Spasms Under Left Breast and Rib Cage

Hi,

My symptoms of left-sided chest spasm with and sometimes without pain started during my third pregnancy. The sensation primarily resides underneath my LEFT breastbone, neck and jaw, and sometimes sharply on the top of the left side of my head.  

Cold air is definitely the strongest provocation, as is stress and prolonged or heavy, sudden exertion. Sometimes I can even feel the spasm by placing my hand underneath my left breast. (It's that strong).

I'm 39, a non-smoker, not overweight or unhealthy other than the spasms which started during my third pregnancy. I had an extensive work-up at the CCF, including an ergonovine cath for possible coronary artery spasm. Although I experienced SEVERE chest pressure when the ergonovine was injected, the echo didn't reveal a "focal" artery spasm, and the cardio recommended that I have an esophaegal motility study.

My local doctors, (a GI specialist, cardio and internist) conferred and said that the GI study wasn't indicated, and sent me to a reknowned cardio who specializes in female-pattern heart disease instead. (They did scope me and test for acid reflux, both which were negative).

My new cardio said that more than likely, my experience during the CCF cath was a "global" reaction to the provocation agent. He recommended a second cath and participation in the NHLB's WISE study.

After a positive adenosine cath, the cardio diagnosed me with endothelial dysfunction secondary to microvascular disease. (My coronary flow reserve was moderately abnormal, according to the cardio). I'm taking an ACE-inhibitor and diuretic, (my EF was 50%).

I'm blessed (and cursed) to be the daughter and sister of neurosurgeons. My father said the new cardio was a "charlatan," and that anyone injected with adenosine would experience what I did.

I am confused.

What can you tell me about microvascular disease; endothelial dysfunction; adenosine versus ergonovine provocation; and finally would you suggest any further work-up to see what else could be causing chronic, left-sided spasms?  

Thanks,
Carolina

[Kevin Pho, MD]

You clearly have had a comprehensive cardiac workup.  I can answer some of your questions.  I am not a cardiologist, and cannot comment on microvascular disease nor adenosine vs ergonovine provocation.

It has been postulated that endothelial dysfunction is the initial step in atherosclerosis.  Combined with family history, endothelial dysfunction can be an important predictor in coronary artery disease.

Endotherlial dysfunction has been the target of many investigational therapies in the prevention of coronary artery disease.  This includes L-arginine, N-acetylcysteine, and endothelial receptor blockers.  Of course, lowering the LDL cholesterol, smoking cessation, weight loss, exercise, and aspirin also should be done.  

If the cardiac management has been optimized, you can consider looking elsewhere for possible causes.  Despite what you have been told, GI causes can certainly lead to some of your symptoms.  Your endoscopy would have ruled out the major causes of the discomfort.  You can consider further GI testing such as esophageal motility studies (to evaluate for motility disorders).  A chest/abdominal CT scan can determine for any organ pathology or lung disease that may be leading to your symptoms.

These options can be discussed with your personal physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
kevinmd_b

[mmfd]

Carolina, try posting  your questions on the heart board at Medhelp.  The best times to get through are between about 8 and 11 am.  That board is free, and has physicians from CCF answering.  Good luck.

[tinsmansbronco]

A related discussion, breast spasm was started.