Anxiety or heart?

[tanns]

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.

[tanns]

How do you KNOW when the symptoms are IDENTICAL?  This is crazy!!  I feel fine for a few minutes and then it creeps up on me again.  My pulse is regular and NOT fast.  That would be a sign of anxiety/panic right-a fast heart rate??  I would be in the er right now if I didn't think it would send my family over the edge!  (They've been very supportive through this stuff but it is getting old!)

[RCA7591]

tanns,

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

[heartfluttersflyawayplz]

wow ryan you are awesome

[louwho72]

I know what you are going through I do the same thing, it is so insane,
I just got out of the hospital a few weeks ago with the full, stress test stuff.

Everything came back great,, but I still have the symptoms. I ask the doc,how do I know if it is anxiety or really heart stuff, he said you dont, you have to come in and get checked out,,, I know if I went in every time I had a symptom it would be every other day,,, I say if you cant get control over your panic,, and the symptoms keep coming I would go get checked out... Its better safe then sorry.
I am sorry you are going through this,, it is hell,,
I hope things get better,,,

[396SS]

Ryan sums it up.  I have chest pain (right now actually), PVCs, faintness, and to sum it all up was diagnosed with a mild mitral valve prolapse only to get another opinion that says I have absolutely no prolapse.  Soooo, long story short - I've seen many cardios, had many work-ups over the years echos, monitors, stress tests) and all are FINE.  It is anxiety for me, that's for sure.  I take Toprol (beta blocker) and Valium as need for anxiety.  Works for me.  

[tanns]

Ryan,

Thanks for your very detailed response.  For those who are reading this I must sound like a complete basket case but I assure you, I'm not.  I guess that is what makes this so hard for me.  I didn't have any problems until Nov 05.  An out of the blue panic attack sent me on a cardiac rollercoaster that has lasted this entire time.  It took me a good year to see that panic attack as just that---a panic attack and not a heart attack.  I still don't have a reason for that panic attack and that, too, bothers me.

I agree though, it is highly unlikely that I have a cardiac condition that was missed by FOUR cardiologists and two rounds of thorough testing.   After many other doctors as well, I finally went to a psychiatrist who was to say the least, very unhelpful.  Within 8 minutes he wrote a prescription and by 20 minutes I was out the door with an Effexor prescription in hand and appointment for 30 days.  I cancelled the appointment and shredded the prescription.  I know I am not doing well but I know that THAT wasn't the answer.

I don't have a rapid resting heart rate and rarely, even though I think I am panicky feeling, does it go over 100 (except exercise and exertion).  I do, however, have quite a few of the other symptoms.  I don't know what to do now.  I could go back to my first cardio, he is willing to prescribe anything.  He gave me xanax the first day and Lexapro within a month (back in 05 when this started).  Neither helped and the xanax was a complete nightmare.

I deal with chest discomfort daily in some form.  Yesterday and today seem different but I don't know really if they are too different.  They are more heightened though and that scares me.  I don't feel like I am getting a deep breath and the chest is achy now, probably because I was tense in my sleep.  

Thanks for responding.

[RCA7591]

tanns,

Effexor (SNRI) is reported to induce or worsen cardiac manifestations of anxiety. It is also reported to increase blood pressure (in particular, diastolic blood pressure). Wrong choice of med for you, IMHO. Good thing you never took it.

Lexapro (SSRI) is no better for addressing cardiac manifestations of anxiety (it usually worsens it). Again, wrong med in my opinion.

Xanax is indicated for the temporary relief of generalized anxiety, and is best suited for sporadic attacks. It is also valuable for terminating a panic attack. Xanax is a poor choice for the long term management of anxiety disorders, and Cardiac Neurosis is a long term disorder. In some folks, the fast onset of action also causes extra-pyramidal side effects (opposite to those the drug is intended to treat).

Klonopin has a far slower onset of action (1 hr average), and reaches 1/2 of steady-state in roughly three days when dosed BID. The effects are much more subtle when compared to Xanax, which reduces the likihood of extra-pyramidal effects. Klonopin is also indicated for the long-term management of anxiety disorders, and the smooth accumulation to steady-state (and maintanence of steady-state when dosed BID) makes it the ideal anxiolytic.

In the case of anxiety states presenting with cardiac manifestations, cardiac neurosis, or dysautonomia, the anxiolytic (Klonopin) may not be enough to supress all symptoms. This is particularly true if there is sympathetic or autonomic hyperactivity (inappropriate release of adrenaline).
Therefore, the addition of a beta-blocker is often necessary to obtain maximum benefits.

I would still recommend Klonopin (starting dose 0.25 bid, increasing to 0.5 mg bid after three days), and a beta-blocker.
There are various types of beta-blockers on the market, some non-selective and some cardio-selective. The cardio-selective beta blockers have fewer side effects. The dose needs to be individualized to the patient's needs (this may take some trial and error).

My initial thought would be Klonopin 0.5 mg, bid, combined with Timolol 5 mg, bid (titrating the dose of Timolol as necessary, until the desired effect is obtained). Average dose of Timolol is 10 mg, bid.

A cardio-selective combination may include Klonopin 0.5 mg, bid, and Atenolol 25 mg, qd (titrating the dose of Atenolol until the desired effect is obtained). Average dose of Atenolol is 50 mg, qd.

Since the shrink was a quack, I'd ask the cardiologist about implementing one of the combinations above. Ultimately, one of them will help you (again, some trial and error may be needed).

I read your post on the heart forum. 64-slice CT produces more false positives than false negatives (likewise for the nuclear stress test). Provided those were clear, along with the ECHO and MRI, the liklihood of you havng heart disease is slim to none. If there was any remaining doubt, cardiac catheterization would've been suggested and performed. Fortunately for you, technology has advanced to a point where you were not required to undergo catheterization (an invasive and risky procedure).

-Ryan

[tanns]

I went to the cardiologist yesterday.  They did an EKG and, of course, it was identical to the one they did initially back in 2005.  I asked about klonopin and a bb and he was really, really reluctant.  Instead he wants me to see an internal med doc that is also a naturpath.  He said that he believes that cardiac wise there is nothing else that can be done and a bb isn't going to be the answer.   We did agree that anxiety is gaining control of this situation.  

I appreciate your help and advise.

[tanns]

".....and Cardiac Neurosis is a long term disorder"

Can this come out of nowhere??  I mean, I have never been a worrier and especially not a health worrier.  This all has come on after that first panic attack in Nov 05.

Does this type or similar disorders EVER go away?  Like I've said before, I left the Mayo Clinic feeling pretty good about my health.  I felt I had the top notch checkup and I thought that it would be enough to put all this craziness to rest.  Still the physical symptoms persist and they are quite honestly, frightening.

[RCA7591]

"Can this come out of nowhere?? I mean, I have never been a worrier and especially not a health worrier. This all has come on after that first panic attack in Nov 05.

Does this type or similar disorders EVER go away? Like I've said before, I left the Mayo Clinic feeling pretty good about my health. I felt I had the top notch checkup and I thought that it would be enough to put all this craziness to rest. Still the physical symptoms persist and they are quite honestly, frightening."

--end quote--

tanns,

The answer is yes, it can come out of nowhere. In fact, Neurocirculatory Asthenia never has a gradual onset. It is always abrupt, linked with a fixation on one's heart or heart function after some acute event (ie: panic attack).

You most likely attributed the first panic attack to a heart attack, and now have developed a heightened sense of awareness with regard to your heart function. You are also probably skeptical that what you experienced was indeed a panic attack. You likely still have doubts, and you are making yourself sick with obsessive thinking.  Some folks think they have had a stroke, brain tumor, etc. There is always a fixation on some bodily function. The term "hysteria" can be applied to all of the sub-variants, or NCA/Cardiac Neurosis for those presenting with cardiac complaints.

All of the variants fall into the category of "anxiety neurosis" or "somatoform disorder". They are all treated in much the same way, but NCA is more complex.

Will it ever go away? That's your decision to make, but the symptoms will fluctuate with your mood, and it usually gets "better" over a prolonged period of time. You're not going to have a heart attack (at least not anytime soon), and eventually, you'll come to terms with that fact.

Yes, the physical symptoms are real. They can all be attributed to hyperventilation, and to the inappropriate release of catecholamines (adrenaline) which stimulates both the autonomic and sympathetic nervous systems. Anxiety triggers both systems, therefore treating the anxiety (with the Klonopin), will help supress some of the inappropriate triggering. The actual physical symptoms that result from an overactive nervous system may be treated with beta-blockade (which blocks some of the effects of adrenaline). Therefore, the combination of Klonopin and some beta-blocker often gives maximum benefits. Using this combination of drugs and positive thinking may send the NCA into "remission" (but it may recur at any time, particularly under stress).

The only reason why you're not improving is because you still believe that you have an undiagnosed heart condition. You are re-living November of 2005 over and over in your mind, when you should've put it to rest after the negative Mayo work-up. Easier said than done, however. It's not quite that simple.

Would still highly recommend the Klonopin/Beta-Blocker combo, and some daily physical activity.

Best to you,

Ryan

[tanns]

I'm not sure if you'll see this, especially because it's on page 2 now, but I thought I'd give it a shot.

I just had a 24 hour urine for catecholamines and metanephrines.  I got a message yesterday that it was normal.   I did have bananas, citrus fruits and 1 diet dr. pepper that day and have since learned that these can interfere with the results.  Can't find out much info on that though, even by calling the lab.  Anyway, those results were normal.  That confuses me because I feel like the craziness that comes on after some of the chest discomfort is so misplaced.   I was in the pool today with my kids and feeling pretty relaxed and bam, it starts again.

Also, I have said from the start that it feels like there is something stuffed inside my left chest.  When I lay on my stomach it feels like something is in there pushing that side up and making it very uncomfortable.  I have noticed it feels a little like if you were to pinch a hose in half and the pressure of the water builds up.  It is very odd.  

Believe it or not, I do feel very comfortable with my workup.  Well, most days.  If the horrible heartburn, chest, jaw or neck issues are persistant, I get scared.  The panic attack still confuses me but I could almost get past that if this nonsense would just stop.  I walk regularly, at least 4 miles a day most days.  I take a great multivitamin and eat pretty good.  

If anxiety has quick shots of a dread feeling, like your going to die.  And a jittery, crazy feeling in the head that makes you think you should be trembling all over, but your not.   And if you feel like you are going to throw up and swallow hard to keep from doing that at times.  And lots of little things too.  If that is what it feels like, then I have to throw my hands in the air and accept that I have that too.  If the chest pains, neck and jaw and heartburn symptoms are all part of that, then I MUST be causing them and so far, no amount of positive thinking and self talk is working on getting rid of those.

Wow, that really didn't make sense.  Well, it feels better just to get it out.  Thanks for responding and advice.  I do appreciate the time.

[RCA7591]

The foods you consumed could've had an impact on VMA (vanillylmandelic acid), but not on the fractioned catecholamines and metanephrines.

Normal results exclude Pheochromocytoma as a basis for your symptomatology. Unfortunately, the results won't be positive for anxiety induced catecholamine release (which is the endogenous form).

I assume they ruled out a thyroid condition as well?

The only other thing(s) worth testing from an endocrine standpoint is Cortisol and PTH (parathyroid hormone). The Cortisol should be of the 24-hr collection type.

If those two come back normal, I'm not sure what else I can add that hasn't already been discussed.

-Ryan

[tanns]

Thyroid did come back normal.  I did see an endocrinologist at the Mayo too but it was not a very good visit.  It was about an hour after my stress-MRI where I was injected with adenosine.  Not a very pleasant experience and I was VERY "out of it" for the visit.  I felt drugged and I think it was just the "stress" of the MRI injection.  Anyway, he did an exam but the internal med doc is the one who did most the lab work (all normal results) or it had just recently been done by my local doc.  I had a blood cortisol level but not the 24 hour one.  

I appreciate your thoughts and opinions and the time it took to write them.

Thanks.