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Dr. Andrew Rynne

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What causes pain and heaviness in chest with shortness of breath?

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Dr. Sukhvinder Singh

Cardiologist

Practicing since :1998

Answered : 1306 Questions

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Posted on Mon, 25 Aug 2014 in Hypertension and Heart Disease
Question: Dear Dr.

I had a massive heart attack in the year 2000. Within two weeks angioplasty was performed on me in LAD coronary Artery. After four years i.e 2004 I had undergone Bypass surgery for four vessels grafting. Every year during medical checkup my TMT result was showing negative. This year also my TMT is negative and report is like this: I am 54 years old, height is 173 cm and weight is 64 Kg; total exercise period was 12 minutes and achieved 88% of maximum predicted heart rate with a calculated workload of 14.30 METS. There was no significant respiratory symptom related to exercise. Exercise was terminated due to fatigue and achievement of target heart rate. Resting blood pressure and response to exercise was normal. Resting ECG was normal. Exercise ECG: ST depression during exercise-4 stage. ST level was -0.90 mm in V5; XXXXXXX HR: 88 %; Maximum workload: 14.30 METs. Conclusion: good exercise capacity. Negative TMT. My other reports: EF as per ECO is 55 %, blood sugar and cholesterol reports are normal. I am taking medicine now Nikorane 5 twice a day, Tenelol-12.5 once in a day at night, Rosuva statine 10 once in a day and Clevix 75 once in a day. My problem is I am getting pain and heaviness in my right side of chest since ten years (after Bypass). Because of this I am feeling short of breath and heaviness while initial walking. I consulted Chest specialist and Gastroenterologist. Sonography, CT scan reports for chest and abdomen are normal. Colonoscopy and Endoscopy reports are normal. During barrium x ray reflux is detected. Gastroenterologist has prescribed me anti reflux tablet (Nexpro fast 40), which I am taking since five years. I am very much strict about consuming less oil, less fat and less Sugar in diet. My problem has reduced but not eliminated. One physician has advised me to go for angio graphy to rule out the right side pain and heaviness problem. My cardiologist is not suggesting Angiography because of Negative TMT report and said right side chest problem is not related to heart. What is your opinion? Could you please advise me what can I do now? What is the solution for this?

Warm Regards,

XXXX
doctor
Answered by Dr. Sukhvinder Singh 10 hours later
Brief Answer:
please see below.

Detailed Answer:
Dear sir
For a male of 54 years of age, 7 minutes and 48 seconds of exercise which makes 8.8 METs is excellent capacity. You have much more than this with a negative TMT. I will not advice angiogram in any such patients.
If pain is related to reflux, it usually increases after meals especially if one take large meal with lots of water and goes to bed early after meals.
It may be a pain related to surgical wires. You can consult your cardiac surgeon. It may be simple ribs related pain, you may consult an orthipedician.
Avoid large meals, drinking water with meal and going to bed early after meals.
If the pain increases on touch or pressure, it is likely to be local.
Sincerely
Sukhvinder
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sukhvinder Singh 20 hours later
Dear Dr.

I have attached my medical reports for your reference. Please go through my report and after reviewing it please suggest further medical checking is required for heart or Stomach. I have under gone through TMT, 2D-EcoCardiography, Esophago Gastro Duodenoscopy, CT Scan of chest, CT Scan of Lumbosacral Spines, USG Abdomen, Barium meal examination, CT Scan of Chest and whole Abdomen. All reports are normal. I am consern about my symptoms and worried about it's permanent solution. Otherwise I have to manage to live with same symptoms in future.

Warm Regards,
XXXX
doctor
Answered by Dr. Sukhvinder Singh 5 hours later
Brief Answer:
PLEASE SEE DETAILS

Detailed Answer:
Dear Sir
I have gone through your reports. There is marked gastro-esophageal reflux. I asked you how your pain is precipitated and suggested a few circumstances but did not get reply on them. Please detail them.
What happened during the TMT test/ Did you get that pain or not?
There is evidence of disease of spine at certain levels.
Two very important aspect of pain are how it is precipitated and the clinical examination findings.
Waiting for your reply.
Sincerely
Sukhvinder
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sukhvinder Singh 4 days later
Dear Dr.

Thank you very much for your reply. My pain and heaviness is from front, back and below the right side of chest rib. Because of this I feel littel short of breath during normal condition. When I walk, initially I feel right side heaviness and short of breath. After walking one Kmtrs it gradually goes away and I feel better. During TMT I have not experienced chest pain. Infact after completion of TMT, I was feeling better. I also started believing that this pain and heaviness is because of nerves or surgical problem. Two months back my Gastroenterologist had prescribed me Nexito 10 for one month. During that period I was littel comfirtable. As per my knowledge this tablet is for treating anxiety and nerves pain. I am not taking large meal and going to bed after one Hr. I am happy to know that you are not suggesting angiogram. Again I request you to answer me that what is your opinion after gone through my scane TMT report ? Any further investigation is required or not ?

Warm Regards,
XXXX
doctor
Answered by Dr. Sukhvinder Singh 3 hours later
Brief Answer:
please see below.

Detailed Answer:
Dear Sir
The relief of pain with nexito and medication related to reflux point to a cause not related to heart. Moreover absence of pain during tmt with excellent exercise capacity rules out the pain to be anginal. I would like you to consult a good internal medicine specialist. Right now, it will not be prudent to advice further tests.
Sincerely
Sukhvinder
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
doctor
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Follow up: Dr. Sukhvinder Singh 45 hours later
Dear Dr.

As per your recommendation, I will definitely consult good internal medicine specialist. I want to know that during my TMT cardiologist has stopped Tenolol-12.5 before 24 Hrs and continued Nikoran 5. Is it Ok ? Reason for asking this question is that many cardiologists are suggesting to stop Nikoran 5 also before TMT. What is your view on this?

Warm Regards,
XXXX
doctor
Answered by Dr. Sukhvinder Singh 1 hour later
Brief Answer:
Please see below.

Detailed Answer:
Dear Sir
Beta-blockers like atenolol or metoprolol should be stopped for 4-5 half-lives i.e. approx 48 hours prior to test and nikoran and nitrates should not be used on the day of test. Since 12.5 mg is a very small dose of tenolol , its effect on test, when stopped 24 hours prior to test, will be negligible.
However, nikoran given on the day of the test may influence the results. Still you had a very good exercise capacity.
What would have happened if nikoran was also stopped on the day of test is anybody's presumption.
My query will be if Nikoran was so effective that it prevented development of angina during so much of stress, why is it not preventing angina in your day to day life. Hope you got my point.

Feel free to discuss further.
sincerely
Sukhvinder
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Sukhvinder Singh 18 hours later
Dear Dr.

Thanks for reply. What is your view on CT Angiography ?

Warm Regards,
XXXX
doctor
Answered by Dr. Sukhvinder Singh 5 hours later
Brief Answer:
please see details.

Detailed Answer:
Dear sir
1. In our practice we usually restrict CT angiogram to patients with low probability of having disease. Your case is of course of low probability after negative treadmill test. But there are issues. It uses 70 ml of XXXXXXX almost double that is used in conventional angiogram. There is risk of allergy and kidney damage. It also has its share of false positive results especially in right coronary artery images. Then we have to go for conventional angiogram. If it shoes lesion in non significant areas or small vessels, again we will have to rely on stress test.
Advantage will be if it comes out to be totally clean, we will be sure about coronary arteries.
2. I will suggest examination by a good internist before any further test. If he also could not find any other cause, CT angio may be an option.
Sincerely
Sukhvinder
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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