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37 Year Old. Having Diabetic. ECG ,ECHO And TMT Normal. What Are The Chances Of Costochondritis?
Question: i am 37 diabetic with good glycemic control,have chest pain for last one year,pain is on left sometimes radiates sometime not.sometimes i get just pain in left hand.I had my ECG ,ECHO and TMT done which are normal.My lipids are within normal.Pain happens continously except on sleeping.sometimes it happens on right side also.I had slip disc last year till that time it was fine,I had my MRI done with reduced disc space in L3 and a cervical rib.I have seen a cardiologist who said it to be costochondritis.My chest wall is tender to touch.
Hi
Thanks for writing in.
I am a cardiologist and read your question with diligence.
Well, to diagnose a heart attack pain we follow World Health Organization Criteria (two out of three have to be positive)
1. Pain or angina equivalent symptoms rapid breathing rapid heart rate
2. Abnormal EKG especially EKG changes are dynamic that is change with time
3. Blood tests for heart enzymes that is Creatine Phospho Kinase Myocardial
isoform(CPK MB) or Serum Myoglobin or Tropinin T or Troponin I.
Usually, cardiac pain can not be localized with one finger and there is neverr ever tenderness. You have evidence of cervical rib and tenderness in costo chondral junction thus the diagnosis of costochondritis has been made. Heart disease has been excluded to a a large extent by ECHO and TMT. Pain in left hand can be because of cervical rib or cervical spondylosis.
Still, you have chosen cardiologist to answer, that indicates you are still suspicious. Well, false negativity (Test negative and Disease is still there) of TMT to the tune of 15% is there. So we will analyse your risk factor profile. With your help we can compete the risk factor of coroanary artery disease so as it can be prevented for next 50 years.
At age 37, you would have some identified risk factors for coronary artery disease; others you can fill in by personal knowledge and investigations. The idea is if you have a back ground of more known risk factors your chances of pain (even atypical pain for heart) originating as a result of heart in future are much more. At any age, following is the list of risk factors for future development of Coronary Artery Disease. Let me enumerate and you can place yourself the risk you are carrying ('*' means you have the risk factor, '+/-' means I do not know and about others you know better):-
A: MODIFIABLE RISK FACTORS
Diabetes +/-
Hypertension*
Smoking+/-
Stress* (globalized world and modern life styles; Yogis and children <3 Yr. escape) Obesity and Sedentary Life Style +/- ( your height and weight is not known to me)
High Bad Cholesterol and Lipid Component +/-
Total Cholesterol above 190 mg%, LDL above 130 mg%, VLDL above 40 mg%,
Triglycerides above 150 mg%, Apolipoprotein B above reference valueLow
Good Cholesterol and Lipid Component: +/- (not mentioned)
Apolipoprotein a below reference range for the lab and HDL below 40 mg% for B: NON MODIFIABLE RISK FACTORS
Family History of Coronary Heart Disease+/-
Increasing age*Being a Man (as opposed to women) till the age 45*
From the list, above you have some risk factors at least not much is known
Sress I have identified. Therefore, I will strongly recommend to complete the list.
Strategies include:1. Treat the risk factors you have: For stress add progressive muscular relaxation exercises (originally from one of the asana of yoga called called Savasana: corpse pose if literally translated. This has opposite effect to heavy isometric exercise (which a hypertensive person or with bony disease like you ought to avoid). Additionally, this is a great stress buster. No yoga session is complete without the final pose – Savasana. The body needs this time to understand the new information it has received through practicing yoga. Even though Savasana is a resting pose, it’s not the same a sleeping! You should stay present and aware during the five to ten minute duration of final relaxation. Instructions: 1. Come to lie down on the back. 2. Let the feet fall out to either side. 3. Bring the arms alongside the body, but slightly separated from the body, and turn the palms to face upwards. 4. Relax the whole body, including the face. Let the body feel heavy. 5. Let the breath occur naturally. 6. To come out, first begin to the deepen the breath. Then move the fingers and toes, awakening the body. 7. Bring the knees into the chest and roll over to one side, keep the eyes closed. 8. Slowly bring yourself back up into a sitting position. Second thing is to maintain ideal body weight, avoid junk food and isotonic exercises. Brisk walking at the rate of 5 KM/ Hr for 40 minutes (whether on treadmill or outside) every day will go a long way.To compete the list of anti risk factors as I call them. If you are overweight It is never too late to change. With your weight everything you do will have to be under supervision. It need not be cardiologist but your primary doctor can guide your way back to health - I am happy to read that because of family history you got even coronary angiography done. You may need drugs (which has been advised correctly) and he/she (or ask the dietitian) to advise you about diet low in calories and cholesterol, advise you on quantum of exercise. You ought to keep your weight under control for you do not want heart attack. If you like non vegetarian you cannot take red meat but there is no bar (in taking certainly quantity had to be less) on egg white, roasted chicken and roasted fish.So DIET DRUGS AND EXERCISE IS MY ANSWER TO RISK FACTORS
ABOUT YOUR COSTCHONDRITIS
Follow your doctor's advice.
It can be frustrating to know that there's little your doctor can do to treat your costochondritis. But you can take self-care measures to make yourself more comfortable, which can give you a greater sense of control over your condition. Try the following:
Over-the-counter pain relievers. Costochondritis symptoms can often be
controlled with acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin, others)
or naproxen (Aleve).
Heat or ice. Try placing hot compresses or a heating pad to the painful area
several times a day. Keep the heat on a low setting. Ice also may be helpful.
Rest. Avoid activities that make your pain worse.
About pain in the hand, cervical rib and possible cervical spondylosis
Follow your doctor's advice, ask about cervical collar.
Hard bed and thin flat mattress use
Use thin pillow
Do Neck exercises which a physiotherist advice you after your condition has been evaluated completely.
Hope you found something useful in this answer. If you have any follow-up query I shall be happy to answer.Regards
With Best Wishes
Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)http://www/ WWW.WWWW.WW
Thanks for writing in.
I am a cardiologist and read your question with diligence.
Well, to diagnose a heart attack pain we follow World Health Organization Criteria (two out of three have to be positive)
1. Pain or angina equivalent symptoms rapid breathing rapid heart rate
2. Abnormal EKG especially EKG changes are dynamic that is change with time
3. Blood tests for heart enzymes that is Creatine Phospho Kinase Myocardial
isoform(CPK MB) or Serum Myoglobin or Tropinin T or Troponin I.
Usually, cardiac pain can not be localized with one finger and there is neverr ever tenderness. You have evidence of cervical rib and tenderness in costo chondral junction thus the diagnosis of costochondritis has been made. Heart disease has been excluded to a a large extent by ECHO and TMT. Pain in left hand can be because of cervical rib or cervical spondylosis.
Still, you have chosen cardiologist to answer, that indicates you are still suspicious. Well, false negativity (Test negative and Disease is still there) of TMT to the tune of 15% is there. So we will analyse your risk factor profile. With your help we can compete the risk factor of coroanary artery disease so as it can be prevented for next 50 years.
At age 37, you would have some identified risk factors for coronary artery disease; others you can fill in by personal knowledge and investigations. The idea is if you have a back ground of more known risk factors your chances of pain (even atypical pain for heart) originating as a result of heart in future are much more. At any age, following is the list of risk factors for future development of Coronary Artery Disease. Let me enumerate and you can place yourself the risk you are carrying ('*' means you have the risk factor, '+/-' means I do not know and about others you know better):-
A: MODIFIABLE RISK FACTORS
Diabetes +/-
Hypertension*
Smoking+/-
Stress* (globalized world and modern life styles; Yogis and children <3 Yr. escape) Obesity and Sedentary Life Style +/- ( your height and weight is not known to me)
High Bad Cholesterol and Lipid Component +/-
Total Cholesterol above 190 mg%, LDL above 130 mg%, VLDL above 40 mg%,
Triglycerides above 150 mg%, Apolipoprotein B above reference valueLow
Good Cholesterol and Lipid Component: +/- (not mentioned)
Apolipoprotein a below reference range for the lab and HDL below 40 mg% for B: NON MODIFIABLE RISK FACTORS
Family History of Coronary Heart Disease+/-
Increasing age*Being a Man (as opposed to women) till the age 45*
From the list, above you have some risk factors at least not much is known
Sress I have identified. Therefore, I will strongly recommend to complete the list.
Strategies include:1. Treat the risk factors you have: For stress add progressive muscular relaxation exercises (originally from one of the asana of yoga called called Savasana: corpse pose if literally translated. This has opposite effect to heavy isometric exercise (which a hypertensive person or with bony disease like you ought to avoid). Additionally, this is a great stress buster. No yoga session is complete without the final pose – Savasana. The body needs this time to understand the new information it has received through practicing yoga. Even though Savasana is a resting pose, it’s not the same a sleeping! You should stay present and aware during the five to ten minute duration of final relaxation. Instructions: 1. Come to lie down on the back. 2. Let the feet fall out to either side. 3. Bring the arms alongside the body, but slightly separated from the body, and turn the palms to face upwards. 4. Relax the whole body, including the face. Let the body feel heavy. 5. Let the breath occur naturally. 6. To come out, first begin to the deepen the breath. Then move the fingers and toes, awakening the body. 7. Bring the knees into the chest and roll over to one side, keep the eyes closed. 8. Slowly bring yourself back up into a sitting position. Second thing is to maintain ideal body weight, avoid junk food and isotonic exercises. Brisk walking at the rate of 5 KM/ Hr for 40 minutes (whether on treadmill or outside) every day will go a long way.To compete the list of anti risk factors as I call them. If you are overweight It is never too late to change. With your weight everything you do will have to be under supervision. It need not be cardiologist but your primary doctor can guide your way back to health - I am happy to read that because of family history you got even coronary angiography done. You may need drugs (which has been advised correctly) and he/she (or ask the dietitian) to advise you about diet low in calories and cholesterol, advise you on quantum of exercise. You ought to keep your weight under control for you do not want heart attack. If you like non vegetarian you cannot take red meat but there is no bar (in taking certainly quantity had to be less) on egg white, roasted chicken and roasted fish.So DIET DRUGS AND EXERCISE IS MY ANSWER TO RISK FACTORS
ABOUT YOUR COSTCHONDRITIS
Follow your doctor's advice.
It can be frustrating to know that there's little your doctor can do to treat your costochondritis. But you can take self-care measures to make yourself more comfortable, which can give you a greater sense of control over your condition. Try the following:
Over-the-counter pain relievers. Costochondritis symptoms can often be
controlled with acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin, others)
or naproxen (Aleve).
Heat or ice. Try placing hot compresses or a heating pad to the painful area
several times a day. Keep the heat on a low setting. Ice also may be helpful.
Rest. Avoid activities that make your pain worse.
About pain in the hand, cervical rib and possible cervical spondylosis
Follow your doctor's advice, ask about cervical collar.
Hard bed and thin flat mattress use
Use thin pillow
Do Neck exercises which a physiotherist advice you after your condition has been evaluated completely.
Hope you found something useful in this answer. If you have any follow-up query I shall be happy to answer.Regards
With Best Wishes
Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)http://www/ WWW.WWWW.WW
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
thanks for the reply,but i am a diabetic with good glycemic control.Like i have just woken up ,its heaviness on the keft side which will be there from now till i sleep.Sometimes it is not there.I do walk for 4km five days a week,and there is not much oain on doing so.For costochondritis i have tried naproxyn with no change.My suspicion remains cardiac but i have not heard it for years without further deterioration.I was obese but because of my back have put down lots of weight
i never underwent coronary angiography as mentioned in your reply
Hi,
Unfortunately, the glycemic control as conventionally measured does not give a guarantee that your blood sugar had been normal almost every minute of the day. So even those with Diabetes on treatment are counted in as far as risk factor is concerned. Nearest we can measure is glycated hemoglobin (HbA1C). This reflects glycemic control over preceding 12 weeks. If it is below 7 very good control, 7-8 good control, 8-9 fair control and above 9 poor control over last 3 months. Therefore unless your HbA1C is below 7 we will have to change for diabetes as risk factor from +/- to *. Above 7 means at times your random sugar does cross 180 mg% and chances of neuropathy and its contribution to symptoms would remain possible.
I am sorry about mentioning coronary angiography in wrong context that was inadvertent error.
Nevertheless, coronary angiography is the gold standard for including in or excluding out Coronary Artery Disease with 100% certainty. This is especially true even in controlled diabetics like you who might have developed neuropathy and angina symptoms would be silent or one would have angina equivalent symptoms. Cine CT is other option and relatively non invasive for excluding significant coronary artery disease and is an OPD procedure. You will have to convince your doctor to order either of two on suspicion only specially when you are a diabetic.
If you have any further query I will be most happy to answer. Regards
With Best Wishes
Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW
Unfortunately, the glycemic control as conventionally measured does not give a guarantee that your blood sugar had been normal almost every minute of the day. So even those with Diabetes on treatment are counted in as far as risk factor is concerned. Nearest we can measure is glycated hemoglobin (HbA1C). This reflects glycemic control over preceding 12 weeks. If it is below 7 very good control, 7-8 good control, 8-9 fair control and above 9 poor control over last 3 months. Therefore unless your HbA1C is below 7 we will have to change for diabetes as risk factor from +/- to *. Above 7 means at times your random sugar does cross 180 mg% and chances of neuropathy and its contribution to symptoms would remain possible.
I am sorry about mentioning coronary angiography in wrong context that was inadvertent error.
Nevertheless, coronary angiography is the gold standard for including in or excluding out Coronary Artery Disease with 100% certainty. This is especially true even in controlled diabetics like you who might have developed neuropathy and angina symptoms would be silent or one would have angina equivalent symptoms. Cine CT is other option and relatively non invasive for excluding significant coronary artery disease and is an OPD procedure. You will have to convince your doctor to order either of two on suspicion only specially when you are a diabetic.
If you have any further query I will be most happy to answer. Regards
With Best Wishes
Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
sir thanks,i told you i am symtomless on walking and symtoms persist throughout the day for last year,did complete cardiac workup in march which was negative.My simple question is should i need angio.....does cardiac pain occurs 24 X 7 without clinical deterioration...In your first reply it was mentioned that i dont require invasive tests
my Hb1AC is 7 and vit D3 level 5,is this the culprit,my question just is do i carry on or go for angio...i have seen a cardiologist who feels it to be muscular pain...
Dear
Hb A1C denotes very good control.
Regarding angiography , I will go with the advice of the cardiologist who has examined you.
By nature of our job (as cardiologists we simply can not go wrong in diagnosing coronary artery disease) we are trained in such a way that our threshold for doing investigations even coronary angiography is deliberately kept low. Idea is one may get few normal coronary angiography but no patient would miss coronary angiography being done. Therefore, neither your clinical features give any clue to wards heart disease nor a considered opinion of a cardiologist. So, my suggestion keep coronary angiography on hold if you have angina or angina equivalent symptoms on exertion, one can revisit the decision. If you go through list of risk factors there are very few you have and your chest pain is quote atypical.
Personal Regards.
With Best Wishes
Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW
Hb A1C denotes very good control.
Regarding angiography , I will go with the advice of the cardiologist who has examined you.
By nature of our job (as cardiologists we simply can not go wrong in diagnosing coronary artery disease) we are trained in such a way that our threshold for doing investigations even coronary angiography is deliberately kept low. Idea is one may get few normal coronary angiography but no patient would miss coronary angiography being done. Therefore, neither your clinical features give any clue to wards heart disease nor a considered opinion of a cardiologist. So, my suggestion keep coronary angiography on hold if you have angina or angina equivalent symptoms on exertion, one can revisit the decision. If you go through list of risk factors there are very few you have and your chest pain is quote atypical.
Personal Regards.
With Best Wishes
Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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