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What Causes Severe Anxiety And Chest Pain In An Elderly Person?
Question: I am a 56 year old who until recently had a relatively stable bicuspid aortic valve (moderate regurgitation). I have no symptoms (other than feeling tight feeling around the chest and back and severe anxiety, which based on heart tests the sensation has been determined to be of non cardiac nature and most likely anxiety or oesphagititis related). It is not made worse by exercise.
Notwithstanding, my regular annual stress echo has identified some issues and left me confused about where i stand with my condition. I am trying to interpret the results of my stress echo test and do not know what they mean:
(1) No induced chest pain or ST segment depression
(2) Normal LV size, with normal resting systolic function. LV volume =126ml, EF = 66
(3) There were no resting regional wall motion abnormalities detected
(4) Mild dilatation of the aortic sinuses and dilatation of the ascending aorta. The trans sinus diameter measures at 4 cm. The sino tubular juncture measures at 3.7 cm. The ascending aorta measures at 4.1 cm
(5) Bicuspid aortic valve with moderate -severe (3/4) aortic regurgitation
(6) No induced regional wall motion abnormalities
(7) No evidence of inducible ischemia at cardiac workload
(9) Normal sinus rhythm - 80 beats and no arrthrymias during exercise component
(10) Normal BP response to exercise
(11) Treadmill terminated at 7 and half minutes due to severe anxiety attack. The report actually says dypsnea but I was not short of breath at all just very nervous
(12) Immediate post exercise echocardiogram: There appears to be vigorous contractile augmentation in all myocardial segments, (LV vol =132 mls; LVEF =67. No induced regional wall abnormalities.
(13)Sub maximal augmentation of systolic contraction.
(14) Atrial Areas/Volume : LA Area 25cm2
(15) Rest LV Systolic function : LV Vol 126ml. LV Vol (BSA/SEX) ULN 164 mls; LV EF =66%
(15) Post EX LV Systolic Function: LV Vol 132 mls LVEF = 67%
Questions
(1) Can you explain in plain english what this means and my likely prognosis?
(2) I had recently increased my atenolol from 50mg to 100mg based on my psychiatrist trying to get my high anxiety levels under control. Could this have affected the outcomes of the stress echo? My Cardiologist said your psychiatrist would not have increased your atenolol to 100Mg. I assure you he did.
(3) At what stage am I likely to require a new aortic valve and do you think a minimal chest incision is an option?. The later is clearly my preferred option and appears to be the way of the future.
(4) Are the aortic related measurements a cause for concern?
(5) All my cardiologist said to me was see you in six months, you will need surgery and most importantly get your anxiety under control. If my condition is so bad, why have I not been referred straight to a cardiac thoracic surgeon.
(6) I have no restrictions on exercise which is good for me as an active person.
(7) My cardiologist is one of the best in Brisbane but I have asked my general physician for a second option from another leading cardiologist at the same practice. He has a good bed side manner.
Symptoms:
I have had continuous tightness around the chest and back for a couple of months- but based on my Stress echo and normal cardiogram my cardiologist is very confident that high anxiety levels is the culprit, particularly as it is not induced by exercise. No other symptoms, other than the Bicusid Aortic valve.
Medications: Atenolol 100mg - 50 mg in morning and 50 at night ; Kloponin -2 mg at night and 2 mg during day. The later helps brilliantly with sleep and controls panic attacks during the day. It just has a significant affect on coordination - with my tennis game suffering significantly .
Notwithstanding, my regular annual stress echo has identified some issues and left me confused about where i stand with my condition. I am trying to interpret the results of my stress echo test and do not know what they mean:
(1) No induced chest pain or ST segment depression
(2) Normal LV size, with normal resting systolic function. LV volume =126ml, EF = 66
(3) There were no resting regional wall motion abnormalities detected
(4) Mild dilatation of the aortic sinuses and dilatation of the ascending aorta. The trans sinus diameter measures at 4 cm. The sino tubular juncture measures at 3.7 cm. The ascending aorta measures at 4.1 cm
(5) Bicuspid aortic valve with moderate -severe (3/4) aortic regurgitation
(6) No induced regional wall motion abnormalities
(7) No evidence of inducible ischemia at cardiac workload
(9) Normal sinus rhythm - 80 beats and no arrthrymias during exercise component
(10) Normal BP response to exercise
(11) Treadmill terminated at 7 and half minutes due to severe anxiety attack. The report actually says dypsnea but I was not short of breath at all just very nervous
(12) Immediate post exercise echocardiogram: There appears to be vigorous contractile augmentation in all myocardial segments, (LV vol =132 mls; LVEF =67. No induced regional wall abnormalities.
(13)Sub maximal augmentation of systolic contraction.
(14) Atrial Areas/Volume : LA Area 25cm2
(15) Rest LV Systolic function : LV Vol 126ml. LV Vol (BSA/SEX) ULN 164 mls; LV EF =66%
(15) Post EX LV Systolic Function: LV Vol 132 mls LVEF = 67%
Questions
(1) Can you explain in plain english what this means and my likely prognosis?
(2) I had recently increased my atenolol from 50mg to 100mg based on my psychiatrist trying to get my high anxiety levels under control. Could this have affected the outcomes of the stress echo? My Cardiologist said your psychiatrist would not have increased your atenolol to 100Mg. I assure you he did.
(3) At what stage am I likely to require a new aortic valve and do you think a minimal chest incision is an option?. The later is clearly my preferred option and appears to be the way of the future.
(4) Are the aortic related measurements a cause for concern?
(5) All my cardiologist said to me was see you in six months, you will need surgery and most importantly get your anxiety under control. If my condition is so bad, why have I not been referred straight to a cardiac thoracic surgeon.
(6) I have no restrictions on exercise which is good for me as an active person.
(7) My cardiologist is one of the best in Brisbane but I have asked my general physician for a second option from another leading cardiologist at the same practice. He has a good bed side manner.
Symptoms:
I have had continuous tightness around the chest and back for a couple of months- but based on my Stress echo and normal cardiogram my cardiologist is very confident that high anxiety levels is the culprit, particularly as it is not induced by exercise. No other symptoms, other than the Bicusid Aortic valve.
Medications: Atenolol 100mg - 50 mg in morning and 50 at night ; Kloponin -2 mg at night and 2 mg during day. The later helps brilliantly with sleep and controls panic attacks during the day. It just has a significant affect on coordination - with my tennis game suffering significantly .
Brief Answer:
I'm waiting for the requested data to be uploaded
Detailed Answer:
Hi and thank you for asking!
I read your query and understood your concerns.
Based on the data you provided I would
like to say that the oly abnormalities present on the stress echo are:
- A slightly dilated ascending aorta (It should be confronted with previous echo examinations)
- A moderate to severe aortic regurgitation.
Fortunately for you there were no sign of induced ischemia during the test and this exclude heart as the main cause of your symptoms.
However moderate to severe regurgitation may aggravate your anxiety contributing to more and more panic attacks.
Before giving my opinion about aortic surgery I would like to check by my self your echo tests (it's very important to confront them with previous one). Can you please upload the echo reports?
I'm waiting for the requested data to be uploaded!
Wish you health!
Dr. Shehu
I'm waiting for the requested data to be uploaded
Detailed Answer:
Hi and thank you for asking!
I read your query and understood your concerns.
Based on the data you provided I would
like to say that the oly abnormalities present on the stress echo are:
- A slightly dilated ascending aorta (It should be confronted with previous echo examinations)
- A moderate to severe aortic regurgitation.
Fortunately for you there were no sign of induced ischemia during the test and this exclude heart as the main cause of your symptoms.
However moderate to severe regurgitation may aggravate your anxiety contributing to more and more panic attacks.
Before giving my opinion about aortic surgery I would like to check by my self your echo tests (it's very important to confront them with previous one). Can you please upload the echo reports?
I'm waiting for the requested data to be uploaded!
Wish you health!
Dr. Shehu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I do not have last years report - only 2013. Results as follows:
Exercise test EC G: the patient achieved a satisfactory workload and did not develop and tachyarrhrymias. The pulse and BP responses were appropriate. There was no induced chest pain. The recovery phase was normal.
Resting Echocardiogram: Satisfactory overall LV function (bicuspid aortic valve with moderate aortic regurgitation - mild LV hypertrophy /mildly dilated aortic root at 38mm.
Immediate post exercise echocardiogram - there has been normal augmentation of function in all segments.
Recovery Echocardiogram - no change
Conclusions:
1.Symptom limited test to moderate load
2. no induced arrhythmias
3.Appropriate pulse and BP response
4.No induced chest pain or ST depression
5. No induced wall motion abnormalities
6. No specific evidence of induced ischaemia or arrhythmias on treatment
Exercise Statistics- XXXXXXX Protocol:
Limiting event: fatigue
Heart Rate: Resting 77; Peak 144; Predicted 168
BP: Resting 135/80, Peak: 160/-mmHG
ST Segments: Omm for all
Workload: Resting 1.0 Mets; Peak: 13.2 Mets; Predicted 11.6 mets
M-Mode and LV function
LV diastolic: (3.7-5.5cm); LV Systolic -
LV Septum 1.2 (0.6-1.1cm) Posterior Wall - (0.5-1.1cm)
FS - (37+7%) EFC - greater than 50%
RVSP: 36 mmHG Peak LA area - 22 cm2
2D and LV function
LV volume 127 mls; EF Simpson 70 (greater than 50%)
LV Volume ULN 158 Mls
Exercise test EC G: the patient achieved a satisfactory workload and did not develop and tachyarrhrymias. The pulse and BP responses were appropriate. There was no induced chest pain. The recovery phase was normal.
Resting Echocardiogram: Satisfactory overall LV function (bicuspid aortic valve with moderate aortic regurgitation - mild LV hypertrophy /mildly dilated aortic root at 38mm.
Immediate post exercise echocardiogram - there has been normal augmentation of function in all segments.
Recovery Echocardiogram - no change
Conclusions:
1.Symptom limited test to moderate load
2. no induced arrhythmias
3.Appropriate pulse and BP response
4.No induced chest pain or ST depression
5. No induced wall motion abnormalities
6. No specific evidence of induced ischaemia or arrhythmias on treatment
Exercise Statistics- XXXXXXX Protocol:
Limiting event: fatigue
Heart Rate: Resting 77; Peak 144; Predicted 168
BP: Resting 135/80, Peak: 160/-mmHG
ST Segments: Omm for all
Workload: Resting 1.0 Mets; Peak: 13.2 Mets; Predicted 11.6 mets
M-Mode and LV function
LV diastolic: (3.7-5.5cm); LV Systolic -
LV Septum 1.2 (0.6-1.1cm) Posterior Wall - (0.5-1.1cm)
FS - (37+7%) EFC - greater than 50%
RVSP: 36 mmHG Peak LA area - 22 cm2
2D and LV function
LV volume 127 mls; EF Simpson 70 (greater than 50%)
LV Volume ULN 158 Mls
Brief Answer:
Following advice
Detailed Answer:
Hi back,
First of all I apologise for answering you after such a long time.
After reviewing your echo reports I would like to say that the aortic dilation is increased rapidly with 3 mm within 3 years (1 mm per year) and it should be considered for aortic surgery.
Also another important finding is that the aortic regurgitation has increased in severity over the three years period from moderate to moderate to severe.
My opinion is that you should be scheduled for an appointment after sixth months to confirm the actual progression rate. If the progression rate of aortic dilation (0.5 mm per sixth month) and or aortic regurgitation has become severe you should go directly for aortic surgery.
Hope this will help!
Wish you health!
Dr. Shehu
Following advice
Detailed Answer:
Hi back,
First of all I apologise for answering you after such a long time.
After reviewing your echo reports I would like to say that the aortic dilation is increased rapidly with 3 mm within 3 years (1 mm per year) and it should be considered for aortic surgery.
Also another important finding is that the aortic regurgitation has increased in severity over the three years period from moderate to moderate to severe.
My opinion is that you should be scheduled for an appointment after sixth months to confirm the actual progression rate. If the progression rate of aortic dilation (0.5 mm per sixth month) and or aortic regurgitation has become severe you should go directly for aortic surgery.
Hope this will help!
Wish you health!
Dr. Shehu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you . Just one more question. Assuming surgery is needed, am I a potential candidate for minimally invasive chest incision surgery.
Brief Answer:
Following advice
Detailed Answer:
Hi back,
It all depends on the type of surgery and on the results of examinations.
Since, most probably you will go for aortic valve replacement and for ascending aorta prostheses, you most probably will be a candidate for traditional cardiac surgery (instead of minimal invasive cardiac surgery).
However, the final conclusion will be made after all the needed test before operation.
Wish you health!
Dr. Shehu
Following advice
Detailed Answer:
Hi back,
It all depends on the type of surgery and on the results of examinations.
Since, most probably you will go for aortic valve replacement and for ascending aorta prostheses, you most probably will be a candidate for traditional cardiac surgery (instead of minimal invasive cardiac surgery).
However, the final conclusion will be made after all the needed test before operation.
Wish you health!
Dr. Shehu
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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