. So, I decided to go to a cardiologist and they gave me an EKG, Echo test and Stress test...all of which came back normal. I still kept having the attacks, but I would just take xanax for them which I don't like doing because they just make me fall asleep.

Now to current, at the beginning of the month of December, the "attacks" changed again to what feels like im about to have a full blown heart attack and they seem to get worse each one I have. I can be doing nothing or in the middle of telling a joke and almost instantly, my left arm will tighten up, chest will begin to almost "clinch" and then pulse with pain (right over my heart on the left side), breathing becomes difficult or tight and I get dizzy and confused easily. As a result of this new, more difficult to handle "attack", I went to the emergency room becasue I thought I was about to pass out during one of them. They ran and EGK, did blood work, CT scan of head and X-ray of chest and all came back normal. They said to visit a nueroligist, so I went and had him run blood work for a possible thyroid imbalance...however, it came back normal too.

This brings me today (12/31). I had an extremely bad attack yesterday and it has lingered since 6pm last night to this morning. While my symptoms are not as bad (mainly becasue I have taken 1mg of xanax) they are still around. I am at a stand still as to what to do next. This has become a debilitating problem as I cant leave my house without a xanax in my pocket and I am afraid to go to out and have fun for fear of the next attack since they are progessively getting worse. I hate taking Xanax becasue it just puts me to sleep or makes me "foggy". One important fact is that I have only had to stop exercising once because of an "attack"...usually I can workout without any problems but the one time I did have to stop, I felt like I was going to pass out IMMEDIATELY once I began running on the treadmill. I don't workout if I feel like I am about to have one of these attacks. I have to take my xanax before bedtime so that it will still be in my system when I workout in the morning...otherwise I wake up with the symptoms I mentioned earlier.

I have two questions:
1. Do I need to see a psychologist or specialist for anxiety or is this possibly a physical problem that I have not addressed or been tested for?
2. Is there any drug that you would reccommend I can suggest to my general care doctor that would work better than Xanax at managing these "attacks"?



A few things about me and my family:
- father had a heart attack at 39, triple bypass at 49
- sister is diabetic and wears an insulin pump
- grandmother died of heart attack at 72
- I have had high cholesterol (once at 253) but took lipitor for some time and lowered it to 151. I stopped lipitor once I began having these problems
- I have used drugs and alcohol in th past but never been addicted, it was more a social and weekend thing
- Despite the sporadic alcohol and drug use, I workout and diet daily...I have done this since I was 15
- I have ran 2 marathons in the last year (12/07 and 2/08) and participate in sprint triathlons and 5-10K, often on the weekends
- I work as a motgage banker, which can be very stressful but has never been an issue in the past
- I am 30 years old, single male with a MBA and also help run a start up business...all of which sounds stressful but I find fun and enjoyable


Thank you for time and any insight you can provide.


-C
 John Kenyon, CNA - Wed Dec 31, 2008 12:45 pm

User avatar Hello -

First, thanks for your detailed and comprehensive post. While there are things in it that would naturally be suggestive of a heart problem, that seems to have been ruled out -- for now. Since you have a history of elevated cholesterol and a family history of early heart disease, I would suggest you restart the Lipitor at once, as that is one of several things you have working in your favor (your lipid reduction was typically dramatic, and that's how you want it to stay).

As for the symptoms, they are somewhat different from most panic attacks in that they mimic more accurately a "real" heart attack -- almost to a fault, actually. The fact that the pain is felt over your left chest would lessen the likelihood of this being heart related, but that's now been more than ruled out anyway. Panic attacks can certainly cause very real chest pain (usually felt on the left side, by the way). This is partly due to tension, partly due to unwitting use of accessory muscles in the course of hyperventilating (again, usually unwittingly, sometimes knowingly but because the subject believes he is not gettiing enough air), and partly due to muscle tetany secondary to hyperventilation (which can also cause sensations of numbness or tingling in the hands and around the mouth, along with lightheadedness).

The fact that you generally tolerate your daily workout with no symptoms is one more argument against heart disease (at least active heart disease, again noting your family history, which means you'd be wise to be followed by a cardiologist on at least an annual basis). The "last nail" would be that all this responds to Xanax. The problems with Xanax are several, although it is a most excellent "rescue" drug. First, it is primarily a rescue drug intended to abort panic attacks, not prevent them, and secondly, it can have a strong sedative effect in many people, as you have experienced. I wouldn't ditch them, as they may carry you through an awkward situation while out (or at home for that matter), but you definitely could benefit from both something to (temporarily at least) stabilize and perhaps prevent the attacks (either an SSRI antidepressant, any one of several could be tried) or clonazepam, a long-acting relative of Xanax which is a maintainance drug and is taken twice a day to ward off panic attacks. My personal preference is the latter, since the side-effects are minimal (generally less or no noticeable, significant sedative effect); While SSRI meds work well for many people, they are slow to "kick in", usually require some dosing adjustment, and can, in people with acute anxiety problems, actually exacerbate the issue during early use.

All this could be worked out with a psychiatrist or psychopharmacologist, in conjuntion with a therpaist who specializes in cognitive behavioral therapy (CBT), a self-limiting, interactive form of psychotherapy which actually teaches the patient how to manage the problem (in your case panic attacks, in others either generalized anxiety or depression), and then, given those tools, the patient can avoid open-ended talk therapy which can go on for years. (Nothing wrong with talk therapy, but CBT has its place also).

I would stress, however, restarting the Lipitor ASAP, and having an annual cardiolgical checkup because of family history. Other than that, in order to get back to enjoying life to the fullest, you'll need to get this current problem under management, and the plan spelled out above, I think, would probably work wonders. I don't think your MBA and startup business status need be overly stressful at all, although some insight into where it might be (via CBT) probably wouldn't hurt and might actually aid in the enjoyment of it. Mainly, you need to be able to enjoy all aspects of your life, and panic disorder will certainly bring things to a screeching halt. Foruntately it is manageable, if not technically "cureable" and the proper medication (with Xanax kept handy for breakthrough symptoms early on) and CBT, together could pretty much eliminate this before it begins to really hamstring your life.

Best of luck to you. Thanks for bringing your questions here, and please follow up with us as needed.
 cjn - Wed Dec 31, 2008 4:01 pm

Thank you for the quick reply. It was very helpful.

I do have one more question I forgot to ask earlier. Why do I get these panic attacks at odd moments? Or why do I get them when im not stressed out?
It seems logical that I would get them when I am very busy at work or having stress in a relationship, but I don't. I get them while im daydreaming at work or watching TV at home....it literally happens in seconds. It is this inability to determine when I might have another one that makes it so tough to manage and adds to the symptoms...

Thank you again.
 John Kenyon, CNA - Thu Jan 01, 2009 12:05 pm

User avatar You're very welcome and you pose an excellent question -- for which I just happen to have an answer, since this is a very common issue for PD sufferers.

While panic attacks can be brought on by situational stress or an upward anxiety spiral, they are most notable for their apparently coming "out of nowhere." They are extremely common when seeming nothing untoward is going on. There is some controversy about why this is, with some arguing it is the result of subconscious concerns playing out "under the radar", while others suggest, rightfully so, that panic attacks are a seizure-like event, originating in the temporal lobe of the brain, and so can come on without any intellectual content being involved. I strongly suspect both are right and probably more often than not it is a combination of the two, but based on observation alone, I tend to favor the second explanation as being the more common one. This would account for why this problem responds so well to certain anti-seizure drugs, specifically clonazepam. In either case, you are far from alone in wondering about this, as it is a classic part of the usual panic attack patient's narrative.

I hope this answers your question. Good luck to you.
 cjn - Sun Jan 04, 2009 12:39 pm

Thank you agsin for responding to my last question. You have been extremely helpful. I think ive learned more from your replies than visiting all the different doctros ive have seen through the course of all this.

I did have one more question and it is about the Xanax. I didnt stress in my initial reply that since these attacks became more serious in the beginning of December, I have to take the Xanax everyday. I have the 1mg blue generic ablets (alprazolam) and I usually break them up into quarters or halves and take 1 qtr in the morning, one in the afternoon and then a full half before bed. If I don't do this this, then it almost like clock work, I will get them above mentioned symptoms everytime. I have to carry one in my pocket incase the last dose I took itsnt enough and doesnt completely work...and this happens about every two or three days too (one of these happened on 12/30 and then prompted me to write my initial post that morning on 12/31). Is it posible to just feel like this permenantly? And not necessarliy have it just in an "attack" form that comes and goes? (the chest pain, shortness of breath, exhaustion, over all depressed feeling and high anxiety). I wanted to make sure it was understood that I basically have to live on the Xanax to function.

Thank you once again.

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