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Posted on Thu, 10 Aug 2017 in Hypertension and Heart Disease
Question: 32 male caucasian - obese - asthmatic - probable hypertension - probable anxiety.

Last October I was stressed out and was working very hard in the yard with a pickaxe. I believe I injured myself because ever since that day I have had intermittent fairly sharp chest pain. Urgent care said it was likely a pulled muscle as I exhibited no other symptoms and heart/lungs sounded fine. The pain does not seem to come from exertion as I can feel it when driving a car, sitting at my computer or laying down. It seems to be more related to movement and posture from my point of view as I can generally adjust position, take some Advil and relieve it. I can work out in the yard for 2-3 hours or walk around the mall and I experience nothing. It is like a 2-3 on the 10 pain scale - more annoying and scary than actual pain.

Fast forward until last week I continue to have this and most doctors have told me its costochondritis or some type of inflammation. An X-ray from 2 months ago did show some cartilage in my chest from a lump I found and I may have bronchitis. They say thats a fairly normal finding on an X-ray for asthmatic. I signed up for a weight loss program through a doctor and they did routine tests. My cholesterol, sugar, all good and most everything is fine except very marginally elevated triglycerides. I have been working on my diet.

The ECG however said possible anterior infarction - age undetermined. That doctor explained the machine picked up on that due to shallow T-wave inversion on leads V2-V3. I shared with my family doctor and he did not seem concerned and said either a right bundle branch block and/or normal variant. At my request he did schedule a stress test with a cardiologist for this week.

So my question is the ECG finding significant? Will the stress test demonstrate if I have a blockage or more serious condition? Should I insist on an echo or other test?

If its not significant then what could be driving the chest pain? Asthma? Stress? Costocondritis? I do not believe I have GERD but it is possible.
I should add that the pain is most pronounced when I stretch, yawn, laugh, etc. Then it becomes maybe a 4-5 and short in duration.

Some days its more of a flare up and it is with me most of the day regardless of what I happen to be doing.

I don't believe I am having any problems with breathing outside of standard asthma. Oxygen saturation has always been 99-100% with the finger test.

Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:
I would explain as follows:

Detailed Answer:

Welcome and thank you for asking on HCM!

I carefully reviewed your uploaded ECG report and would explain that it indicates the presence of incomplete Right Bundle Branch Block.

But, this ECG finding does not seem to be related to your chest pain.

It could be an incidental finding.

The chest pain characteristics that you refer seem to be related to a musculo-skeletal issue (including chostochondritis).

They are not typical of any cardiac disease.

Anyway, the cardiac stress test will help investigate for the presence of coronary artery disease.

Considering these ECG findings, I would also recommend performing a cardiac ultrasound to examine your heart function and structure. But, the cardiac ultrasound is not a specific test for coronary artery disease. It will just help investigate for the possible causes related to these ECG findings.

Hope you will find this answer helpful!'

Feel free to ask me again whenever you need!

Kind regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ilir Sharka 51 minutes later
Hey Dr. Iliri,

Thanks for the thoughtful reply. I have a couple questions for you:

1. From my cursory research it seems incomplete right bundle branch block could be caused by my personal/genetic hypertension or I could even be born with it. It seems rather benign in lieu of any other problems. Is it your experienced assessment that this does not indicate I had a MI in the past?

2. Any specific reason you do not believe the heart to be the cause of chest pain? Is it because of duration (months) and form of pain? The ECG has not really helped me as it has created more overall anxiety but I also do not want to believe at my age I have had a MI.

3. By incidental finding you mean that another ECG could not even demonstrate the inverted T-waves? I understand the improper lead placement, body movement, etc. can throw these things off. I will be curious if the professionals at the cardiologist office encounter the same abnormality.

4. Assuming I pass my stress test I will ask my cardiologist about an ultrasound. Is that the same as an echo? I have never done a stress test so a bit anxious about it but if I work in the yard 3 times a week for 2-3 hours I don't see why a treadmill walk would be very challenging.

Thanks in advance for your thoughtful clarifications.
Answered by Dr. Ilir Sharka 16 hours later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello again,

Here are my answers to your questions:

1- Yes, I agree with you that incomplete right bundle block is a benign condition, which could be even born. As a cardiologist, I would like to reassure you that it is not indicative of any past MI.

2- The chest pain characteristics that you refer are not typical of any cardiac disorders (the exacerbation of the pain by body movements, the fact that it is not related to physical activity, the relief by ibuprofen, which is an anti-inflammatory drug). Instead all these pain features are typical of a musculo-skeletal pain (including costo-chondritis).

3- By incidental finding, I mean that these ECG changes are present, but they are not related to the chest pain. As I explained before, they could be present since birth, but you have not performed an ECG before. I do not think that they are artifacts (related to the ECG machine), but they do not indicate any cardiac disorder which would explain the chest pain.

4- I agree with you on the fact that it is very probable that your tread mill test will result normal, considering the fact that you make a lot of physical activity without having any complaints. But, it will give more information on your heart electrical activity during physical exertion (which you can not determine without the ECG leads on) and will help reassure that you do not have coronary artery disease.

Hope to have clarified some of your uncertainties!

Wishing all the best,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ilir Sharka 6 hours later
Thank you for your insightful and detailed response. You have helped my anxiety a great deal. I will not use anymore of your very valuable time. Best of luck to you in the future.
Answered by Dr. Ilir Sharka 10 hours later
Brief Answer:
You are welcome!

Detailed Answer:
I am glad to have been helpful to you!

If you have any questions in the future, feel free to ask me directly at any time.

I would be happy to answer to all of your questions!

Wishing all the best,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Answered by
Dr. Ilir Sharka


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