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Forum Name: Cardiology Diagnostics

Question: Constant chest pains


 ltunes - Wed Feb 16, 2005 4:49 pm

I'm 31 female experiencing chest pains since Aug/04. The pains are dull in the upper left section of my chest. They spread to my left shoulder and sometimes to my arm. I also experience shortness of breath and this is present even without the pain. These pains typically last less than 10-15 seconds each but they will reoccur throughout the day.

Back in Sept, I had a chest x-ray, blood work, ECG, ECHO and stress test with nuclear imaging. All the results came back normal. My problem is that the symptoms have not gone away and I'm concerned that something was missed. Would all these tests be definitive in diagnosing a heart problem? Could blockages in arteries still exist as I've read that these tests are not as accurate in young females?

Since 6 months have passed, should any of them be repeated since my symptoms still exist. I am very concerned and would appreciate some advice.

Laura :(
 Dr. Yasser Mokhtar - Fri Feb 18, 2005 10:29 am

User avatar Dear Laura,

To determine whether or not chest pain is caused by coronary disease, the risk factors for coronary disease in the patient complaining of chest pain are assessed and the characteristics of the chest pain are looked at and the probability of this pain being caused by coronary disease is then determined. If the patient has many risk factors for coronary disease (these are hypertension, diabetes, smoking, drinking, family history, advanced age, male gender and hypercholesterolemia) and the characteristics of the pain are typical as compared to characteristics of the pain caused by coronary disease, the probability of the pain being caused by coronary disease is high and such patients don't even go through stress test but they are directed to coronary angiography. If the patient does not have any risk factors and the pain is atypical, the probability is low and such patients are not even subjected to stress tests. If the patient has one or two risk factors and the chest pain has some of the typical features, these are the patients that are subjected to stress test because the probability of this pain being due to coronary disease could not be determined.

In your case, you did not mention whether or not you have any of the risk factors for coronary disease and from your description, it sounds that the pain that you have been suffering from is atypical as compared to that of coronary disease. This being said, however, females of the child bearing age are protected against coronary disease unless they have diseases that are considered major risk factors for coronary disease such as hypertension, diabetes and high cholesterol for a long time enough to affect their coronaries (because these diseases take quite a while to affect all the blood vessels in the body including the coronaries).

So, to begin with, you are a female of the child bearing age and unless you have been hypertensive, diabetic or have high cholesterol for the last 10-15 years, you are protected against coronary disease, in addition, your chest pain is atypical, so the probability of your chest pain being secondary to coronary disease is low. On top, you had a stress test (if it was an exercise stress test and you kept exercising till your heart rate reached its goal without you having chest pain, this is a very good sign that you don't have coronary disease) with nuclear imaging (which increases the sensitivity and specificity of a regular stress test quite a bit) and it was negative. So, i am confident that the chest pain that you have been having is not caused by coronary disease. Also, echocardiograms show changes in the way the heart muscle contracts if the patient has coronary disease and yours was negative as well.

If after six months, you are still having the same chest pain, and if this chest pain was not secondary to coronary disease to begin with, then, i would say that still this pain is not seconadry to coronary disease after 6 months.

If you are still really worried about this being caused by coronary disease, then the ultimate test is a coronary angiogram where a dye is injected into your coronary arteries and the arteries is visualized with x-rays real time. Of course, this procedure is not without cmplications and i am not sure whether or not a cardiologist would be willing to perform it in your case because of low probability and the negative stress test that you had.

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

Yasser Mokhtar, M.D.
 ltunes - Fri Feb 18, 2005 12:04 pm

Thank you for your reply, Doctor.

In response to your question about my risk factors. There is no family history of coronary artery disease. My blood pressure is normal as is my cholestrol level. I am a non-smoke and not diabetic although my grandmother was but she lived to be 90. I'm 5 feet tall and weigh 105 pounds so I'm not overweight although I'm afraid I'm not very active.

My big concern is that my chest pains persist and my shortness of breath is also constant sometimes with little exertion. This causes me much anxiety.

I was able to complete the stress test (with thallium) to my maximum heart rate but am still concerned that a blockage might be present as my symptoms have not disappated.
At the time of the test, the cardiologist was confident that my pains were not related to my heart but that was 5 months ago.

With them persisting, I'm not so sure. How accurate is the stress test with thallium at ruling out blockages in someone with my medical history? I just don't know what other tests I could ask for extra reassurance without going the route of an angiogram as I'm sure the doctor will discourage.

Your thoughts would be greatly appreciated,
Laura
 Dr. Yasser Mokhtar - Fri Feb 18, 2005 12:22 pm

User avatar Dear Laura,

Thank you very much for the update.

If you reach your maximum predicted heart rate on the treadmill and you did not get any chest pain and the thallium was negative, this is a very good indicator that you don't have any blockages and that actually you have a very good coronary reserve and that you don't have to worry one bit.

Since this is the same chest pain (no change in the characteristics of the chest pain) and you are the same peron with no change in risk factors, the probability of this being due to coronary disease is still the same (even after 6 months), low.

The gold standard to diagnose coronary diseases is coronary angiography. So, if you want to be 100% sure, the way to go is coronary angio but still i am not sure that many cardiologists will go for it.

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

Yasser Mokhtar, M.D.

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