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Anxiety Community
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Anxiety or heart?
by tanns, Jun 12, 2007 12:00AM
I have been battling chest pains for going on two years now. I have had the full run of tests (twice over) and all have come back clear (have not had cath). I am have been told anxiety and have fought that diagnosis for a long time. I tried Lexapro which did nothing for the chest pain.
Anyway, I have not been feeling 100% for a while and have just "dealt" with it because I knew I've had a really good workup by more than one cardio. Today is different. I have the chest pain, as usual, but I have a tightening up my neck and into my jaw (which I've had before too). I am pretty scared but can't tell if I am getting panicky about it or if it is really something this time.
I feel nauseous and am fighting to stay "sane" if that makes sense. I don't have any other symptoms except those that are heart related. (I posted in the heart forum too because I am so freaked out now!).
I don't know if I have a specific question, just wondering if anyone has this weird stuff too. I don't have a long history with anxiety but I am quickly getting one.
Anyway, I have not been feeling 100% for a while and have just "dealt" with it because I knew I've had a really good workup by more than one cardio. Today is different. I have the chest pain, as usual, but I have a tightening up my neck and into my jaw (which I've had before too). I am pretty scared but can't tell if I am getting panicky about it or if it is really something this time.
I feel nauseous and am fighting to stay "sane" if that makes sense. I don't have any other symptoms except those that are heart related. (I posted in the heart forum too because I am so freaked out now!).
I don't know if I have a specific question, just wondering if anyone has this weird stuff too. I don't have a long history with anxiety but I am quickly getting one.
You have undergone more than an extensive work-up from a cardiac standpoint, and nothing significant was found to explain your symptomatology. You now present with chest pains with radiation to the left neck, of which the etiology is unclear. It is reasonable to state that this pain is not ischemic, and that it is not from a cardiac origin, for if it were, the doctors would've identified the source. It stems from a far more complex origin - the human psyche:
Your problem is Neurocirculatory Asthenia, also known as Cardiac Neurosis.
I will describe this psychiatric illness in great detail below. It is unique in that it presents with very real physiologic signs and symptoms, and often times they are indistinguishable from a true cardiac illness:
DEFINITION:
Neurocirculatory Asthenia (NCA) is a well defined symptom complex consisting of intolerance to effort, shortness of breath, palpitation, left chest pain, tachycardia, weakness, and anxiety; symptoms occur at rest or on exertion, and are out of proportion to the precipitating activity or to whatever organic disease may also be present. Always found in association with a psychiatric disorder, the syndrome may be considered a special physiologic expression of pathologic anxiety. Those cases diagnosed as NCA by the cardiologist are almost invariably diagnosed by the psychiatrist as anxiety states, anxiety neurosis, or anxiety hysteria. The justification of continued use of the term NCA lies in three considerations:
(1) The symptoms present a well-defined clinical picture.
(2) Often the physiologic component has become a disabling factor in itself, and special diagnostic studies are required to evaluate the cardiac status
(3) The physical disability may have been made more severe by enforced rest and avoidance of exercise, and the resultant poor circulatory responses to effort can be demonstrated in the laboratory in a fairly definitive way. Even so, it is better to consider the primary diagnosis an underlying psychiatric condition and to use the term NCA or effort syndrome as a qualifying term.
PRESENTING SIGNS AND SYMPTOMS:
The typical patient complains of breathlessness, tiredness, faintness, fatigability, palpitations, and precordial pain usually inframammary, occurring on light exertion but also at rest and with emotional stress. There may be a variety of vasomotor symptoms such as flushing and throbbing sensations. Some strictly psychogenic symptoms are often present; insomnia, restlessness, tremors, anxiety, apprehension, depression, and fantasies of dying. There may be partial or total disability. These patients are often of hysteric personality, very suggestible, and have picked up on medical terminology referring to the heart. There is likely to be some iatrogenic factor, in that warnings about the heart, childhood murmurs, and heart disease in near relatives have contributed to the patient’s fantasies about his heart. Sometimes a phobia for active exercise may be apparent when the patient is asked to exercise and he becomes anxious or apprehensive and has the typical symptoms before making any effort. Patients who consult a psychiatrist are likely to emphasize psychiatric symptoms -the conscious anxiety, depression, or fears; patients more concerned with the physiologic symptoms more commonly consult other practitioners. The chest pain is a pseudoangina, usually associated with tenderness of the chest wall or postural changes. *Signs* are those chiefly of anxiety; rapid resting pulse, rising higher than normal in standing, tremulousness, cold, clammy hands, and excessive sweating. The coldness of the extremities distinguishes the disorder from Hyperthyroidism. Breathlessness is of an irregular, rapid, shallow type rather than deeper breathing of heart or lung disease, and there are frequent sighs. The patients complain of not being able to get a satisfactory breath, rather than that of true dyspnea. The relationship to effort is inconsistent in that often the whole syndrome occurs without any effort at all.
PHYSICAL EXAMINATION:
There is usually a normal physical examination with the following exception: rapid resting pulse, rising more than normal on exertion or on standing; tendency to rapid/shallow respiration with sighing; fine tremors of hands. An early, systolic murmurof the usual functional type is present in about 1/3 of the patients without heart disease. The sleeping pulse drops to normal, unlike the pulse in Hyperthyroidism. Mental examination reveals an apprehensive, suggestible person, usually preoccupied with his illness.
COURSE:
NCA is always associated with a psychiatric illness, usually an anxiety state, and follows the course of the underlying disorder. Some persons have symptoms for many years and may have a variety of hysterical and hypochondriacal fixations. A phobia for effort, or other phobias, may have developed particularly for crowds and crowded or closed places. Rarely this syndrome will present in a pre-psychotic or psychotic patient. Symptoms fluctuate with state of mind, and a patient who is temporarily confident and feels happy and successful may lose his NCA only to have it return when he again becomes anxious or fearful, or feels defeated. In other patients, the syndrome becomes fixed and a phobia for exercise eventually develops, and if untreated, may last for a lifetime. NCA accompanying medical ailments such as convalescence from a severe febrile illness tends to improve with time as anxiety lessens. Patients with coexistent heart or vascular disorders may have considerably fixity of symptoms, although many improve following proper diagnosis and careful treatment of both the psychological disorder and the accompanying cardiovascular disease.
LAB FINDINGS:
The electrocardiogram is usually normal except in some patients with the changes on effort characteristic of sympatheticotonia, particularly a generalized depression of ST-T waves, sometimes with partial T inversion of chest leads CR4 - CR7.
TREATMENT:
Long-acting Benzodiazepine anxiolytic (Klonopin 0.5 mg, bid), and beta-blockade to reduce sympathetic activity (if present). Atenolol 25-50 mg, qd, Propranolol 20 mg, bid, or Timolol, 10 mg, bid.
Would suggest speaking with a Psychiatrist about Neurocirculatory Asthenia (in light of your multiple, negative cardiac work-up's). I know how real your symptoms feel (I've been there myself), but you need to take control of this before it buries you.
A cardiologist at a major medical center would also be knowledgable about this condition, but would be hesitant to treat it (as it is largely psychological). My personal cardiologist has stated that over his 40-year career, he has treated two types of folks: (A) Those with heart disease, and (B) Those who thought they had heart disease. The latter outnumbered the former.
Wishing you the best,
Ryan
I just got out of the hospital a few weeks ago with the full, stress