Continuing Chest Pains

[jmike1_]

I posted once, so this will be my last, but I was hoping to get advice on what to do now.  I've had 4 heart caths since MAR 06.  For the 1st, I received 3 stents in my LAD.  On the 2nd, another stent in my LAD.  During the 3rd, they found nothing.  And during the 4th, they used a pressure wire and found "physiologically sig distal LAD stenosis just distal to the most distal stent, in a very small tortous segment of the vessel that is not readily amenable to stent placement, and insignificant mild instent stenosis mid-sten just prior to a jailed diagonal branch."  I have had unstable angina since 1 FEB 06, which has continued after each heart cath as well.  Over the past few weeks, the chest discomfort is increasing - pressure in center of chest, deep ache in center of chest that goes through to my back, and strange aches in my left arm (like a cramping muscle).  I have had a stressful 3 weeks, working on a follow-on assignment to avoid a medical eval board (active army).
My questions:
1)I've avoided treatment for my increase in discomfort to avoid a board, but my docs have told me that they are reluctant to do anything else anyway (afraid they'll do more harm than good).  W/ as much invasive work as has been done, should I just learn to deal w/ the discomfort for awhile?
2)Can you recommend any options I should pursue (not gastro, have been tested, and had a clear cat scan (was in CCU this weekend)?
3)Does your clinic accept TRICARE - have thought about taking leave to see you if you think you could help.
4)Should I take meds and wait.
5)Thoughts on bypass?  
Thanks!

[CCF-M.D.-MJM]

Hello Mike,

First of all, thank you for serving our country.  I have a great deal of respect for people like you.

1)I've avoided treatment for my increase in discomfort to avoid a board, but my docs have told me that they are reluctant to do anything else anyway (afraid they'll do more harm than good). W/ as much invasive work as has been done, should I just learn to deal w/ the discomfort for awhile?

Without seeing all your tests, it is difficult to know how to approach this.  If I were seeing you as a second opinion, I would order an exercise stress test with nuclear imaging.  This would answer two questions for me:

1. Do you have pain with exertion and what is your functional capacity?
2. If you have ischemia, what arterial distribution.

These are important questions.  Anxiety and non specific chest pains can masquerade as coronary artery disease and do not get better with procedures.  When you have people with real coronary artery disease and chest pain symptoms that are not caused by the blockages, it becomes very difficult.  I would want objective data to tell me that coronary disease is causing your pain.

Additional tests can be done to determine if the problem is small vessel disease (cannot be fixed with stents).

Consider getting a second opinion outside the army.  We do see military patients and our happy to do so.


2)Can you recommend any options I should pursue (not gastro, have been tested, and had a clear cat scan (was in CCU this weekend)?

The first thing I would do is prove this isn't coronary artery disease.  If we can prove it something other than coronary disease, that can change the focus of your treatment.

Another point I want to make very clear:  non specific chest pain syndromes are very difficult to diagnosis, can act just like coronary disease, and can happen to almost anyone.

3)Does your clinic accept TRICARE - have thought about taking leave to see you if you think you could help.

Call 216-444-2200 and ask how to a schedule an appointment to meet with a cardiologist.  I will recommend one for you -- Arman Askari.  Gather your stress test results, CATH FILMS (NOT REPORTS, but you can bring reports too.  He will want to see the films.)  Other institutions can do this as well, but if you decide to come here we would be honored to take part in your care.

4)Should I take meds and wait.  5)Thoughts on bypass?

Take the meds and come for a second opinion.  Let someone review your cath films and decide on the next best step (medical therapy, cath, bypass, etc) .


I hope this answers your questions.  Thanks for posting and serving our country.



Thanks!

[jmike1_]

Didn't have room to add my meds:  Lipitor (80mg), niacin (1000mg), isosorbide mononitrate (30mg), metoprolol (25mg), nifedipine/adalat (90mg), lisinipril (2.5mg), plavix (75mg), aspirin (81mg - baby aspirin), and nitro pills (have been taking a few every day lately).  Thanks again!

[moosejuice]

Firstly, i am so sorry for doing this but i have been trying to post on this site for last 2 yrs without
any luck and i really need some
advice.
I am 26 yrs old and have had pain in left arm for past 5 yrs.
It begins as pain in my bicep and a squeezing sensation and then my hand and wrist go numb and the pain seems to come
from a vein in my wrist which feelis like it is pulsating.
At first i ignored this but in last 2 yrs i have also developed an abnormal heart beat..sinus arrythmia.
I so not suffer from anxiety and i have had a stress test, echo, cardiolite, calcium scan showing score of 1 and holter
all with normal results.
I now have dizziness and a sensation that i am far away and not in the room.
I am also very confused and find it vey hard to take care of my 6 month old daughter.
When i was pregnant i had pain travelling up into my neck from my arm and felt ill the whole time.
This pain is bought on by normal physical activity but especially lifting when i get an electrical sensation in my
chest.
I have no remarkable family history excepy my grandfather had heart attack at 57 but was long time diabetic.
When my mother was 30 she suffered what she believed was a heart attack but refused to go to the hospital.
It was after alot of heavy lifting and she had extremely severe chest pain..she is now 58 and has recently been diagnosed
stable angina but surely if she had had a heart attack they would have known on her stress test.
I am also an ex smoker (30 per day) but quit 2 yrs ago and have recently lost 5 stone going from 15 to 10.
A cardiologist i had to see privately thinks i am having spasms but wants to prove this with another holter.
The cost of these tests is putting me and my family in severe debt but i dont know what to do.
I also suffer from raynauds disease and have a right bbb.
Please can you advise me.
Again i am very sorry for using somebody elses post.
I am in the UK.
Thank you

[jmike1_]

Thank you very much CCF-M.D.-MJM for your detailed response.  I will check into getting an appointment at the Cleveland Clinic as soon as possible.  Also thank you to Al Dente for your (as usual) insightful response.  My doctors haven't talked to me about cardiac microvascular disease - their focus has more or less been to send me to various other clinics because they don't think the pain is cardiac related (I of course completely disagree, and the additional tests I've gone through seem to support my opinion since they've all been negative).  Good news is that I'm moving in a few weeks, and as a result will get to have a different set of eyes look at my problem.  However, I think it is a good idea to go to CCF if possible, since they are the #1 rated cardiac care facility in the U.S.  You said you visited them - were you happy with the treatment you received?  Also appreciate you sharing your meds w/ me.  If my problem can only be treated w/ meds, then I certainly think my current mixture could certainly use a lookover.  Again, thanks for your continuing great posts on this site.  Hearing from another young guy is quite helpful.  Take care, and hope your problems get better soon as well!

[dmarq95]

Very intrigued with your dilemma.  I am 33 years old and I have had two caths, one in January, one in April, both with stents, the first in the LAD at 70% blockage and the one in April in the at Ramus intermdius at 90%.  My first cardiologist who performed the first cath that the noted that Ramus Intermdius was 50% blocked in January noted it.  I have had continued unstable angina that diminishes after a few weeks of both stents and then slowly returns within a few months.  Due to the unstable angina, my cardiologist has me scheduled for another cath this Thursday.  My cardiologist is concerned in that if he finds another blockage over 70% he would be very perplexed and look for additional therapies.

I have Heart Disease in my family, both my father and his father, but not as early as me.  The area of intrigue is that I am a a returning National Guardsman from Iraq.  I served as an Infantry Company Commander in Baghdad and did not have any symptoms or concerns until a month after returning last October.  First I had palpitations and then after following up with my cardiologist with the usual increasing level of tests, had my first cath/ stent a few months later.  

My question to you is that have you recently had a tour in the Middle East and did your symptoms occur shortly thereafter?  Just curious to know if one has anything to do with the other.  

Thanks and good luck with your coronary journey.

[jmike1_]

Sorry to be so late in getting back to you, but I've been off-line for a few days.  I have been to Iraq, but it was during Desert Storm.  I was stationed in Moscow, Russia during most of OIF/OEF and have not participated.  With my current health issues, don't know if I'll be able to deploy again - will see!  My guess is that the stress of being in Iraq is probably the biggest culprit vs. any environmental/chem/bio issues in Iraq.  Combat naturally invokes as much stress as anything we'll ever face in our lives, and my guess is that could have kick-started your problem.  Very sorry about all you are going through, and I wish you the best with your upcoming cath.  This unstable angina is a pain (literally!!!), and I wish us both luck in overcoming the problem.  Thanks for your post - sorry to hear that we have so much in common though.  And thanks for your service - being in the Guard is a tough road lately....wish you the best.  God bless!

[pepaw]

How have you avoided the MMRB? I am a 45 year old active duty infantryman, I returned to the army after a 13 year break in service and am in the mmrb process at this time due to mi in may 05. I had 1 stent placed due to a 100% blockage in the rca.
How is your EF or your mets ? Have you suffered a MI or was the blockage found before you had one? I will never understand how the military works when it comes to the different ways it treats the same problem. Hope you get to feeling better