Hi there,
Thanks for writing.
I am a qualified and certified cardiologist and I read your mail with diligence.

You are right about positive tests and people having heart attacks. However, something is positive in them too. World Health Organization has decided to for diagnosis of heart attack one has to fulfill two of these criteria (and most of cardiologists agree)
1. Typical pain that is mid line central suffocating may radiate to neck and left arm, always associated with some shortness of breath (may also be associated with sweating palpitation)
2. Typical ECG changes if one is normal subsequent ECG may show changes
3. Elevation of enzymes like myoglobin, creatine phospho kinase MB fragment, Troponin T or Troponin I levels
In my opinion these criteria were partly satisfied when you were taken to ER first time. You ought to consult a cardiologist if already consulted take a second opinion. For heart attack due to coronary artery disease is a serious disease and all doubts should be settled. If you have any other question, I will be most happy to answer. Regarding other tests you must undergo are (apart from thorough physical examination) Pharmacological Stress Echo Test (if your ECG is normal), Lipid Profile, Fasting Blood Sugar and other tests suggested by the doctor who examines you. Good Luck.
With best wishes.
Dr Anil Grover,
Cardiologist
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW

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Thanks for writing back.
First the easy answer, damage to heart muscle raises the troponin level which settles within a time span (normally up to two weeks or so to come back to normal but depends when your sample was taken). So two values being different is explainable.
You are right that you could be having coronary artery spasm. However, it is not a diagnosis of exclusion, I mean, it is demonstrated when coronary angiography is done. A brief explanation to which most of the cardiologists agree I am enclosing, this is what is believed. I quote (I am endorsing only part of what is believed that is treatment):
"A coronary artery spasm is a brief, temporary tightening (contraction) of the muscles in an artery wall in your heart. This can narrow and decrease or even prevent blood flow to part of the heart muscle.

If the spasm lasts long enough, it can lead to chest pain (angina) and possibly a heart attack (myocardial infarction). These spasms may also be referred to as Prinzmetal's angina or variant angina (EKG CHANGES ARE DIFFERENT IN PRINZMETAL ANGINA) . Unlike typical angina, which usually occurs with physical activity, coronary artery spasms often occur at rest.

Coronary artery spasms are more common in people with risk factors for heart disease, such as high cholesterol and high blood pressure, but the spasms can happen in people who have no risk factors, too. Coronary artery spasms can also occur in people who have conditions that affect their immune systems, such as lupus.

Coronary artery spasms may be triggered by:
Tobacco use
Exposure to cold
Extreme emotional stress
Use of illegal stimulant drugs, such as amphetamines and cocaine

Treatment of coronary artery spasms may include medications such as:
Nitrates, which can relieve chest pain
Calcium channel blockers, which can help reduce muscle tightening in your chest
L-arginine, a supplement that can help prevent spasms
Statin medications, which not only lower cholesterol but have other beneficial effects on your heart arteries to prevent spasms

You can reduce your risk of coronary artery spasms by quitting smoking and controlling high cholesterol and high blood pressure" END OF QUOTE

I have not seen your coronary angiography, therefore, I am not in a position to tell whether you have disease of smaller vessels or not which I still suspect. In my opinion there is no other explanation but for a minor muscle damage (or heart attack) to explain your first visit to ER. Good you have recovered. If you have any more question. I will be happy to answer. Good Luck.

With Best Wishes.

Dr Anil Grover

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Thanks for writing back.
Well, in medical science no test is 100% specific and 100% sensitive. I had always thought troponin qualitative level come close to that but It seems that laboratory error can occur; that is best I can think of if the logical explanation written in my last email is wrong.
If we take coronary angiography into account, if muscle had got damaged and you have normal coronaries then there are only three explanations
1. Prolonged spasm of coronary artery.
2. Thrombotic occlusion where thrombus got dissolved.
3. Small (smaller than normally seen on angiography) vessels disease.

That is why I asked to take a second opinion because everything is not fitting in. Good Luck.

Regards

Dr Anil Grover

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Thanks for writing back.
Why are you not happy that you have concurrence of two persons sitting across the world on the point that you do not have heart disease. Cardiologists are trained to keep threshold of suspicion very low ans suspect too early this way heart attacks are not missed. That created the whole series of issues here. Reason is missing a heart attack can risk life over diagnosis initially may cause some inconveniences to the patient, so please understand the dilemma a cardiologist faces. I expect stress echo to be normal. Good news does not end here if you keep your blood pressure down and stress level under control it is unlikely that you will have heart disease in next 30 years. Is not that something worth knowing. Good Luck. Forget this as a nightmare, it makes me happy for you. It was pleasure interacting with you. Regards.
Best Wishes.

Dr Anil Grover

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