Thank you for the question! I have asked this before but symptoms have somewhat changed and I'm looking for reassurance. 33 year old female, 109lbs, 5'4", normal blood pressure, non smoker, blood work in last month total chol 169, ldl 107, hdl 46, tri 78, high sensitivity crp 0.18, my mother died of complications from stent procedure after major heart attack at 53. That is only heart issue either side of family her parents and grandmother still alive when she passed. This has turned into a fear of a heart problem. I have had in last 5 years ekgs (most recent 3 weeks ago) 3 echos most recent 2011), 3 event monitors( most recent 2011), 2 exercise stress tests (most recent September 2012). All normal although at times some ekgs have printed out borderline abnormal and was told it was due to anxiety at time it was done. Repeats on same visit normal. last stress test stopped after about 12 minutes cause reached max heart rate and nurse said had enough info. no symptoms during test. My symptoms for last month almost same as what led to stress test except have had a more burning chest sensation. Sometimes feels like pressure others burning or both. Always right in center at times in my throat as well. Have tried reflux meds with no real relief. Have awoke 3 times in middle of night with it and after Xanax I fall asleep but usually chest feelings are still there I just don't worry about it and fall asleep. dizziness off and on am tired some days and fine others. exercise 15-30 minutes a day don't get pain during but sometimes after. If having it and start to exercise it doesn't get worse and may go away but feel it after sometimes worse. Dr says anxiety and possibly gi related. Says no more cardiac testing its not my heart. I go to therapist once a week. When I read other women's posts about listening to your body and push for tests it scares me that the drs and cardioligist could have missed something. Thank you for any thoughts and reassurance!
I’m sorry to hear about your mother. Given her passing from heart attack-related complications, I think it is only natural that you are fearful of having a heart problem too. As a cardiologist I see many people with experiences similar to your own so you are definitely not alone. The focus of care in your case would include (1) ruling out heart disease and considering other causes for your chest pain (2) defining your future risk of heart disease and considering preventive treatment if necessary and (3) helping you manage your fear and anxiety. Let’s work through each of these steps with the information you have provided.
Ruling out heart disease: Your family history does put you in a higher risk category for coronary disease or blockages in the coronary vessels. However, you currently have a normal EKG, a normal echocardiogram and a normal stress test which means that you are at a lower risk of having coronary disease right now. All of these tests provide an indirect measure of how blood is flowing through the heart. Sometimes we want a more direct measure of how blood is flowing through the heart. A CT scan (“CT coronary angiogram”) is a low risk and non-invasive way to look at the blood vessels that supply blood to the heart (“the coronary vessels”). CT is not recommended in pregnancy (due to the risk of radiation to the developing baby) and some people can have allergic reactions to the contrast or ‘dye’ that is used to highlight the coronary vessels. Knowing that you have normal coronaries may provide you with some peace of mind so it’s worth discussing with your cardiologist.
Other causes for your chest pain: So the question is what is causing your chest pain? Gastrointestinal reflux is one of the most common alternative causes of chest pain and is usually experienced as a burning sensation in the middle of the chest, worse after spicy/fatty meals, and relieved with antacids. Dietary changes can help, including avoiding spicy/fatty meals, avoiding alcohol, and not over-eating. A 4-week trial of proton pump inhibitors (such as omeprazole) is reasonable if the symptoms are suggestive of reflux. Patients with reflux symptoms not responding to treatment should see a GI specialist to discuss gastroscopy, in which a small telescopic camera is used to inspect the esophagus in sedated patients.
Musculoskeletal chest pain is very common – this pain is made worse with movement of the arms and chest and may be reproduced by touching the area causing pain. This can be caused by muscle strain and also inflammation at the point where the ribs join the breast-bone. A short term trial of paracetamol and anti-inflammatories can be helpful in this instance. Less commonly patients with chest pain can have irritation/inflammation of the sack (“pericardium”) in which the heart sits. This is called pericarditis. Pericarditis is experienced as a sharp and sometimes severe chest pain, felt deep within the chest, and sometimes relieved by leaning forward. It can be triggered by a viral infection, other medical conditions associated with inflammation (so called “auto-immune diseases”), or commonly have no reason at all. Pericarditis is diagnosed on the basis of the symptoms reported along with supporting findings on ECG and blood work. Since you have a normal high sensitivity-crp of 0.18 and a normal ECG and echocardiogram, the likelihood of pericarditis is reduced.
Defining your future risk of heart disease: Your future risk of heart disease is increased because of your family history. That is true, but there are many other factors that impact on your risk of cardiovascular disease and these are within your control. The general advice I offer to all patients is (i) stop smoking (ii) reduce your intake of saturated fats as found in red meat (iii) minimize salt intake including take-out foods (iv) and exercise 30-60 minutes daily aiming to raise a sweat. Additional targets include your blood pressure and cholesterol which should be monitored in partnership with your family doctor. Your cholesterol profile is mostly within target; the only improvement you might see with exercise and increased intake of dietary fiber is an increase in HDL. HDL is the good cholesterol and helps fight coronary disease. Based upon your height and weight your body mass index (BMI) is 18.7, putting you within the normal weight range (normal = 18.5 – 25). Based upon the information you have provided it would appear that there is no indication for any specific preventive medications (i.e. cholesterol lowering agents, aspirin) because the risks and side-effects of these medications would outweigh the benefits. This may change over time and that is why a repeat assessment of body mass index, blood pressure, and fasting cholesterol & glucose, would be recommended in another 12-24 months.
Managing your fear and anxiety: Many patients are disappointed when all of their tests are normal because they are still no closer to understanding what is causing their symptoms. I acknowledge that your symptoms are real – you are experiencing chest pain. But if all of your heart tests are normal we can be confident that your current risk of having a heart attack is low. That means that there is some alternative reason for chest pain that it is non life-threatening and can be managed over time. Knowing that you are not a high risk patient and that you can learn to manage your symptoms is important. Congratulations on taking the step towards therapy – discussing the events surrounding your mothers passing challenging your fear and anxiety will be important as you take charge of your symptoms. The mind-body connection is a powerful one, so anything that leads to healthy thoughts and feelings (exercise, meditation, listening to music, and reading) should be part of your daily routine.
I also wanted to add that I have been waking up alot in the middle of the night and have times that I feel like I can't get a good breath in. I'm also suffering from major seasonal allergies and I do take albuterol as needed and allergy meds. I sometimes feel like my legs are jelly and weak. I just can't imagine how all these symptoms and mostly the chest burning/pressure can be brought on by my thoughts and anxiety. Thanks again!
Thank you for your response. My cardio won't do the ct scan. He said that he's thorough and very good at his job and that my heart is healthy. He said I need to focus on the anxiety. I have been on prevacid twice a day and take tums when needed but I really don't notice a difference. Maybe a small change some days. It's definitely worse on days that I'm stressed and focused on it. My dr also said he's not really considering my Mom as a strong family history because she was a heavy smoker and she is the absolute only family member in a large family that had any cardiac issue. Can stress from my anxiety be harming or have already done damage to my heart? Thank you!
From the information you have provided it does sound as if the likelihood of you having any major heart problems is indeed low. Your doctors comments regarding family history are also reasonable - your mom being a smoker means she had a non-genetic reason for an increased risk of heart attack. Your report of worsening chest pain on days that you are stressed and/or focused on it also favors stress as an underlying cause.
I always advise my heart patients that a second opinion from another cardiologist is not a problem for me. In fact it ensures that I am not missing anything and it gives patients peace of mind to know that their case has been thoroughly reviewed. If you strongly believe that a second opinion from another cardiologist would be helpful you are well within your rights to obtain one. However if after 2 separate reviews it is determined that your heart is OK, then you will need to consider an alternative cause for the pain and also the role that anxiety is playing.
If all of your heart tests are normal the next question is who should continue to help investigate and treat your chest pain? If all of your cardiac tests are normal it is reasonable to take a step back and return to your family physician. He/she may arrange additional tests or referrals that they can suggest (i.e.gut specialist, respiratory physician). While this is being followed up I would also recommend that you discuss your feelings of anxiety with your therapist.
Rather than focus on the impact of stress on your heart I think it may be more helpful to decide what steps you can take to manage your symptoms. Notice that I said manage your symptoms - the goal is not to be symptom free tomorrow as that is both unlikely and unrealistic. Perhaps write a list of the things that help reduce your pain and work out how to integrate them into your daily life. Again, I would recommend discussing this with your therapist and asking him/her to help you with specific strategies for dealing with anxiety when it arises.
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