Angina, heart attack, heartburn, or imagination?

[WTL]

Do good results from a stress/echo test, ECG and resting echocardiogram preclude angina or heart attack? Do normal cholesterol/triglycerides and blood pressure mean you cannot have blocked arteries?

I passed these tests, so I can't figure out this squeezing pain I get in my chest. The pain is also in my jaws where they hinge - sometimes the pain hits there first. It never comes with exertion, only at rest, even while sleeping. No pain in the arms. I get sweaty, but can still move around easily. It lasts 5-15 minutes, but the other night it went on forever, and today it feels like muscle strain across my chest. (Since I got the flu last Christmas I feel weak and breathless climbing stairs, and I used to run stairs at our stadium and climb hundreds of steps in our neighborhood - yet I passed the stress test!)

First I thought it was heartburn because I have hiatal hernia, but it's not a burning pain at all, and neither Prilosec, Tums nor water help. I get these maybe 3-4 times a year, but I've had 3 this year already. I've tried nitrogylcerin a couple of times during the attacks, inconclusive results, only gave me a blinding migraine the other night.

I'm 61, 6-2, 185, just muscle, athletic and very active all my life, married and happy, don't drink, don't smoke, normal bp, live a good life...well, except for prostate cancer...but I began having these attacks a few years BEFORE I got the cancer diagnosis. Could anxiety cause such pains? I'm not at all hypochondriac, I just want my normal life back, but cancer (had surgery two weeks ago) left undiagnosed by doctors who should have known better doesn't reassure me.

What makes me anxious about the attacks is that my grandfather dropped dead of a sudden heart attack at the age I am now, and he was built the same as I and didn't smoke or drink either, and had no sign of heart disease. Should I get a CT scan of my heart arteries?

[Darcy Green Conaway, MD]

No, normal stress tests cannot rule out coronary disease-- they look for disease that is significant enough to decrease blood flow (usually that means you need to have at least a 50-70% blockage; the body can compensate when the blockage is smaller than that).
To me your symptoms sound typical of pain caused by blockages in the arteries and I think you should see your cardiologist. I would consider a cardiac catheterization but your doctors know you much better than I do obviously. Please do not disregard these symptoms, even in the setting of a normal stress test. You could also consider a coronary   CT ('calcium score').

[WTL]

Thank you very much for your reply. I haven't pursued this yet due to financial constraints - no insurance and I'm having to pay out of pocket for my cancer treatment. My new insurance starts on May 1, though it won't pay for much. I've also resisted going back to my doctor and having to demand a CT scan - he's declined to order one in the past, preferring the stress test (though I told him these occur at rest) and saying I don't need it; and since the stress test was good, I feel like I'm being seen as a hypochondriac (and I do wonder about that myself - but the pain and symptoms are very real, so it's confusing to me).

Three other things occur to me, however, and maybe - I hope, despite what you said above - they mean this isn't my heart: 1. My c-reactive protein and homocysteine have been normal; 2. I can walk and talk and think (and type) during these episodes and don't feel especially weak; 3. these attacks can last for a long time - the one I'm experiencing now woke me up at 2:50 am and I'm still feeling it an hour later despite taking two nitroglycerin 20 minutes apart (and water, and Tums); the pain is still in my jaws where it started and in my chest, though it hasn't really increased and seems to wax and wane.

I had one yesterday morning at about 6 am while I was sitting at the computer that also lasted an hour or so - that time the nitro seemed to work somewhat, maybe keeping it from getting worse. But later in the day I walked to the store and coming back up the hill and stairs to my house I was completely depleted and breathless. I'm a surfer, d*** it!

As you can imagine, these sensations worry me a lot and I'm hoping to hear that my normal blood levels of those factors and the duration of the squeezing-clenching pain mean it's not angina or heart attack. I've read about unstable angina and how it occurs at rest - it's scary reading.

I thank you again for taking the time to read and respond. I know how busy doctors are. My urologist even works on Sundays.

[WTL]

Hi again, Dr. Conaway

I took your advice and saw a cardiologist, who agreed that I should indeed have come in, that such symptoms must not be ignored or dismissed as anxiety without further testing.

I got the calcium scan - my score was 813! That sent me into a tailspin, certain my life could end any minute.

But after getting those results, he immediately had me do the thallium stress test, which I passed well, both the stress part and the scan, which revealed no blockages (well, he said no major blockages - I'm gonna pursue that - I want to know if I have any blockage at all). I also have moderate plaque in my carotid arteries. He told me all this on the phone, calling just to reassure me, so I'll find out more when I see him the week of May 18th.

During all this testing he told me that he himself as well as several of his patients have calcium scores that high or higher, and very, very few have had heart attacks because they're taking steps to prevent them. In my case all I have to do is take meds because my physical condition and diet are both excellent.

He's recommending a statin-niacin combination and baby aspirin. My blood pressure is normal and so is my blood work, but HDL is low normal while triglycerides and LDL are high normal (that test wasn't fasting); we're awaiting results of the fasting Berkeley Panel (unfortunately, the night before I forgot about the test and had a very buttery shrimp dinner - who knows what that did to my lipids). I'm already taking the baby aspirin, and he'll know what to prescribe once the blood results are in.

He still can't explain the chest-jaw pains. He's thinking maybe muscle spasms or something to do with my esophagus, but the jaw pain coming just before or at the same time as the chest pain is a puzzler (maybe it's related to carotid artery plaque?) - and they always happen when I'm resting. That's a characteristic of unstable angina