Question :

Persistent chest pain with normal stress test and echo?

Dear Ask The Doctor:
I am 38 yrs male, smoker about 5-6 nos per day, wt. 78 kgs, occasionally drinker, employed in polluted metal processing industry (dust, fumes, heat) since last 15 yrs. I do not have any family history of heart diseases except of my maternal uncle who suffered an attack recently at 52 yrs age. I am experiencing peculiar pains (a sort of periodic pin piercing) in my left chest since past 5 to 6 months along with gas forming sensations and a muscle pulling sensation near left collar bone at back, also slight shivering in left arm and face. Also sometimes I feel deep breathing while at rest (no particular time pattern), however this does not happens on stress. These symptoms occur throughout the day at irregular intervals each lasting for about 5 to 6 minutes. Please note that these symptoms do not worsen on stress (I regularly work on treadmill for 10 to 15 minutes daily). I had a checkup with two well reputed Cardiologists and underwent some tests including Lipid profile, Echo cardiograph,E.C.G,Stress TMT and Stress echo cardiograph. 1. Cholestrol-148 and 114 mg per dl 2. Triglyceride-86 and 112 mg per dl 3. HDL-31.7 and 43 mg per dl 4. LDL-121.1 and 48.6 mg per dl 5. VLDL-17.2 and 22.4 mg per dl 6. Blood sugar(Fast)- 93 and 92 mg per dl 7. Blood sugar (PP)-104 and 102 mg per dl 8. ECG- Normal in both the tests 9. Echo cardiography- Normal in both the tests 10. X-ray (chest) PA view- Normal Hilar shadows, Both Lung fields clear, Costo and Cardio phrenic angle clear, Cardiothoracic ratio within normal limits, Trachea centrally placed, Soft tissue and Bony cage normal, Both Hemi diaphragms well outlined - Normal Chest radiograph. 11. TMT- by Bruce protocol 11.A- Exercise time-9.08 mins rest HR-92, maximum HR-176 bpm (95 percent) rest BP-120-80, maximum BP-160-80 maximum Work load-10.10 METS Target HR achieved.(This was Stress TMT). 11.B- Exercise time-11.55 mins rest HR-96, max HR-168 bpm (90 percent) rest BP-120-80, max BP-184-100 max Work load- 19.30 METS, Target HR achieved. (This was Stress echo). Results of both tests- Resting ECG normal, Functional capacity normal, Good exercise tolerance, HR response to exercise is appropriate, BP- appropriate response, Chest pain none, Arrhythmias none, ST changes none, Overall impression- Normal Stress test, Negative for inducible ischemia. On having doubt about my lungs,I also underwent a CT scan of chest and P.F.T to check the status of my chest, whose results were: CT scan(Plain and Contrast study)-Lung parenchyma normal, no area of altered attenuation or focal parenchymal nodule seen, Trachea and main stem bronchi are normal, Mediastinal vasculature is unremarkable, Tiny lymph nodes in bilateral axillary region, Prominence of bilateral segmental and sub segmental bronchi with minimal peribronchial cuffing. Possibility of bronchitis with early bronchecatic changes. P.F.T- Spirometry Within normal limits, FEV1-FVC percent Pred- more than 95 and FVC percent Pred - more than 85. I was prescribed by my pulmonologist Grapto R, Muclear 600 and Monarquin 400 mg. I was prescribed by cardiologist 1 as Clavix- 75 mg (1 per day), Unincontin-400 (half per day), Clotezole 100 (half per day), Tonact 40 (1 per day), Vertidom (while severe dizziness), Budicort puffs (2 puffs - twice a day), Olways 20 (1 per day), Zevert MD 24 (one and half per day) whereas Cardiologist 2 prescribed Nitrocontin 2.6 mg (1 per day), Tonact 40 (1 per day) and Clavix 75 mg (1 per day) along with Harty (1 per day) tabs instructing to discontinue the rest Cardio-1 prescriptions. I am really confused which dose to follow since the pain sometimes still reappears and I think none of the prescriptions proved to be effective in curing my pain. As per both the cardiologists, my heart is normal, then why this pain is occurring and why such heavy doses of medicines? Also, please suggest whether I should go for Angiography or not (my present cardiologist says no need). Should I continue all medicines? Please guide. Sir, I am eagerly waiting for your early reply. Regards, Raman


Answer :

Dear Patient: 
Personally, I believe you should continue the prescription meds of Cardiologist 2 and the pulmonologist. Doctors follow certain guidelines but some of them have their own style. Some doctors are confident prescribing more medicines, others would want to keep it at a minimum and observe further. It is also possible you could have pulled a muscle on that area and that was causing the pain; sometimes, after it gets inflamed, scar tissue can develop which may cause persistent chest pain. Since you have done several tests already for the heart and lungs, and those were pretty accurate ones, I honestly think you don’t have a serious heart condition. You most certainly don’t need angiography.  Angiography is a procedure wherein a dye will be injected and finds its way to the blood vessels supplying the heart muscles. This will give a picture if these blood vessels are blocked or patent (open). I would agree with your doctor not doing angiography since your stress test, ECG and echocardiography are all normal. These tests, especially when done together, are very accurate in detecting clogged coronary (heart) blood vessels. It is also noteworthy that angiography involves radiation. Too much radiation is not good and can cause certain cancers as well. It seems you have anxiety issues. Anxiety can also cause chest pain. You have emphasized the chest pain is apparent when NOT in stress; chest pain of clinical significance is usually associated with shortness of breath, chest tightness, dizziness, fainting, and worsens during exercise (walking up a flight of stairs, running, etc). I also noticed the HDL (good cholesterol) was low and the LDL (bad cholesterol) was high. The goal should be to increase the HDL (good) and decrease the LDL (bad) cholesterol. This does not look good and is a risk factor for heart disease. I would suggest you re-direct your efforts in trying to correct these abnormal blood cholesterol levels. I commend you for doing exercises regularly and if you can increase it to 15 mins everyday, much better. Try quitting smoking if you can because it is also a risk factor for heart disease. With regards to food, have more of green leafy vegetables because it will prevent absorption of cholesterol from the diet. Use canola oil, olive oil, eat more of peanuts, pecans, walnuts, avocado, salmon and mackerel. I do hope I have appeased your concern and take care always.


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