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Angina or costochondritis or anything else?
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Angina or costochondritis or anything else?

Myself 38 year old male. Never touched tobacco or alcohol.

It all started from late last year (October 2009), when I felt I've some problem in breathing and a pinching pain at the left chest at times. The pain often radiated to the left shoulder and left arm. In the arm the pain was particularly in the inner sides and near the armpit.

As suggested my primary care physician(PCP) I underwent an ecg followed by an treadmill stress Eco test (full Doppler and color Doppler). All results were normal.

The PCP told it might be a case of anxiety/stress.

Last time (may,2009) I checked my Triglycerides was 89, HDL Cholesterol: 50, LDL Cholesterol 114, Total Cholesterol/HDL ratio: 3.6

Days went on and the pain came and go. The duration of pain varied from a few seconds to several hours. Sometimes it felt like a sharp pinch and sometimes a dull ache or tightness or just plain discomfort. Even after the pain vanishes, sometimes I had a feeling of malaise for a whole day. The breathing difficulty was also there.

I've noticed physical exertion has little role in causing the pain, but if I'm awake late at night say till 1-30 AM or get angry and shout it causes the pain to appear.

In January end this year I had a strong discomfort while sleeping at night and that woke me up. I went to my PCP next morning and got an ECG done, all normal again. Next week I had a 'nuclear stress test' with all normal results. The doctor again said it could be a skeleto-muscular pain triggered by stress/ anxiety.

Till date I live with the pain that comes and goes.Same varied chest pain that radiates to shoulder and left hand.

I've the problem of breathing too. It's not that I've to gasp but it feels like my lungs are not completely filled up. Late night out triggers the pain and I'm trying to go to bed early. I've no sleeping problem.

Painkillers like Naproxen or Ibuprofen helped me only little. I've located some points on my ribs and rib joints that pains when I press them, but that's NOT severe pain and the pain on those points comes and goes too.

So what's going wrong ? My PCP(splz. internal medicine) ruled out cardiac problem. Or do I have to consult a cardiologist ? can this be a case of Costochondritis or anything else?

BTW I've a high uric acid detected since May,2009 and I'm also deficient in Vitamin D, for which I'm taking Vit. D supplements.

Suggestions  are most welcome
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Avatar_f_tn
Here's what you know so far:  (1) Something hurts in your chest.  (2) You sometimes have trouble breathing, as well.  (3) From the work-up that you've had, it doesn't seem like your heart is the source of the problem.  (4) The pain and dyspnea don't seem to be going away by themselves.  

I think a reasonable person would continue to pursue a solution.  

Just from my totally nonprofessional opinion, it seems like it's time to start looking at the other organs and structures in the chest.  Lungs, bones, aorta, whatever.  Have you had chest x-rays?  That's a cheap test, easy to tolerate, and it would give you an overview of the chest.  CT or MRI could be done subsequent to simple x-rays, if indicated.

Do you have fever or any other signs of infection? Have you had basic blood chemistry (besides the cholesterol) and CBC done?  Those are cheap, also.  

Anxiety, I don't know.  That's sometimes an easy answer for the docs when they can't point to anything else.  You don't need to post the answer to this, but I'll ask it for you to think about -- do you have a pattern of translating your mental stress into physical symptoms?  People don't usually start doing that at age 38.  If you've always had a tendency to express anxiety in terms of physical aches and pains, that's one thing.  But if that's never been your style, then I doubt you're doing it now.  

Good luck.

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I'm just stabbing in the dark, but what about coronary spasms?   Maybe somebody that knows more about that (or anything else) can weigh in, here.
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712042_tn?1254572809
I'm losing my posts to you.I'll send a note.I have heart spasms all the time.Do the chest x-ray via your PCP to eliminate non-displaced rib fracture etc. Then go to cardiologist if CXR is negative.Remain calm,spasms can occur with or without exertion,and react to cardiac demand stressors like shouting, fight or flight.There are good calcium channel blockers that can help. Joan. Thanks sykdnsr.
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Avatar_m_tn
many thanks skydnsr and joanincarolina. I'm yet to do chest xray. I'll ask my PCP for it.
And I DO NOT think I'm anxious or stressed to such an extent that I'll get all these.

I forgot to mention that I used inhaler(salbutamol) to get relief from breathing problem, but that didn't help me AT ALL.

I had a total blood cell count in May,2009. I believe it was all fine. The report is as follows:
WBC 6.4,RBC 5.11,Hemoglob 14.4,Hematocrit 42.5, MCV 83, MCH 28.1,MCHC 33.8,
RDW 13.4, Neutrophil 61.4,Lymphocytes 28.8, Monocytes 7.8, eosinophils 1.4, basophils 0.6, platelet count 176

Thanks again
  
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Your blood work was done several months before the symptoms started, so maybe have that repeated to rule out a low-grade infection.  If you're not having fever, coughing, phlegm, or other signs of infection, I think it's unlikely.  But it's a cheap test, and it has been going on a year, now, since that was done.  

Also, as someone who has had an aortic aneurysm, I always think of the aorta.  A thoracic aortic aneurysm wouldn't be expected in a young person, but it's not unheard of, either.  The basic shape and size of the aorta can be seen on a chest x-ray, and if it doesn't look normal, you can have more detailed imaging.  Or if for some reason the aorta is not clearly shown on the x-ray, you can keep it in the back of your mind to have it checked out.  If the thoracic aorta is suspicious, that's a cardiothoracic surgery issue.
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Vitamin D deficiency?  Maybe there is a bone issue, perhaps a nondispaced fracture as joan suggests?
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PS, about the chest x-ray, get the radiologist's report.  Actually, I suggest getting all of the written reports on all of your tests.  What the doctors tell you and what they write in your records is sometimes two different things.  For instance, the first time I went to the emergency room with what turned out to be a bad aortic valve and aortic aneurysm, I was given a chest x-ray as part of the work-up and was told by the ER doc that the x-ray was "normal."  When I looked at the radiologist's interpretation, a long time later, the radioloigist had said right there, "aortic ectasia."  (Ectasia means enlargement.)  My aneurysm was visible on a simple chest x-ray, well before anyone thought it had any signficance.  
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Avatar_m_tn
Many thanks skydnsr. I've the thorough reports of the two stress tests. I'll try to post it here. So far I've no cough fever etc. problem. Is coronary spasm is also known as Prinzmetal's Angina?

BTW I'm 5 Feet 9 inches tall, and 190 pounds. I do sedentary work in front of computers
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I had never heard of Prinzmetal's angina before, but apparently yes, it is the same thing as coronary spasm.  (I just looked it up.)  Hopefully, joanincarolinal will respond more fully, because she is the one who knows about coronary spasms.  I never heard of coronary spasms until recently, when one of my friends was diagnosed with them.  I think they are also called cardiac spasms or heart spasms.  My friend told me that they also used to be known as coronary asthma, in the old days.  

With coronary spasms, the coronary arteries constrict for no known reason, and that causes an angina attack.  People who have coronary spasms don't necessarily have plaque in their arteries.  The arteries can be completely clean and without any blockages.  So I think coronary spasms can be tricky to diagnose, because unless you happen to have an attack during a stress test or an angiogram, nothing shows up.  I take it you never had an attack during your stress tests?

Maybe an event monitor would show something when a person had a coronary spasm attack; I don't know.  Another question for joanincarolina.

Nitroglycerine is supposed to relieve the pain from coronary spasms, so maybe it would be diagnostic if you could try nitroglycerine when you get your chest pain.  I don't know what the consequences of taking nitroglycerine would be if you DON'T have angina; you would need to know that before trying it.

How's your blood pressure in general, and have you ever taken your blood pressure when you were having one of the attacks?  ACE inhibitors usually help prevent coronary spasms.  My friend that has them was taking spironolactone prior to her diagnosis with coronary spasms, and she could never tell that it did anything for her.  As soon as she started on Norvasc, which is an ACE inhibitor, she felt better than she even knew she could feel.  And she didn't think she felt that bad, to start with.  It's just that there was a dramatic difference in her sense of well-being when she went on the Norvasc.
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712042_tn?1254572809
I'll answer the questions. First, the best term for coronary vessel spasm is 'variant angina'. No tests caught any of these spasms;I was hospitalized after my first negative cath and would have the nurses run an ekg strip when I had the spasms/pain..NOTHING.I'm a cardiac nurse and saw the strips myself. Stress tests I passed according to the test parameters, even when I was clutching my chest and short of breath. PVCs and aberrant beats, shortness of breath on exertion,pain,holter monitors etc meant nothing.Later years found T-wave conversions but at that point the spasms were a regular event. Nitro does relieve them but they can generally come on so quickly that it's like putting the cart before the horse.It relieves some of the after-burn and even with me wearing nitro patch, I still have them. Only adverse reaction with nitro may be a headache..never had one. A calcium channel blocker (CCB) is helpful; norvasc can be a good choice.There are categories of CCBs, and when one doesn't work try another, or in some combo. Spasm:think of a larger heart vessel that in a second(s) quivers and narrows quickly, reducing blood flow to whatever part of the heart the vessel feeds, even down to microvessel level, and quickly opens back up.No damage (?) to the heart muscle but it is painful. My local heart doctor understood my symptoms, regardless of negative tests.I'm a little complicated with MVD on top of or concurrent with the 'finally caught' vessel spasms.Joan
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I have also had variant angina also known as prinzmetals.  I was diagnosed during 2nd heart attack because my arteries wouldn't quit spasming.  After the first attack, docs put me on beta blockers which exacerbated my spasms.  Apparently I have an allergy to them.  Now I am on calcium channel blockers, imdur (all day nitro), sublingual nitro, ranexa for angina, they did put a stent in the artery in order to stop the spasms so I also take plavix to prevent clotting as well as aspirin and lipitor.  It isn't something to mess with and I was VERY healthy prior to all of this.  Don't let docs tell you it is nothing or not related to heart.  Good luck :o)

Jules
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Avatar_m_tn
Now I've a new blood test report. I've been in the emergency room for a lower right abdominal pain recently. As I had the chest pain at the same time so the ER doctors did some cardiac tests too.

The lipid profile report is quite good as the doctor thinks:
TG:95 HDL:40 and LDL:51, Chol:110

In the ER I was put on a continuous heart beat monitor for 18 hrs. at least, cardiac protein markers tested (which were all normal) and a couple of EKGs, all normal again. I had a resting heratbeat of 75-80 most of the times. My Blood pressure generally keeps on a lower side with 100-110/90.

One 'strange' thing was noticed however. In the ER while I was resting, my heart rate suddenly shot to a staggering 170 , but within say five seconds it came down to normal. I felt a simultaneous push on my left chest, something i never felt before. Almost immediately an EKG was  done but again with no abnormalities.  I got discharged after 24 hours with no cardiac problem.

My pain occasionally came back, and recently I visited a cardiologist, who after judging all my parameters told that this DOESN"T look like any cardiac problem including coronary spasm and statistically I've a very low chance of having a cardiac problem.

Still I'm having the chest pain, today after having a cup of coffee and lying on the couch I had a sudden dizziness lasting for about 60 seconds, the first time I felt after after quite a few years !!!!!!

I really don't know what's wrong with me.

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Avatar_m_tn
*My BP varies between 100-110/70
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Avatar_m_tn
I am 100 percent sure you have costochondritis.  It can be chronic and very painful.  My father, who is the best diagnostician I know, has suffered from this since he was young.  Every one of your symptoms, the pain in ribs, armpit, down the arm, breathing, scream costochondritis.  If you find something that works, please let us know.  Would love to rid him of his pain.
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