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Pain on left side of chest whenever stressed, have a myocardial bridge in LAD. Reasons ?

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Cardiologist, Interventional
Practicing since : 1996
Answered : 192 Questions

I get pains on left side of my chest whenever I get either depressed, excited or stressed, but dont get any pains on physical exertion. I have a myocardial bridge in the LAD. What could be the reason for this and what should I do ? I had done a stress test around 5 months back, which was negative for ischemia.

Posted Wed, 2 May 2012 in Hypertension and Heart Disease
Answered by Dr. Raja Sekhar Varma 1 hour later

Thanks for your query.

Since the stress test is negative for ischemia and coronary angiogram showing a myocardial bridge (assuming that the rest of the coronary arteries are absolutely normal), there is really no reason to worry.

Myocardial bridge refers to a piece of cardiac muscle that course above a coronary artery. Usually, the myocardium (heart muscle) lies below the artery. However, in certain circumstances, a muscle strip can run over the artery. This is found usually when there is an increased thickness of the left ventricular muscle (as can happen in people with hypertension or hypertrophic cardiomyopathy).

When the muscle contracts each time the heart beats, the artery is squeezed to an extent depending on the severity of the bridge, rate and force of contractions. Usually this does not cause any major ischemia, since the majority of the blood flow in the coronary arteries occurs when the heart is relaxing between two beats (diastole).

On occasions like stress, anxiety, emotional disturbances, the heart rate as well as the force of contractions can cause some limitation of blood flow. This can translate to some chest discomfort.

It may also be possible that you are just feeling the normally increased force of contractions and you are being aware of this due to the increased thickness of the cardiac muscle.

Hiatal hernia with Esophagitis can cause heartburn due to the acidity and reflux of acid from the stomach to the food pipe.

The drugs that you are currently taking seems to be adequate. I might recommend a stronger drug than Nebicard. A long acting Metoprolol succinate or bisoprolol may be better. These drugs will reduce the heart rate and the force of contraction better, in turn reduces the discomfort. Also, spasm of the muscle can be partially prevented using a calcium channel blocker like diltiazem or verapamil. You could discuss these options with your treating physician.

Keeping your BP at a target of 130/85 mmHg will be beneficial. It will be prudent to avoid situations which can increase anxiety, stress and emotional upsets. Stress reduction techniques like yoga may prove useful and might be the key to prevent such episodes in future.

I hope this answers your query. Feel free to get back to me for any further clarifications.

With regards,
Dr. R.S. Varma.
Above answer was peer-reviewed by
Follow-up: Pain on left side of chest whenever stressed, have a myocardial bridge in LAD. Reasons ? 1 hour later
Dear Dr. Varma,

Thanks for the response. Yes. the rest of the coronary arteries are normal. I had an ECG done two days during a similar painful episode. It was normal. My heart rate during this period was 59 and my BP was 126/80.

In terms of the medication, I had started with metoprolol and then was moved to bisoprolol and then to diltiazem. I was not able to tolerate metoprolol and bisoprolol. I had a stress test and 2D echo last January. Both the stress test an 2D echo were negative. Basis which, the doctor changed my course to nebicard.

My BP is normally in range around 125/80.

I have been told these pains are because of muscle spasms as a result of excitement/stress caused by anxiety and have been told to take a paracetamol or apply an ointment such as volini.

I am utterly confused and worried whenever I get these pains. I have the following questions:

1. Are these pains cardiac in nature (your response suggests they could be) or are they plain muscular spasms?
2. How can I differentiate a cardiac pain from any other pain?
3. Why do I get these pains only on getting stressed or excited, I don't get these when I exercise? I normally walk for about 30 minutes and do yoga alternate day for about an hour or so.
4. What should I be doing? What medications should I take?


Answered by Dr. Raja Sekhar Varma 1 hour later
Thank you for the feedback.

1) and 2) Are these pains cardiac in nature? How to differentiate cardiac pain from non cardiac pain?
If the ECG during the episode when you had ongoing pain did not show changes, it is most unlikely to be due to myocardial ischemia.
If it is a pricking or stabbing type of pain which lasts just a few seconds, it is unlikely to be cardiac.
If there is pain when you press on the chest wall where it hurts, or if the pain appears to increase during XXXXXXX breathing or movement of the chest (as in twisting your body, bending sideways, etc), it is more likely to be musculoskeletal.
Pain related to food (before food, after food, etc) is likely to be related to your hiatus hernia and esophagitis.
If the pain is relieved on applying ointments like Volini, it is likely to be muscular pain.

However, these are only useful pointers. If the pain persists, you need to get an ECG done and if indicated, blood tests to ensure that there is no cardiac problem.

3) The changes in the physiology and hormonal/reflex changes that take place in the body during exercise are subtly different from those that occur due to stress, excitement and anxiety. Hence, sometimes pain occurs during these moments while you may be pain-free during exercise.
Sometimes, the stress/conflicts in the mind can get translated to actual physical pain. This has been called as a somatoform pain disorder.

4) What medicines?
Since your BP is under control, there is really no need to change your medicines. Since you did not tolerate metoprolol or bisoprolol, and since you seem to tolerating nebivolol, you can continue with the same. You could also see if you can tolerate a very low dose of diltiazem added to your current medication.

I would also suggest that you take Nexito daily instead of alternate days. Your physician might also want to consider amitryptiline instead of Nexito, since this might give you better relief from the pain. However, some people do get some side effects with amitryptiline. Any change in these medicines should be done only as per the advice of your treating physician, since dosages will have to be tailored to your individual needs.

I hope this clarifies your doubts. You can always get back to me with any specific question that you may have.
With regards,
Dr RS Varma

Above answer was peer-reviewed by
Follow-up: Pain on left side of chest whenever stressed, have a myocardial bridge in LAD. Reasons ? 20 hours later
Thanks Dr. Varma,

This is really comforting. My cardiologist tells me not to worry and not to go for repeat ECGs oftem, but every time I get pains for 2-3 days, I take an ECG. My question when should I get an ECG? What is the reliability of the stress test and at what periods should one do that? I normally have a full body profile done once a year, however, because of my insistence (chest pains have been persisting for the last four years or so) doctors have been doing Stress tests once in three months.

Another question, I was taking Nexito once a day and I changed to alternate days since last 4-5 weeks. Also, I was changed from Fibator 10 mg to atorva 5 mg. Could these pains be a result of change in the medications? I have read that the side effects of atorva are muscular pains?

Thx. in advance
Answered by Dr. Raja Sekhar Varma 1 hour later
Thank you for the reply.

Since the ECG is a reliable, non-invasive and inexpensive test, there is no harm in getting the ECG done if there is a doubt. However, when repeated ECGs have clearly shown no changes, getting another ECG for the same kind of pain will not really help you either.

An annual stress test should be adequate. A treadmill test done properly and ensuring a good exercise level is quite accurate. Tests like Dobutamine stress echo, stress nuclear imaging, etc are even more reliable. Doing stress tests repeatedly and too often may not help you.

I think you should take Nexito daily. Since the chest pains have been present for 4 years and since you have changed the dosage only since the last 5 weeks, it is unlikely to be the cause for your pains. Certainly, you may have aggravations of the pain due to the increase in anxiety and stress levels.

Fibator is a combination of Fenofibrate 145mg and Atorvastatin 10mg. Your current tablet of Atorva 5 mg has no fenofibrate and only 5 mg of Atorvastatin. The dosage is dependent on your lipid profile. A reduction in the dosage can only serve to improve the muscular pains (if it were related to the statin!).

Also, the muscular pains due to statin are not usually localized to the left side of the chest. They are usually felt at the shoulders, hips, lower back, thighs, etc. They are usually associated with high doses of statins. If you still want to rule out that possibility, you can do a serum creatine kinase (total) level.

I hope this answers your query. I wish you all the best for a healthy life.
With regards,
Dr RS Varma
Above answer was peer-reviewed by
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