Atypical chest pain

[Charlote__0]

  I am a 55 y/o female with a strong family history of diabetes but am unaffected at this time.  I also have hypothyroidism treated with .15 Synthroid with a TSH of 2.09.  I was evaluated for atypical chest pain and have had an echo showing R and L atrial enlargement and L ventricular hypertrophy.  Recently I have had an increase in episodes of atypical chest pain which usually starts in my R jaw and may or may not proceed to my mid-chest.  I become diaphoretic, my BP generally goes above 170/90 (my normal is about 135/80) and my EKG shows no ectopy.  Nitro helped during this last episode which lasted more than 20 minutes.  Usually I just stop what I'm doing and ride it out knowing it will eventually subside.  When I was first diagnosed with hypothyroidism (Hashimoto's thyroiditis) I was having these pains at least once a month preceded by a week or so of increasing fluid build-up where I felt SOB.  An echo at that time showed MVP but once I was medicated appropriately the episodes decreased to no more than once or twice a year.  My echo no longer shows prolapse and a thallium exercise treadmill was essentially normal.  I still precede these episodes with the build-up of fluid, feeling more and more SOB until the chest pain occurs.  I have diuresed heavily afterwards with no diuretics.  My Internal Medicine doctor is at a loss and told me to try some research on my own.  My labs are essentially normal except for an LDH of 1250 and an AST of 49 which is a change.  Chest X-ray is WNL except for a linear density in the left base which is unchanged.  I told my doctor I'm just low on naturietic (?sp).  He just laughed.  He offered me a return visit to the cardiologist and if that evaluation is normal then a work-up with an EGD, etc.  I have a mildly progressive decreased exercise tolerance in the last year or so but am otherwise essentially healthy, working daily at my nursing job and maintaining my home.  I would appreciate any other suggestions you might have for follow-up.

[CCF Cardio MD - MTR]

Dear Charlotte, thank you for your question.  Your history is complicated, but I think there are a few areas to comment on.  First, the atrial enlargement and left ventricular hypertrophy are most likely caused by hypertension even though you state that your BP is usually normal.  Thus, I think you should check your BP frequently and seek treatment if it is consistently > 130/90.  Second, your hypothyroidism is appropriately treated since you now have a normal TSH.  I'm not sure why you had edema before treatment for hypothyroidism but you don't appear to have any left ventricular dysfunction, so that certainly would not be the cause of the edema.  Third, if your thallium treadmill test was normal, then I doubt that you have any coronary artery blockages.  However, the only way to definitively rule out blockages is to have a cardiac cath which is an invasive procedure that does carry some risk.  Fourth, your elevated LDH is not specific for any disorder and probably doesn't mean much.   Finally, I doubt that you have a deficiency in atrial natriuetic peptide (ANP).  ANP levels are rarely measured clinically so I wouldn't suggest pursuing that line of inquiry.  Thus, it may help for you to see your cardiologist again and you may want to discuss the option of undergoing a heart cath.
I hope this information is useful. Information provided in the heart forum is for general purposes only.  Only your physician can provided specific diagnoses and therapies.  Feel free to write back with further questions. Good luck!
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.   The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem