Vascular Spasms or Supraventricular Tachycardia?

[Americanguy3]

Hi Im a 28 year old male who has experienced moderate to severe chest pain in the last 2 years. During this time I  have been in and out of ER's and have also had met with a 4 cardiologists and had what I deem to be a thorough cardiac work up. The work up included: multiple ECG's (over 10), a 48 hr. holter monitor, an echocardigram, an event monitor, and a stress test. With the exception of one ECG that showed a Premature Ventricular Contraction, and a "flat P-wave" the doctors have not been able to find anything. During that time period I have completely elimnated all cafeine, all chocolate, and all stimulant's. Even with that I am still feeling pain. Iniitially my symptoms included an increaed heart rate (tachycardia), with loss of sensation in my left foot and left hand, which were also accompanied with sweating in my hands. At first my symptoms subsided a little bit, but have since come back. Now, I'm completely exercise intolerrant for example if I go walking for  1 mile I experience chronic chest pain and tightness afterwards. In addition the pain has radiated to the top of my of my back to my upper left side. My question is what do I have or what should the doctor be looking for to see what I may have? They have ruled out a heart attack, and the doctor's at the ER have said after a chest x-ray there is no sign of heart enlargement. What might I have, and what can I do to manage or eliminate the pain so I can return  back to my active lifestyle? Lastly, I was active throughout my life, I was soccer player, and after that continued to run 3.5 miles a day. For the most part I have maintained a healthy weight to height ratio 5'8" inches tall and a weight of 155-160 during my active years (it has since gone up 168 to 172). My first bout with chest pains came when I used prescription adderall in March of 2009, I have not used it since but still experience these symptoms. Could it be Supraventricular Tachycardia? or is it more likely to be Vascular/arterial spasms. Anybody experience anything similar?

[Jaimy]

Have you been checked for Thoracic Outlet Syndrome?

[Americanguy3]

Thanks Ed. I tend to agree with your conclusion. I'll keep your suggestion in mind.

[ed34]

It would appear to be more stable angina, so a stress echo would be a valuable test. A nuclear perfusion scan doesn't always reveal problems, I've had 4 now and every time they showed lots of vascularization. The only revealing test was a stress echo which gave indications of ischemia in the distal LAD.

[Americanguy3]

Hey guys thanks for all of the insight, it is indeed very helpful. While I definitely will urge the doctor to look for vasospasms I'm a bit in the dark now. It seems from the commentary that vasospasms occur primarily without any known trigger, and more often than not while at rest. However, my symptoms rarely if ever occur while at rest, and more often than not are alleviated by rest. In fact it's strenuous exercise that brings it on and rest is almost required to alleviate that symptoms. With that said does that put me out of the realm of unstable angina/vasospams? Furthermore, if it does are there any other diagnosis I can attempt to have them search for?

[ed34]

Is that now a standard hospital procedure?

[kenkeith]

July 2011 journal:

Coronary spasm can be provoked with pharmocolocial agents:..... "Coronary spasm was provoked in all fixed lesions by intracoronary injection of either ACh or ergonovine. Coronary spasm also was induced in 12 vessels without fixed stenosis. Moreover, 10 patients with and without fixed lesions had coronary spasms on injection of both ACh and ergonovine.

In the majority of previous studies,1246719 regarding the effectiveness of the induction of coronary artery spasm in patients with vasospastic angina, all subjects exhibited variant angina. However, in this study, all patients demonstrated coronary spastic angina with nonvariant angina, and no patients had spontaneous ST-segment elevation. Moreover, almost all patients had single-vessel or nonsignificant coronary stenosis, more than half of the patients had sporadic anginal attacks (ie, less than one attack per month), and no patients had more than or equal to two sporadic anginal attacks per day. In these patients with nonvariant angina, we compared the clinical usefulness of two methods, invasive and noninvasive tests. In patients with coronary artery spasm and variant angina, evidence of ischemia can be obtained readily by noninvasive procedures. However, it is difficult to detect evidence of ischemia by noninvasive methods in patients with coronary artery spasm and nonvariant angina.

In variant angina, pharmacologic agents such as ACh or ergonovine are effective in reproducing ST-segment elevation in patients in whom spontaneous ST-segment elevation was demonstrated".....

http://chestjournal.chestpubs.org/content/119/1/155.full.html

[ed34]

Testing is very difficult and really it relies on the expertise/experience of the Cardiologist. They have the symptoms to go on, because vasospasm is variant angina. In most cases, episodes occur at rest, and there are no symptoms between attacks. This is probably why most tests reveal nothing, unless you are having a spasm at the time. I was very lucky because my spasms were witnessed during angioplasty, but probably caused by the procedure. It began when the catheter wire went through the artery wall, when trying to chip away a blockage of hard plaque, and lasted three months. Some research has shown that vasospasm is far more common in arteries with atherosclerosis and vasospasm can get worse. Depending on how much the artery constricts, determines the damage. In some cases the constriction can be severe, cutting off blood supply and causing death, but of course this is the far end of the spectrum. The other end of the spectrum is where constriction is so small, patients notice nothing going on.
In many cases, diagnosing vasospasm (variant angina) is a process of elimination by Cardiologists and yet some still find nothing and simply state there is not a heart problem. It is important I think that patients demand an explanation because the symptoms are obviously not just in your head. I was known to have the condition, and had to try wearing GTN patches. I tried these low dose patches for three days but couldn't stand the dizziness and headaches. I was then changed over to Diltiazem (calcium channel blocker) and this did the trick. However, one side effect (although rare) was I developed very swollen gums and my teeth were becoming loose. Two of my back teeth actually started to crumble. I stopped the meds and thank goodness, the spasms had stopped.
A patient needs to keep pestering their Doctor about the symptoms and demand the cause is found because ultimately, variant angina can become very dangerous.

[Americanguy3]

Thanks for the reply Ally . I have some questions: first what tests did they run at the ICU. I'm interested to know because they keep giving me an ECG, with the occasional chest x-ray and it shows nothing? Second in the event that my cholesterol is normal where do I go from there? I don't have a history of high cholesterol in my family and I have never been diagnosed with it so how do I get them to check for the vasospasm/unstable angina? Third are you able to exercise with this condition? I really want to exercise vigorously and haven't been able to do this because I have pain afterwards.

Best Regards,

American

[ChatterAlly]

I have experience with both, but would rule out any SVT for now.  I know it is hard for them to find the spasms unless they are looking for that.  It took some convincing for me to get that point across the the ICU team.  Once I did, they were able to look at the monitor data closer and see that I was indeed having vasospasms.  My angina is typical  unstable angina, if that makes sense. Have you done any research in vasospams or unstable angina or small vessel disease? You might want to do that first.  Take care, Ally