Unstable Angina

Hello Doctor,
I'm 34 Year old man, working in Kuwait. I'm feeling chest pain when I walk, even 2 - 3 minutes since last 3 months. I consult doctor over here, they advice for Exercise Stress Test (ETT). but unfortunately after 2nd stage of ETT I feel too much chest pain then they stop the machine and give me result which shows incomplete ETT, but my heart percentage was 80% on monitor screen.
Last 3 weeks back, again I feel chest pain when I was sleeping. I rush to Hospital emergency, they took my ECG and diagnose that unstable Angina. They admitted me for 3 days and taken so many medical/ blood test. After that they advice for Nuclear Stress Test (Thallium), that was done two weeks back on 7th Sep, 2010. but again physician advice to repeat the Nuclear test. Doctor still did not tell anything to me that either this is heart problem or not. I am so much worried that either I have problem in my heart or not or what is the problem exactly ?

Can anyone advice me about my diagnoses, is that ok or not.

Thank you,

K Y Khan

[lvhguy]

For an accurate test guidelines are that you achieve a heart rate of 85% of your predicted maximum, if you do not achieve this and only achieved 80% the test needs to be interpreted with caution if there was no evidence of inducible ischemia.
You are young so they are probably reluctant to do an angiogram and ordered a nuclear stress thallium.
This involves absorption of radioactive tags that are less absorbed downstream from a blackage by the heart muscle. A gamma camera takes a picture of the radiation emitted and normal perfused heart muscle glows whereas areas with poor circulation do not glow on the image.
It does have a large limitation to the test in that it if you have severe 3 vessel disease, then everything is uniformly dim and therefore can be interpreted as normal.
This is why some argue a stress echocardiogram which is an ett combined with ultrasound can differentiate. Where as nuclear testing is better at picking up single vessel disease.

So ok, now that I have confused you. I would press to have an angiogram done, thats the gold standard diagnostic test and the symptoms you describe are considered more accurate than stress testing.
Then you will know definitively.

I would discuss this with  your physician and get a definitive diagnosis with the best test possible.
Although the fact that you had chest pain and didnt show st segment depression on  your ekg while exercising is a positive sign because if you had EKG changes even at 80% of predicted maximum you wouldve flunked your test. But I'd still seek a definitive diagnosis and get a second opinion if you do not feel you are being adequately assessed

[kenkeith]

An incomplete test usually indicates the heart did not sustain the target rate, as there were indications with signs and symptoms that would put you at a high risk of an adverse medical episode.  Your target heart tarket rate would be 220 minus your age.  I'm not clear what 80% on monitor screen represents?

When there is chest pain with exertion, it often is due to a vessel(s) that have partial or complete backages.  The pain is the result of the heart cells not getting enough blood/oxygen, and exertion adds and increases the demand for blood/oxygen.  At rest there is less demand and your system provides adequate blood/oxygen.

Chest pain when sleeping could be the result of a heart vessel spasm (temporary constriction).  This condition is not always indicated with any tests unless there is a spasm at the time of the test. When spasms are suspected, the doctor may suggesst a holter worn for 24 hours.  The holter monitors your heart rhythm and if there is an episode the EKG will show the ST segment elevated.

If you had more information with test results that would be helpful.  There are many causes other than the heart to cause chest pain.  Apparently, your doctor believes your  heart is the problem.  

Thanks for your question, and if you have further information, etc. you are welcome to followup.  Take care.

[ed34]

It sounds to me as though you have classic stable angina because your symptoms are brought about by exertion. So, what about the sleep episode? Well, your Cardiologist should know that during REM sleep, our heart rates increase and blood pressure rises and during some dreams our hearts can beat vigorously. This is why it's believed some people have heart attacks in their sleep. If your sleep produced a dream to make your heart very active, then this would align with stable angina.
As Kenkeith states, stable angina is a blood flow problem through the coronary arteries, where not enough oxygen reaches a certain area of heart muscle for exertion.

[kenkeith]

I'm not disagreeing with the dx of stable angina, and the possibility sleep related stress that can provoke angina pectoris, but the tests indicates according to the post that OP has unstable angina.

Variant angina pectoris  usually occurs spontaneously (triggering mechanism unknown), and unlike typical angina, it nearly always occurs when a person is at rest.  It doesn't follow physical exertion or emotional stress, either.  Attacks can be very painful and usually occur between midnight and 8 a.m.

And  coronary artery spasm, can be superimposed upon normal or diseased arteries, and can provoke pain in the absence of increased myocardial demands such as variant angina and some cases of stable or unstable angina. There is "also a group of patients who have angina without demonstrable evidence of coronary artery disease" such as heart valve disorder, hypoxia, etc. The tests are equivocal so I was introducing a variant spasm with undiagnosed stable angina...there may not be any vessel occlusion and the chest pain is due to another heart disorder source as well.... lack of information.  
  





Variant angina is due to transient coronary artery spasm.  About two-thirds of people with it have severe coronary atherosclerosis in at least one major vessel. The spasm usually occurs very close to the blockage.
Variant angina is due to transient coronary artery spasm.  About two-thirds of people with it have severe coronary atherosclerosis in at least one major vessel. The spasm usually occurs very close to the blockage.

Related AHA publications:

[lvhguy]

For an accurate test guidelines are that you achieve a heart rate of 85% of your predicted maximum, if you do not achieve this and only achieved 80% the test needs to be interpreted with caution if there was no evidence of inducible ischemia.
You are young so they are probably reluctant to do an angiogram and ordered a nuclear stress thallium.
This involves absorption of radioactive tags that are less absorbed downstream from a blackage by the heart muscle. A gamma camera takes a picture of the radiation emitted and normal perfused heart muscle glows whereas areas with poor circulation do not glow on the image.
It does have a large limitation to the test in that it if you have severe 3 vessel disease, then everything is uniformly dim and therefore can be interpreted as normal.
This is why some argue a stress echocardiogram which is an ett combined with ultrasound can differentiate. Where as nuclear testing is better at picking up single vessel disease.

So ok, now that I have confused you. I would press to have an angiogram done, thats the gold standard diagnostic test and the symptoms you describe are considered more accurate than stress testing.
Then you will know definitively.

I would discuss this with  your physician and get a definitive diagnosis with the best test possible.
Although the fact that you had chest pain and didnt show st segment depression on  your ekg while exercising is a positive sign because if you had EKG changes even at 80% of predicted maximum you wouldve flunked your test. But I'd still seek a definitive diagnosis and get a second opinion if you do not feel you are being adequately assessed