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Discomfort in chest,fatigue,blood pressure,cholesterol,cardiac ct scan

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Cardiologist, Interventional
Practicing since : 1996
Answered : 192 Questions
I am 46 yrs old, 230 lbs, athletic body, run 3 miles 3 times/wk. I am in decent shape. Last week I started to get discomfort in my chest. Not always in the same area sometimes on the lt side and sometimes on the rt. At times its breif twinges and other times it stays for a minute or so. It occurs both when I am sitting or moving, activity does not seem to increase its pain. When I run the level of pain is not more or less and I am still able to complete my runs. However, I have noticed lately that I am very tired at night and I have been falling asleep much earlier than normal. I have not noticed any shortness of breath, get a little winded after climbing 4 fls of steps, nothing unusual

I take Simvastatin and Lisinop/HCTV for BP and cholesteral. BP stays pretty stable at 118/78, .
sometimes spikes to130/90.Cholesteral total is 178 and HDL of 48

Since I was having the chest pains I went into my GP and he ordered a stress/echo test. I had the test yesterday and it took me about 14 min to get up to my HB range. After the test the DR indicated that the images were very clear and that the heart looks perfectly normal

A little past history concerning my heart: 2 yrs ago I has a Cardiac CT for Calcium test completed and all but one of my arteries scored a 0, 1 had a score of 8. In addition 10 yrs ago I had a nuclear stress test completed as part of a physical and it showed an abnormality. So I had a heart XXXXXXX done at that time. The test showed no blockage anywhere, the abnormality was that "the left main trunk was very short, almost nonexistent"

So all my tests have been good to date.Why do I still have these sporadic chest pains?

Do I need additional testing? I know that the Echo/Stress test is about 85% reliable and only picks up blockages over 50% so is this accurate enough?. So what other test should I be asking my DR for? Should I be asking for a heart cath? I would like to rule out that these pains are not from my heart
Posted Wed, 11 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Raja Sekhar Varma 17 hours later
Thank you for your query.

The chest discomfort that you seem to be having is not typical of ischemic cardiac pain. The location of the pain is varying, and it does not appear to be related to exertion. You are able to do all your physical activities without any worsening of the chest discomfort. Your BP and cholesterol levels appear to be under good control. The stress echo has been reported to be normal. Cardiac CT is practically normal. The previous coronary angiogram was also normal. A short left main artery is a normal variation and commonly seen. It cannot be called as an abnormality.

As you said, the accuracy of a stress echo is in the order of 85%. Considering your risk profile and symptoms, this is a good noninvasive test to rule out "obstructive" coronary artery disease. It can be reasonably concluded that the chances of your having obstructive CAD of a degree to explain your symptoms are very less. If the blocks are less than 50% in severity, they are most unlikely to produce chest pain of the type that you are having. Almost everyone will have some deposits of cholesterol in the walls of the coronary arteries with age. Therefore, it is important to control the cholesterol levels as much as possible in order to avoid these deposits from progressing in severity. The statin that you are taking will also help to prevent acute coronary events like heart attack. Remember that the negative stress test does not predict the possibility of future attacks. There is no foolproof way of predicting that. But, if your risk factors are controlled, then the risk of coronary events is also reduced.

So, what else could be the cause of this chest discomfort. From your description of the pains, it appears as if the cause is likely to be musculoskeletal. Neuropathic pain is also possible, though less likely. Acid peptic disease with esophagitis/gastritis is another possibility. Pleuritic pain and pain from pericardium, (the coverings of the lungs and heart) are other possibilities.

Non-ischemic but cardiac pain can occur if you have mitral valve prolapse or ventricular hypertrophy. Hypertension can lead to left ventricular hypertrophy (increased thickness of the walls of the heart). This may result in chest discomfort. But this would be more like a heavy feeling in the chest and not brief twinges of the sort that you are having. Also, microvascular pain can occur due to blockages in the microcirculation of the heart. This cannot be seen even on angiography. This is assumed if you have a positive stress test with normal epicardial coronary arteries on angiogram. Since your stress test is negative, this is not likely either.

Is XXXXXXX required for you now? I dont think so. It may not aid you in diagnosis and there is no indication for a repeat invasive procedure as of now.

I would advise you to continue with your current healthy lifestyle, good dietary habits, avoid smoking (if applicable), limit your alcohol consumption (if any), regular exercise and your current medication. If you can tolerate it, a low-dose aspirin daily may be beneficial for prevention of heart attacks and strokes.

I hope I have been able to answer your query. If you need any further clarifications, please feel free to get back to me.

Dr RS Varma
Above answer was peer-reviewed by
Follow-up: Discomfort in chest,fatigue,blood pressure,cholesterol,cardiac ct scan 5 hours later
Thank you Dr. for your response.

I am happy to hear that you believe that it is unlikely a cardiac issue. I just want to clarify a couple of issues.

The pain that I have does stay around for a while and sometimes (10 to 15 minutes) it feels like a slight burn at times. Also lately my arms have been falling asleep and sometimes hurt when sitting in a chair or driving the car... in addition I get a sore neck or knot in my neck. Also during my last jog my hands were falling asleep and I had to shake them. Can these be attributed to a cardiac issue.

Is it true that if I was experiencing these chest pains and they were cardiac in nature that I should have felt them during my echo/stress test and they should have picked that up during the test? Also you would think that I would not have been able to go over 12 minutes on the test to get to my heart rate if my heart was in distress? Do these facts help increase the reliability of the test results?

If you could answer these question that would be great.

Answered by Dr. Raja Sekhar Varma 22 hours later

Thank you for the reply.

The numbness that you feel in your arms, hands along with the sore neck would indicate that probably, you might be having cervical spondylosis with some pressure on the nerve roots, or other related problems. To clarify this further, you need a neurological examination and probably MR imaging of the neck.

The symptom of "limbs falling asleep" can also happen normally if pressure is exerted anywhere along the course of some nerves, as can happen if you were to sleep in certain positions or if the hands are left to dangle in certain positions. This is solely due to the effect of the pressure on the nerve and can lead to a sensation of "pins and needles".

If your chest pain had been of an ischemic type due to significant obstructions in the coronary arteries, the stress test should have reproduced your symptoms, and shown changes in the ECG and the echo (wall motion abnormalities). If the stress was in the form of exercise (treadmill or bicycle), the fact that you could go over 12 minutes (assuming XXXXXXX protocol was used) is a good sign that your cardiac function is practically normal. These facts do increase the reliability of the test. If the stress was pharmacological (dobutamine/atropine or adenosine, etc), the time needed to reach maximum stress is not really a factor.

I hope I have clarified your doubts. I wish you all the best for a happy and healthy life.

Above answer was peer-reviewed by
Follow-up: Discomfort in chest,fatigue,blood pressure,cholesterol,cardiac ct scan 1 hour later
Thanks..... One last question.... I will get reevaluated by my doctor for these other issues. These type of chest pains couldn't possibly be a sign of something serious like "lung Cancer"... I am not a smoker and they did take a chest x-ray in the mergency room and didn't comment on it. Just wondering?

thanks for this last reply
Answered by Dr. Raja Sekhar Varma 20 hours later
Thank you for your query.

I agree with you that diagnosing lung cancer in the early stages is quite difficult. Symptoms may be non-specific, there may be no signs on clinical examination. Non-smokers can also get affected by certain types of lung cancer. Chest x-ray also cannot rule out early cancer.

Having said that, the probability of cancer in your case would be low. If there were any suspicions, your physician would have ordered more specific investigations like sputum examination for malignant cell cytology, FNAC/biopsy of any suspicious lymph nodes/ lesions in lung, CT of the lung, bronchoscopy, etc.
It is not usual to do these tests, if the likelihood of disease is low.

There is a saying in clinical medicine that "rare diagnoses are rarely correct". In fact, it is true that the most likely diagnosis appealing to common sense is almost always the correct diagnosis. It would be advisable therefore to look at the most likely cause in your case and investigate to prove/disprove it before worrying about rarer/unlikely/remote possibilities.

There is a large list of possibilities as part of the differential diagnosis of chest pain. However, an astute clinician can usually narrow it down to a limited number of possibilities with a good history, clinical examination and relevant investigations.
You should discuss with your treating physician the possibilities that have been raised so far, and he would be your best guide to the way forward.

I am confident that you will be able to overcome your problem and lead a healthy life. Please do not worry.

Dr RS Varma
Above answer was peer-reviewed by
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