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Logical Next Steps after Nuclear Stress EKG?
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Logical Next Steps after Nuclear Stress EKG?

6 weeks ago I went to the ER with Chest Discomfort, BP Was high (240/120).  Labs, X-Ray, EKG normal.  

Background 35 yr old male.  Borderline hypertension most of the time., LDL 150, total 230.  Non-smoker.  About 20 lbs overweight, exercise regularly.

I'm still getting chest pains, mainly shooting in nature, bi-lateral, but occasionally dead center and it's pressure.

1.  They did a nuclear stress echo with exercise, said everything looked normal.  EF 60%.  How often do false negatives show up?

2.  I'm belching constantly.  Many times it relieves the dead center chest pain.  However the upper chest shooting pains come and go.  Should this belching help ease my mind this is not caridac?

3.  Lately I "feel" like my heart is fluttering sometimes.  I've gotten lightheaded a few times, however I do acknowledge that the ER trip and these pains have my anxiety through the roof.  My internist wants me to get an upper GI scope, mentioned this could be my esophogus.  I've been on prilosec for 6 weeks with little change though, might even be worse.  Is the upper GI scope the next logical step?  

4. Should I push for a cardiology consult? My understanding is that angina or MI pains are not shooting in nature(most of mine are under 5 seconds) with the exception of a few times I had this center chest pain.  I've already had an exercise stress with nuclear done that was clean.  The next steps would be an echo, or cath correct?  Would any cardiologist realisically do either with my symptoms?

5. I'm now on low does of altace, norvasc, and crestor.  Is this logical?
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239757_tn?1213813182
PED,

Thanks for posting.

1. They did a nuclear stress echo with exercise, said everything looked normal. EF 60%. How often do false negatives show up?

Its complex, but the frequency of false negative and positive test is based on the probability of the person undergoing the test having coronary disease. In you, with several risk factors, the test would be generally fairly accurate.  There are multiple parts to a stress test that are predicitve of outcomes including the amount of exercies, the ecg and the nuclear portion. If all these were negative in you, i would feel pretty comfortable with this as a definitive step.

2. I'm belching constantly. Many times it relieves the dead center chest pain. However the upper chest shooting pains come and go. Should this belching help ease my mind this is not caridac?

There are a lot of things in the chest that can simulate angina. The GI nature of your symtoms (symptoms) coupled with the negative testing would focus me away from the heart for the time being.

3. Lately I "feel" like my heart is fluttering sometimes. I've gotten lightheaded a few times, however I do acknowledge that the ER trip and these pains have my anxiety through the roof. My internist wants me to get an upper GI scope, mentioned this could be my esophogus. I've been on prilosec for 6 weeks with little change though, might even be worse. Is the upper GI scope the next logical step?

If your internist believes these are coming the stomach and youve failed a simple trial of a peptic regimen (prilosec) then yes, it would be the next logical step.

4. Should I push for a cardiology consult? My understanding is that angina or MI pains are not shooting in nature(most of mine are under 5 seconds) with the exception of a few times I had this center chest pain. I've already had an exercise stress with nuclear done that was clean. The next steps would be an echo, or cath correct? Would any cardiologist realisically do either with my symptoms?

There's an old saying, if the only tool you have is a hammer, then everything looks like a nail.  If you see a cardiologist, then many of them would probably pursue a cath to put this question to rest. I would overall feel pretty confident with your management thus far. I would try to manage your cholesterol with exercise and diet first but have a low threshold for the statin which you are taking, and would try to max out one hypertension medicine before adding a second. I would also look into other secondary causes of your blood pressure problems.  All of these problems can be handled by a skilled internist, but in this era of specialization, many will end up referring you to a cardiologist.

5. I'm now on low does of altace, norvasc, and crestor. Is this logical?

As I mentioned above, I would try to maximize one medicine for blood pressure before adding a second. I would also tr to control your cholesterol with diet and exercise, but have a low threshold for the statin medication if these were to fail.  Your pretty young so I would like to try to avoid committing you to multiple medications unless absolutety neccessary.


good luck
9 Comments
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Avatar_n_tn
i had same prob all test normal, had a 90% blockage of lad. since the i have had 5 stents and a double by pass in 2 years. i had a heart attack 21 days after the last stent. i now have another blockage. the test dont always show anything. a cath is the only way. you should get cathed.
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Avatar_n_tn
This is going to be long, for that, I'm sorry. But I have to share this and get this off my chest because I'm feeling depressed. My problems started 3 months ago. Before that, I was healthy, very active person, heart healthy (riding a bike for about 20 miles for 2-3 times a week). Now I'm almost going to cry as I write my story. I haven't been able to go to work for 2.5 months.

I'm 28, 178 pounds, normal resting blood pressure 115/75, pulse 72. No major health problems before.

One day, woke up with a little sore throat and very mild fever (99.8); after breakfast took a TheraFlu (with aspirin). Than about 2 hours later, while driving started feeling weird, dizzy, started feeling a bit of pulsations in my chest and head, so I stopped. Just started to walk around a little bit to get some fresh air, went into a store, etc. Then things started to get worse in 10 minutes, and suddenly, my heart was racing, I felt my blood pressure was increasing. For about 30 seconds my hands and feet were tingling and numb and I was sweating and flushing. There was no chest pain, no shortness of breath. Didn't call EMS or go to ER given my medical history. I wasn't very worried. Went back home.

My major complaint the next couple days were a very strong feeling of pulsations INSIDE my head, often in my neck, face and jaw. No pain or headache, just strong feeling of pulsations. Couldn't go to work because these feelings were making me dizzy, I didn't want to drive, moreover, I was afraid the initial episode could repeat. It first felt like these symptoms were getting better when I was resting at home, but after 2 days of rest, one night these pulsations started getting worse again, so that morning went to my PCP.

Described her what was going on, she listened and said it is probably viral, told me to just go back home, take advil for pain/fever, plenty of fluids, etc. No blood tests. That's what I did. The next day, in the afternoon, I started to feel terrible, very strong pulsations in my head, which were making me really dizzy and weak. I was lying down and when I got up to go to the bathroom, almost lost my balance and fell down, couldn't stand up. Things didn't get better for 15 minutes os, we called 911.

The paramedics took an EKG on the spot, got my blood pressure (160/100) and pulse (105). I was taken to ER. In the ER they did another EKG, standard ER blood tests, flu and mono test, chest x-ray. My blood pressure and the pulsations in the head were better in 4 hours. They said they saw a patchy area in the lung, and started treating me with Levaquin antibiotics, for possible suspicion of  pneumonia (I had NO runny nose, no cough, no shortness of breath). They wanted to discharge me right away, I objected and was admitted to the hospital for that night. I was not being monitored during the night for my heart rate and BP. They did a couple more blood tests, and a blood culture (negative). My blood pressure standing was higher than my BP sitting down, which was higher than my BP lying down. They said this might be due to dehydration, I got almost 5 liters of IV. Also, they gave me a potassium pill because my potassium was a little bit low in the blood tests. Overnight my BP and pulse was ok, in the morning after breakfast, BP went up to 150/100, pulse 105. The resident said this is nothing to be worried about, I went back lying on my hospital bed. After the first day, my BP and pulse were not stable, so they let me stayed there one more night, but again without any continuos monitoring. Next day I was discharged and sent home with a 10-day course of levaquin and advised to take tylenol. Since then (it has been 3 months now) I have these pulsations in my head.

I followed up with my PCP. She ordered more bloodwork, all negative. My only positive result was cholesterol (256) with LDL of 186. Also, a slightly elevated ALT(SGPT) of 43. She said we'll address my cholesterol later when I get better. Over the next two weeks, I was feeling quite bad. Every once in a while, while I was lying down at home, reading a book, or watching TV, my BP was suddenly rising to 150-160/90-100, and pulse to 100, and it would come back to normal sometimes after half an hour, sometimes after 3 hours. All these were accompanied by strong pulsating sensation in my head, regardless of my BP, but when my BP was higher, the pulsations were worse.

Two weeks later, my PCP ordered a 24-hour urine test to test for possible pheochromocytoma. Negative. PCP insisted that everything should be ok in a few weeks, it is probably a viral/post-viral syndrome. I insisted on a cardiac evaluation and eventually referred to cardio. The cardiologist did some blood tests (CK, CKMB, cTn-I, CEA), all normal. Also checked for connective tissue diseases (ANA TITER, ANA PATTERN, ANA HEP2 TITER, ANA HEP2 PATTERN), all negative. Also checked C-reactive protein, which was at 3.0mg/L (normal range as reported by that hospital is 1.0-3.0) and ESR (6MM/HR, normal range 0-15). He also did an echocardiogram, results had no significance. He said my heart is probably reacting to something else that is going on in my body. I was put on an event monitor for 30 days. The event monitor didn't reveal any significant results. The doc said that he saw that sometimes my pulse was going from 75 to 100, but with normal sinus rhytm. There were occasional PVCs and PACs in one of the readings which were of of no significance he said.

My symptoms kept continuing, sometimes getting a little better. I was sometimes having tingling feeling in my hands, sometimes sharp pains in my upper body that lasts for a few seconds and then goes away. I was sometimes having mild pain in specific spots in my chest. Not too painful, just unnerving. They would come and give me some pain for 10 seconds then go away, come back again in half an hour for another 20 seconds. I was generally feeling very tired and weak.

I was able to start walking for 15-30 minutes after a month. However, my symptoms were still continuing and at random times in the day, getting worse. I was put on atenolol of 12.5 mgs/day, which was then increased to 25 mgs/day after 10 days. After started taking atenolol, my BP was more stable, I wasn't having these 'episodes' as often, and when I had them my BP was going only up to 140/95 instead of 155/100, but the problem didn't go away completely. I was also continuously having the pulsations in my head.

Moreover, I was having sleep problems, most nights I was only getting 2-3 hours of sleep, so I was put on 0.5mg of lorazepam, only to be taken before going to bed. This felt like it helped in the first couple days, but then my sleep problem came back and persists to this day.

While out one day, felt a bit dizzy and the pulsations started to get stronger. We were near another hospital at the time and just walked into the ER when symptoms didn't go away for a while. We had our medical reports with us, they looked over and said a lot had been covered already. They did blood tests which were all negative. They did a chest-xray. They said they saw 'something' in the chest x-ray, so they'd like to do a CT scan of my chest. They did that and said it was a 'false alarm', it is all clean. Also, they scheduled a brain MRI. MRI came clean.

I was referred to a neurology consult, nothing came out of that. During all this time, along with the pulsating feeling in my head, I was having constant, hissing-like tinnitus, so I was also referred to an ENT. An audiogram was done, which was ok. The ENT asked for a brain MRI/MRA to check for auditory canal blood vessels and tumors. The MRI/MRA came back negative.

This was about 2 months into my condition. I had another visit to my PCP. He said there's nothing more that he can do, everything came clean, despite my symptoms. I think he saw that I was very depressed and emotional, so he said that he wants me to start on an antidepressant. He put me on 20mg of Citalopram (Celexa). He also referred my to a psychologist for 10 sessions, claiming that during all this time I was having panic/anxiaty attacks.

This was another turning point during the course of my sickness. I felt so bad after starting Celexa. My BP was up again to 150/100, pulse to 95-100. I was feeling these pulsating even more strongly in my head, and I also started feeling them in my chest. There were other weird symptoms, like my teeth were feeling weird and sensitive, my jaw was shaking uncontrollably a couple times a day for a few seconds. And the worst was, when I yawned, I was feeling like I was going to faint. Everytime I yawned a warmth/flushing sensation was happening, starting from my neck and spreading downwards.

After three days of taking that drug and feeling absolutely terrible, called my PCP. He said normally antidepressants are started with a low dose and then gradually increased, but since he saw that I was very depressed, he started me with 20 mgs! He told me to decrease the dosage to 10mgs. That's what I did. Immediately, the terrible feelings started to feel a little bit better, but I still had them. Apparently antidepressants cause insomnia during the first week/10 days. I wasn't able to sleep a single minute for 4 days straight. After about 7 days, I completely stopped taking that drug. In about two days, the bad symptoms started to go away, and in about a week, I think they went away completely. So I was back to square one, feeling like I felt before I started Celexa.

After all these experiences, changed my PCP. The new doc examined all my files and said I had a pretty extensive workup and there doesn't seem to be much she can do at this point. She ordered some bloodwork just to see if there's anything developing, also asked for another echo. I'm awaiting the results of these evaluations. My doctor strongly recommended me to stop using lorazepam, which I did. She also said that I should get back on my life immediately, go back to work, get out the house etc, even if I'm feeling bad. So that's what I'm doing now. I don't feel as bad as 2-3 months ago, but I have the pulsations in my head continuosly. I am aware of them even more when I lay down, especially when I'm trying to go to sleep. I am generally sleepy/weak, and sometimes have a fullness sensation in my head and chest that comes and goes.

I don't know what else to do. I'm just waiting all this go get better by itself, as my doctor's are telling me there's not much else that they can do. I'm still seeing the therapist, but I don't know if it is helping. I somehow don't think all these are anxiety related. I'm open to any suggestions and hear any similar experiences.

Thanks



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Avatar_n_tn
Hello there,
My heart goes out to you!!!
Anxiety can pop out of no where and yes it makes your symptoms feel so much worse.I have had panic attacks for over 10 years and there have been many ups and downs. Recently in he past 2 years I have developed more heart symptoms pvcs and pacs and funny flutters. When this happens my anxiety can go through the roof. Sounds like you have covered all ground with the docs....so the hardest part is  
getting to place where you feel like your old self before all this scary stuff.....  The anxiety forum is very helpful here. I applaud you for each step you are taking each day, doing things even though you still have the symptoms, etc.It is not easy to do....but worth every step you take, even you slip backwards a few times.


Take care and "feelbetter" soon. K
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Avatar_n_tn
Hi kellebelle,
I apologize if I'm wrong. I think I saw in another thread that you have Hashimoto's, is that you? If so I'd like to ask your opinion about my problem. I was diagnosed with Hashimoto's thyroidism in 2003 because of my high antibodies. T3, T4, and TSH remain normal, I have blood tests every 6 months. I asked my endocrinologist if my sinus tachy and PVCs might be caused by Hashimoto's and he said no. My cardiologist says that though my thyroid still works fine, I do have a thyroid disorder and it may contribute to my arrhythmia. Do you have any experiences or knowledge about this? Can Hashimoto patients with normal thyroid function develop heart symptoms?

Thanks so much in advance

Fran
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Avatar_n_tn
Feelsick - you have my sympathies!  It's as though your life has turned upside down overnight.

I had the same problems as you; I was just moving along through life, then BAM.  Everything started spinning out of control.  Pounding in the head and chest, tingling arms, dizzy, terrified, on and on, every day, all day.  Some days, it was all I go do to get to work without having to pull over and catch my breath and try to control the dizziness and feeling as though I would black out.  This went on for weeks.  I was devastated and sure my life would never be the same.

Ultimately, after many tests, I was diagnosed with panic attacks.  I had a hard time accepting this; surely there had to be something else going on - something more serious, perhaps even fatal!  After a few tries with various anti-depressants, I finally found one that worked for me.

I'm no doctor, but if I were you, I would try other anti-depressants.  It takes time to find one that works.  If your problem is surely panic (which is related to anxiety and depression), you will notice the difference in a few weeks.  Be prepared, however, to get through the period where your body is adjusting.  You may have worse symptoms or side effects that actually mimic the panic.  

Meanwhile, when you start feeling panicky and tingling in the hands, try slowly breathing into a paper bag.  This regulates the amount of oxygen you have in your chest.  When you are in an anxious state, shallow breathing leads to too much oxygen in your lungs, resulting in numb extremities and dizziness.  It's all a vicious circle.  

If your problem is, indeed, physical, the doctors will find it (hopefully), and your anxiety and fears will be more in control with the medication.  

By the way, have you had your thyroid checked?

My heart goes out to you.  You've come to the right place for support.
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Avatar_n_tn
Hello Fran,

Yes, I was diagnosed in 2001 with Hashimoto's. Just like you my thyroid levels are fine, yet the antibodies are there. I am reading a book called the "Thyroid Solution" always trying to see if there is some correlation with the pvc's.Seems like my body has more hyper symptoms than hypo.It is all very confusing.My cardio will not say if there is relationship or not....He thinks I read too much and am over concerned with how my body feels...!Yes, I have to agree that I am highly tuned into my body, yet I am my own advocate and have to pursue help and answers for myself.This forum has helped me more than anything.

My anxiety has flared up over the weekend, so my heart has been acting up.....waking up with tachy epsisodes, pvc's, little flutters. Do you have more symptoms around your monthly cycle???
Anyway back to the Hashimoto's, I am not medicated for this I do have a goiter, recently my skin has been dry but it has been very cold and dry where I live.

It sure is a puzzle, may be someday they will discover how all the pieces fit together and we will all cheer!!!

Have a wonderful week !

Kelly
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Avatar_n_tn
Kelly, you're wonderful! Thanks so much for your reply. It feels so good to know I'm not alone. We
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Avatar_f_tn
I noticed that you two have Hashimoto's. My mother in law was recently diagnosed with celiac disease which causes all kinds of autoimmune responses.  The "cure" is a gluten-free diet.  Look it up, there are several really great sites.  Some related illnesses are Sjogren's Syndrome, Hashimoto's, Osteoporosis, etc. other autoimmune disease.  Almost everything associated with Celiac Disease improves or totally disappears once you get the gluten out of your diet. Classic symptoms are diarrhea, stomach cramps etc. IT IS VASTLY UNDERDIAGNOSED & MISDIAGNOSED.
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