chest pain/discomfort in 33 year old female.

[shelshel73]

I am 33 years old, about 30 pounds overweight, have chronic migraines of unknown origin, and have been experiencing chest pains.  Sometimes they wake me up, sometimes it happens while at rest, and sometimes, yet rarely, they happen while I'm exerting myself.  I am super tired, fatigued.  The pain starts almost dead center of my chest, spreads all the way through my back, sometimes behind my shoulder blades, and I have this strange filling sensation that moves up my throat into my jaw area with the pain.  I tried antacids, pain medication, changing positions, but nothing alleviates the pain.  It lasts anywhere from 3 minutes to 30.  I am on anti-anxiety meds, Tranxene 3.75mg tid, and even take one of those during the pain attacks, but this doesn't feel like anxiety.  My heart will start beating faster during the attack, and it hurts to breathe.  When I started having these spells a few years ago, I had a complete heart workup and everything is fine.  The spells are becoming more frequent and I've noticed my migraines are worse after the chest pain.  I've never been to the doctor while I am hurting.  My breast bone hurts and is sore after the attacks too, so I feel like it's not heart related because of that.  Any suggestions?  I'll answer any questions you need me to.  Thank you.

[Forum-M.D.-MJM]

Hello,
These are always difficult situations to diagnosis.  The odds of the this being coronary artery disease are very low.  As you have probably read, coronary artery spasm is more frequent in people with migraines.  This may represent coronary spasm, but some of your features are atypical for that -- like breast bone pain after the chest pains.  You should see a doctor about this.  It might be worth carrying nitroglycerin with you. If it helps the symptoms, it may be (is not proven to be) coronary spasm.  It might also be worth an empiric trial of a dihydropyridine calcium channel blocker like norvasc or nifedipine.  This may also decrease the frequency of your attacks.  But like I said above, this is worth seeing a doctor about.

I hope this helps.  Thanks for posting.

[bip]

do you have shortness of breath with the chestpains?

[nene41]

Does anyone on this forum know about this Disease

[tanns]

If you try searching for microvascular disease on the search tab, a bunch of previous posts will come up.  Hope that helps.

[Carolina03]

Hi,

I agree the chest wall soreness doesn't sound typical of heart disease. I also don't want to raise your anxiety.

I have microvascular disease; occlusion of the tiny arterioles in the heart. Standard tests cannot "catch" this disease.

The way they diagnose small vessel disease is through a cardiac MRI, PET or cath with a provocation agent. If they're able to reproduce the pain you're experiencing, or see ischemia, then you may have the disease and could benefit from taking a diuretic, statin and ACE inhibitor, or even Renexa, all medications that increased my stamina and reduced my angina. BTW, I hope you're not taking the migraine Rx Imtrex which can cause complications in people with microvascular dysfunction. Here's a WSJ article that's loaded with info:

Doctors Focus New Attention
On Heart Disease in Women

Latest Studies Spur Calls
For Better Testing, Treatment;
Exploring the Use of MRIs
By RON WINSLOW (Wall Street Journal)
February 14, 2006; Page D1

Recent research into how heart disease differs between the sexes is prompting calls for fresh approaches to improve its detection and treatment in women.

Provocative findings from a decade-long study argue that many women have a form of heart disease that is fundamentally different and harder to diagnose than in men. Thus, problems are often missed early on in women, when prevention and treatment strategies might be more effective in preventing heart attacks, heart failure and other serious consequences of heart disease.

To counter this, researchers say that women and their doctors need to be especially persistent in tracking down the problem when chest pain and other symptoms arise. Doctors also need to pay more attention to symptoms that occur more frequently in women, such as fatigue and shortness of breath. In addition, doctors are looking closely at certain tests, such as magnetic resonance imaging, that aren't commonly used now but could help detect hidden heart disease in women.

The findings are expected to stimulate new research into treatments. Women are more likely than men to report recurrent chest pain after such standard remedies as bypass surgery and balloon angioplasty, partly because those procedures don't always reach areas where disease occurs in women. But drugs such as statins, aspirin or ACE-inhibitors, already standard for high-risk patients, may be helpful for women who have the more-hidden form of disease.

Overall, researchers say, women need to be especially vigilant about strategies that can reducing the risk of heart disease, including staying fit, eating a healthy diet and avoiding or quitting smoking.

The impetus behind these messages is growing recognition that for many women, chest pain and other symptoms arise not from obstructions in the large arteries of the heart, as commonly found in men, but from tiny vessels that branch off those arteries to deliver blood to heart tissue.

As a result, disease in women is often not detectable via standard diagnostic techniques, including treadmill stress tests and angiograms, which use X-ray technology to let doctors watch how blood flows through key arteries. Indeed, based on such tests, doctors often tell women their arteries are clear and their hearts are fine. But, too often, the symptoms persist and women either muddle through or embark on a frustrating series of additional tests, researchers say. When the disease is finally diagnosed, it is often at an advanced stage, when its toll on women can be particularly harsh.

"So often these women who have open arteries [on an angiogram] are told they have no problem," says C. Noel Bairey Merz, a cardiologist and medical director of women's health at Cedars-Sinai Medical Center, Los Angeles. "We need to stop reassuring them."

Dr. Bairey Merz is chairwoman of the Women's Ischemic Syndrome Evaluation, a major study sponsored by the National Institutes of Health to examine gender differences in diagnosis and the role of sex hormones in heart disease. The study, launched in 1996, involved 936 women who were referred for angiograms because of chest pain.

In reports published earlier this month in the Journal of the American College of Cardiology, Dr. Bairey Merz and her colleagues identified a disorder of the small vessels in women, which they called "microvascular dysfunction."

The heart's primary job is to circulate freshly oxygenated blood to the brain and other organs throughout the body. To keep healthy, the muscle that does the work needs some of that blood too, and it is supplied by the coronary arteries. Blockages in those arteries starve the muscle of oxygen, leading to chest pain. Major obstructions in the large vessels often causes a heart attack.

Blockages in much smaller vessels, whether caused by disease or by functional problems in cells lining the vessel walls, similarly deprive heart muscle of oxygen-rich blood and can also cause heart attacks -- though not typically in the classic fashion of plaque that ruptures in a large vessel. Exactly how the obstructions in large and small vessels might lead to different outcomes for women isn't yet understood, researchers say. The main issue for now is that when the disease is hidden from conventional diagnostic techniques and the patients are given a clean bill of health, the problem is likely to get much worse before it gets treated, with more potentially dire consequences.

Estimates based on WISE data suggest that blockages in the tiny vessels that branch off the arteries may be the major culprit in as many as three million women. One likely reason for the gender differences is the impact of the sex hormone estrogen, which may protect women against heart disease in their younger years, but make them particularly vulnerable when levels plummet after menopause.

Researchers do note that some six million women in the U.S. have heart disease based on the conventional diagnosis of obstructions in the large arteries. Moreover, some men also develop disease in smaller vessels. Accurately evaluating chest pain symptoms is often daunting for doctors in both men and women patients.

But many heart experts are calling for more research to make sense of emerging differences. "We need to take this knowledge and create a systematic plan for how to deal with it," says George Sopko, project officer for the study at the NIH's National Heart, Lung and Blood Institute.

Researchers have long reported that women often lack the tell-tale chest pain that typically predicts serious disease in men. In women fatigue, trouble sleeping and shortness of breath may be symptoms of impending heart trouble that doctors miss. In addition, says Dr. Sopko, radiating chest pain that often accompanies the onset of a heart attack in men appears to occur less often in women, who are more likely to feel pain in the shoulder or arm. Women are also less likely to experience a fluttering of the heart, he says.

To detect heart disease in small vessels, doctors have a number of diagnostic tools to explore besides traditional angiogram and treadmill stress tests. Widely available techniques, such as thallium stress tests and stress echocardiograms can help doctors determine whether adequate blood flow is getting to heart tissue in patients whose chest pain persists despite having clear large arteries, Dr. Sopko says.

Researchers are also looking at other approaches that use magnetic resonance technology. One such test, known as phosphorous-31 nuclear spectroscopy, was a strong predictor of women in the WISE study who were likely to develop future heart trouble in women with chest pain but clear arteries on an angiogram. That test isn't routinely used, but is available at some research centers. In addition, WISE researchers are pilot testing a coronary angiography procedure using MR technology instead of X-rays in hopes that will also prove effective in detecting disease hidden from the conventional exam.

The issue of how to treat women with disease in the small vessels is still being explored. Dr. Sopko and other researchers recommend treatment with statins, ACE-inhibitors and aspirin in women with microvascular dysfunction even as they await results from future studies on whether they reduce heart attacks in such patients.

Another hindrance is awareness. Both the NIH and the American Heart Association have launched campaigns in the past couple of years to educate women about heart risks, but a recent study indicates only about half of women know that it is the leading killer of women.

[tanns]

I had a cardiac stress-MRI where I was injected with adenosine to try to induce ischemia.  Is this the test you are refering to?  What this have been sufficient?

[nene41]

Thank you so much for all the info.Dr,s also suspected small vessel Disease with me I,m a 41 year old female have had some heart issues such as pac&Svt  also chest pains. Back in2005 I had a cath done Dr,s said all looked good except my left vessels are smaller than my right vessels so they were suspecious of the Disase.Dr,s wanted me to have a cardiac Mri but I refused I work in the emergency room and we give people adenosine and I said no thanks,so I went to the Mayo clinic for a second opinon and the Dr down there looked at my cath on cd from 2005 and said they do not agree that this is small vessel disease 2 cardiologists looked and said there pretty confident it is not, but my cardiologist is strogly suspicious,so it,s like who do you beleive!! My dad died at 46 years old from coronary and small vessel disase so I,m a little worried at times, since I still have chest pains alot I don,t understand why? What are some of your symtoms if you don,t mind me asking? I go back to the Mayo for a stress test in may,I,ve had ekgs,echo lots of blood work they say all looks good.I will be looking forward to your response.

[tanns]

I also went to the Mayo Clinic for help.  (This was after 3 cardios in my hometown)  That is where I had the cardiac-stress MRI and it was NASTY!!!  That adenosine was not fun, I even asked the forum doc here if my response to it was rare and he said no.  Most people have no problem with it, but some do.  Anyway, my trip to the Mayo Clinic was very thorough and I had to leave there knowing there was nothing else I could do if I was given the "all-clear".  And I was.  The problem is the pains still persist and I am not really any better than when I went in.  

I have a few different kinds of things happening.  First I will have to say, I have a pretty good anxiety thing going now.  This all started when I had some chest pains and I couldn't get it out of my head that it wasn't my heart.  Four cardios later, I hate to say it, I'm still not convinced.  Anyway, back to the pains--I have a weirdness that happens under my left breast, deep inside, sometimes like a heaviness too.  I have something weird that happens above my left breast and causes a pain that shoots up my neck to my jaw on the left side.  It feels like a constant pulling feeling, all the way up to my jaw.  I get a horrible taste in my mouth when it happens.  Although it is metallic it isn't a taste more like a stinging when I breathe, like I'm breathing chemicals through my mouth.  Also, I get this feeling in my left chest like I've chest taken in a breath of icy cold air and my chest is burning.  Of course that isn't the case considering I live in Florida!!!  My left arm, on the bicep side, burns down to my elbow joint, randomly of course.  When I start to mention all this I almost have to laugh.  But it isn't funny, they are very uncomfortable and very scary.  

I have had so many tests, I can't possible go through anymore.  The doc at the Mayo Clinic said to just stop.  It is possible it is something is there and just hasn't presented itself yet.  That is REAL comforting!!   I have a CRP of 5, did you have your C-reactive protein tested?  I'm a little nervous about that.  He wants me to have it retested but I'll do it here in town because I won't be heading back there for a while!!  I HOPE!

[nene41]

How ald are you? I live way up in minnesota.My grandparents live in panama city.You traveled a long ways to get your answers,I can understand your still believeing something could be wrong with your heart with all the pain you still have .I guess I,ll find out more once I have the stress test done at the mayo here in may I,m trying to be confident in what the Dr tells me,but sometimes it,s frustrating when they can,t explain the pain away and why it happens.I suppose we should be thankful we sae probably the best cardio docs around .... anyway thanks for talking with me its nice to know your not alone.

[bassclef]

Maybe you have already ruled this out, but have you looked into whether this might be a stomach ulcer? Those can cause strange and intense pain, including what one might think of as chest or back pain. The stomach is higher up than most people think.

[guadamom]

I have been diagnosed w/Microvascular Angina.  I am 51 years old normally in good health. Since March of 2006 I began having shortness of breath and left chest pain along with left arm and shoulder pain.  I had a treadmill stress test that I failed so they did an Isotope Thallium Stress test and CT scan also Angiogram. All have come back normal.  
I have been to the emergency room several different times and each time doctors say I’m fine and first thought it to be Acid Reflex,  and then telling me it’s all in my head.

I have been treated with several different drugs.  I kept telling the doctors that 3 out of my 5 children have Mitral Valve prolasp and Bicuspid Regurgitation.  So after almost a year later, they did an echo reads: Left Atrium is normal in size, Mitral Valve is Mildly Thickened, Left Ventricle Normal in size & wall thickness. Ejection Fraction about 60%. Aortic Root is Normal in size. Three Cusped Aortic Valve is Mildly Thickened. Right Atrium is normal in size. Tricuspid Valve is Normal in structure & opening. No Pericardial Effusion.

1. Normal Left Ventricular size & Systolic Function.
2. Moderate Mitral Regurgitation.
3. Mild to Moderate Tricuspid Regurgitation.
4. High Normal Right Ventricular Pressure.  
5.  Trace Pulmonic Regurgitation.  

After my echo doctors still said it had nothing to do with my symptoms.  And that I don’t have to worry about a valve replacement for at least 30 years.  I was still getting shortness of breath daily and left chest pain. Doctors have all but said that the pain and fatigue I felt was in my head.

Finally I asked the doctor why did I fail the stress test, so he review is again and said he believes I have Microvascular Angina.  And that it is separate issue from my heart valves problem.  I am now taking Nitro caps two times daily and Norvasc once a day.  It seems to be working.  However I still get shortness of breath sometimes and now I feel light headed every day and get dizzy when lying down.  Doctor tells me its vertigo and don’t know why or how long I will have it.   It seems to me with all the different doctors I have seen they don’t all believe in Mircrovascular Angina.  One thing for sure this has changed a lot of things for me.  I can’t do all the things I use too…But I do have to say the Nitro caps and Norvasc I take help..