Chest pain

[maca]

I have been having chest pain off and on for 2 years with exercise or stress. A couple of months ago it began to happen more often and became more severe and occur at anytime. I am a female, 51 yrs. old and overweight (but I have lost 30 pounds and I still working on it). I also had a complete hysterectomy in 2001 and am not taking any HCT. My doctor put me on Metoprolo 25 mg bid and I am taking Benzepril/HCTZ 10mg/12.5 one per day, ASA 325 and Nitro prn.  Last year I had a positive stress test and in 6/05 I had a angiogram which showed normal except for genetically extremely small coronary arteries. the cardiologist instructed me to followup with my primary doctor, continue my medications and continue to lose weight and maintain my blood pressure as low as possible. The nitro does help to relieve the pain and I take it sometimes 2-3 days per week. My resting BP at home ranges from 106/60 to as low as 77/42, but at the doctor's office I am more stressed and it is around 130/77.

My questions are: Are small arteries common? If so, why have I not seen anything written about this in regards to angina? If I continue to lose weight will this help prevent the chest pain? Are the medications I'm currently taking appropriate? What do I have to look forward to in regards to my cardiac care in the future?

Thank you for your time in answering my questions as I have been trying to post these for some time.

[CCF-M.D.-MJM]

Hi MACA,

Are small arteries common?  IF so, why have I not seen anything written about this in regards to angina?

They are not common but we do see them.  The usually host is a long standing diabetic or some one who is over weight with glucose intolerance.

If I continue to lose weight will this help prevent the chest pain?

It is possible that losing weight could help.  You may have endothelial dysfunction -- this is a buzz word meaning that your endothelial cells do not secrete the vasodilators that they should, often related to diabetes or glucose intolerance.  The only way to confirm this is to do a invasive pressure measurement during an angiogram.

Are the medications I'm currently taking appropriate?

If the beta blocker isn't helping, it may be worth trying a calcium channel blocker.  It may help dilated the coronary arteries a bit better, but this is speculation.  The only way to know for sure is to try it and see if it helps.

What do I have to look forward to in regards to my cardiac care in the future?

If the chest pains are from endothelial dysfunction, there are some diabetic medications that are speculated to improve endothelial function -- the so called TDZ class.  A quick google search for TDZ and diabetes will explain more about this class.  This is not considered a mainline therapy yet but trials are under way.  It is unclear how much benefit it may provide.  There is another metabolic syndrome medication coming out to help with weight loss.  It is called rimonabant.  It is a few years from release though.

I hope this helps.

[Carolina03]

Maca,

I've been diagnosed w/ endothelial dysfunction due to microvascular disease after an invasive cardic cath w/ provocation. I had gestational diabetes x3, and am at risk for developing Type II.

I exercise daily, avoid high carbs and sweets. I'm less symptomatic if I adhere to this regime. Increased blood flow due to moderate exercise is probably the most beneficial. If you're symptomatic when you exercise, try building stamina by slowly increasing your work-outs, perhaps in a gym if your doctor gives you the go-ahead.  

I take Lisinopril, Inspra and nitro-spray as needed. I rest when I feel very symptomatic, but then find the will to move on after the chest pain leaves. I try not to let the disease get the best of me, but am smart enough to recognize when it's time to seek medical care.  

Below's some info on the benefits of taking Inspra, which is an aldosterone blocker. Ask your cardio about its benefits in relation to small vessel disease caused by glucose intolerance or diabetes. Studies are on-going, but the combo of the ACE and Inspra has helped me.

Best,
C

Aldosterone, a steroid hormone produced in the outer layer of the adrenal cortex, promotes renal sodium retention and potassium loss. Secretion changes occur in response to alterations of volume status or salt intake mediated by angiotensin II. Aldosterone reduces baroreflex sensitivity and enhances sympathetic activity resulting in reduced nitric oxide­mediated vasorelaxation. This results in reduced serum potassium levels and an increase in left ventricular mass and cardiac output. The aldosterone antagonist spironolactone reduces morbidity and mortality in patients with severe heart failure. The procoagulant properties of aldosterone with inhibition of fibrinolysis potentiate atherosclerosis. Renal glomerulus dysfunction results from basement membrane abnormalities, nephrosclerosis, and renal fibrosis induced by aldosterone, and leads to microalbuminuria.

The authors conclude that aldosterone has detrimental effects on the vasculature, cardiac tissue, renal mesangial cells, and the brain, as well as deleterious effects on baroreflex sensitivity and the autonomic nervous system. Blocking aldosterone actions may have positive cardiovascular and renal effects. Further studies are needed to investigate the efficacy of ACE inhibitor/ARB combinations and aldosterone antagonists in reduction of renal and cardiovascular disease in persons with type 2 diabetes.

RICHARD SADOVSKY, M.D.

McFarlane SI, Sowers JR. Aldosterone function in diabetes mellitus: effects on cardiovascular and renal disease. J Clin Endocrinol Metab February 2003;88:516-23.

[maca]

I guess that I am still a little confused as to why I have the small arteries and why they cause the chest pain. I am not a diabetic and haven't shown any tendency to glucose intollerance. I do exercise as much as possible, I walk 1/2 mile during my breaks at work (morning and afternoon) depending on the weather. I also swim laps 2-4 times per week. When I do have the chest pain I rest for while then go right back to my exercise.

[Carolina03]

Maca,

I am not a doctor, remember that.

Small vessels could be an artifact, i.e., characteristic of who you are, reflecting your genes, etc. It also could be reflective of "female pattern heart disease" where the arteries narrow diffusely. The lesions of typical CAD cause a more focal type of stenosis.

Endothelial dysfunction means that the inner layer of the arteries constrict or don't dilate normally, causing a coronary flow deficit which can result in angina.

There are many risk factors for heart disease, diabetes is only one of them. I'm sure you've read about metabolic syndrome, for example. Or inheritance. My mother has CAD. At the end of the day, even my doc can only theorize as to what triggered microvascular disease.

I hope this helps.

[TerryC]

Hi! You wrote that you have had chest pain off and on for 2 years with exercise or stress. I have chronic pericarditis about 2 years, and it gets worse if I exercise and I have had stress because of it about last six months. I have medication now but it seem not work very well. I am very frustrated.
I think you don't have the same disease, but I write here because there could be many reasons for your symptoms. I hope all best for You!!!

[Angie7]

TerryC.  I too have pericarditis. It is going on or about 7 weeks. I took naproxen for six days, which rid me of the pain. However, after I stopped it ,because it made me sick, the pain returned and I am now on Lopressor. Lopressor does not help to rid the pain and I am frustated. I cannot do normal activities, like walking without having pain.  I am so upset. I feel like a cripple. I must now either change doctors or get on another anti-inflamatory medication. Terry, I can understand your frustation. What medicines did you take for pericarditis? Did any of them work even temporarily? Do you know what caused your pericarditis?

[TerryC]

Hi! At first doctors only wait and see if my pericarditis would go away by itself. Well it didn't!
Then they  give me some anti-inflammatory drug for some weeks. I can't remember the name right now, sorry. It heped some time but the symptoms, especially pain, came back.
Then I get Prednisone for two-three months. It helped also but that drug has some nasty side-effects so my doctors recommend to stop it. It was a big releaf to get rid of the pain for some time, but the pain came back after stopping this medication.
Now I have colchicine. It helps me if I don't exhaust myself. I can now for example walk quite normally but not run. My cardiologist said that I have to take this medication at least a year.
I am sometimes quite frustrated and that's why I wrote to this forum. Thank You very much Angie for your concern:) I recommend that try colchicine or colchicine and anti-inflamatory medication together. Ask it from your doctor.
My pericarditis is idiopathic so the doctors don't know what is causing it. It is also recurrent.
There are some good writings in medhelp archive about recurrent pericarditis if you are interested. I think there is more opinions about colchicine.

[el_scorchito]

I am a 19 year old male, and have been in fairly good health so far.  I am overweight, with a BMI on 30.0.  Also, I have noticed an increase in my blood pressue, the highest reading being 155/42 (after a large meal).  I have had a rather annoying pain in the left side of my chest (near the sternum, also, at times, extending out furthur left on my ribcage) for the past 2 or 3 months.  The pain is fairly consistant, increasing in severity at times.  I did go to the emergency room once for the pain.  After an EKG, the emergency room physician diagnosed me with costochondritis.  I was prescribed an anti-inflammitory (Mobic), for one week.  The medication did somewhat help with the pain, however it has not gone away.  For the most part, the pain does not increase with excersize.  My biggest concern is that this issue my be cardiovascular related, which I understand isn't common @ my age.  I am not sure of what this pain may be caused by, or which course of action I should pursue.

[Angie7]

Terry..What are you specs?Do you know  or can you guess what triggered your pericarditis? Do you have palpitations,too? How was it diagnosed by your doctor? My cardio gave me an echo stress test and he rather confusingly expained that I had pericarditis.  Actually, I had just had an angiogram 4 days prior to the onset of the pain, by another doctor in the same office.  I am very sorry that I had the angiogram. It wasn't a necessity.I should have gotten a second opinion about getting the angiogram.

I am now 61. I think my angiogram stirred up a pain that I use to get rarely  about 30 years ago. Now I have that  pain off and on most days.
I was pain free for part of today.  However, aftersitting on the floor and lifting  a  5 lb dumbell with my left hand,the pain  returned. Took a tylenol and the pain disappeared for about three hours.
Terry, did you  run or jog, prior to your pericarditis? Can you exercise at all?I am finding it difficult to walk at a normal pace, now since my angiogram. I hope there is some opportunity for improvement of our conditions, through some kind of slow and careful physical exercise conditioning. Has anything in the two years worked at all for you?
To el_scorchito...It is a good sign that tests are negative and that you can mostly exercise pain free.  Count your blessings, keep asking questions, educate yourself  and hope the pain is skeletal while you pursue a healthy low fat diet and a suitable daily exercise program. Fear of the unknown is a scary. Forums like this are very helpful. Get second opinions.

[TerryC]

HI Angie! I am now 48. I have had recurrent idiopathic pericarditis now about two years. Some times it is almost away and I feel quite fine because of my medication. Perhaps I exercised too heavy too early and it came back? Now I take colchicin 2x0,5mg per day. It is a common drug to this disease. Have you tried it or Prednisone, a corticosteroid? If  pain is worsen I take also anti-inflammatory drug. Before pericarditis I like to exercise quite lot. I walked, ran, swum, played badminton etc. I was perfectly health.

I don’t know what triggered my pericarditis. My docs can’t find the first piece of my “pericarditispuzzle” and perhaps some of the last pieces are still not ciscovered yet. They flashed out possibility to some kind of surgery, but at first I try colchicin for a long time.

I had some palpitations when my condition was much worse, but medication lower the inflammation.
I have been severe times in  ECG, about eight times in echo and once in MRI. Both echos and MRI showed some effusion in my pericardial sac but neither didin’t show any reason to it.
When I was better I tried to exercice myself lighlty but the pain came straight back. You did experience the same when you lift the dumbbell. Now I don’t excercise at all, I only try to do the everyday doing’s  as light as possibly. Well, better days I walk  slowly max 4 miles, thats my “exercise” nowadays. Some times I feel so fine that I forget to be careful, so the pain cames back. If I now look back, I was worsen (I couldn’t walk without the pain almost at all, even breathing was painful) so this medication works somehow. I think I’ m getting better but very slowly.

Perhaps in future, after some painfree times, I can do some proper exercise. It would be wonderful! You have had pericarditis about two months or so? Avoid exercise now. Rest and wait calm and take medication regular. Is your doc a cardiologist? Cardiologists know this disease best and they can plan your medication, what is suitable just for you. What did cause your pericarditis? Is it recurrent? Have you had MRI? Perhaps your doctor try first common “wait-and-see-technic” because most of pericarditis gets better on its own. Still there are dozens of diseases that cause pericarditis so you have to demand examine if it’s still going on. I “tried” wait-and-see for seven months. I was seeing a (wait-and-see)doctor, not a cardiologist. After that I got my cardiologist and got first medication.

[Angie7]

Hi Terry. Sorry for the delay. i've been sidelined with a broken hand.
I'm now into week 10 of pericarditis.My cardiologist doesn't know what caused my pericarditis. I am guessing a rowing-crewing class or complications from an angiogram. Cardiologist first prescribed Naproxen 500 which he said reduced my inflamation (inflammation). I had to stop Naproxen after about 6 days because of side effects. Then cardiologist gave me lopressor .25. The pain and palpitations almost completely subsided. When I broke my hand, I took a pain killer that was similar to lopressos's lowering blood pressure. So I stopped taking lopressor. Now I am lopressor free and pain killer free. My pericarditis pain is almost gone. I have  to pace myself and my emotional stress, which will bring back cardio pain.
I,too, use to exercise alot. Walking up hills caused NO pain before I contracted pericarditis. Now, atleast I can walk flat 1 and 1/2 miles a day pain free. I am gradually gettin better.
My cardiologist said, soon as this pericarditis gets under control, he will look into my 10 year "long-standing problem" of fast heart-rate and chest pressure that I experience in the early morning hours.
Terry, thanks for your advice.I hope you too are getting better.Keep me informed. Thanks again.

[TerryC]

Hi Angie! It was nice to hear good news from you.

I have been once again in the echo and the inflammation has diminished a bit. There is some left, but this is good news for me because now I know that my medication works somehow. Perhaps my sac don't need surgery.
I have to take colchisine + anti-inflammatory daily, but if those drugs help me I take them gladly. Perhaps some day my pericarditis is only a bad memory:)
I hope your "long-standing problem" will be solved in the future by a good cardiologist. I hope also that your hand gets better every day:)
Thanks for your concern Angie!