Chest pain conflicting diagnosis

Posted by beahind @beahind, Apr 15, 2017

Hello, I am a 57 year old women, non-smoker, occasional drinker, 30 lbs overweight. I am bipolar 2 and have been stable for a decade on lamotrigine and propranolol (which removes the tremor from the Lamotrigine). I work in an extremely high stress industry.

HISTORY
– Uncle with heart surgery (they replaced an artery with a pig part?)
– Son born with a hole in his heart which did not require surgery
– Snoring
– Osteoarthritis- neck, hands, thumbs, and knees in particular
– Two bladder infections and impetigo in the last four months.
– Cough comes and goes
– Vision blurry, I may just need new glasses.
– blood pressure and cholesterol normal.

SURGERIES
– appendectomy (child)
– gall bladder removal in my twenties
– hysterectomy at 35 (ovaries intact)
– rotator cuff surgery at 49
– bladder repair last year
– I had 4 epidurals during childbirth, the last one of which did not work.

EPISODES
– Since 2015 I’ve had about six episodes of crushing chest pain that radiated to my shoulders and back and made it difficult to breathe. Each episode happened a few days after upper body exercise (climbing ladders, lifting).
– ECG and blood work was always negative. Chest X-ray in early 2016 negative
– Discontinued HRT just in case trouble was estrogen related.
– Chest ultrasound negative, blood work ordered, and referral given to Internist.
– Physiotherapy prescribed which I have attended for two months. It has helped with muscle pain.
– I requested a psychiatric referral. Dr. Prescribed Ativan for use during attacks.

PAIN CHANGED
– Two months ago I had an episode sitting up at 2 am, another laying down at 6 am, and another laying down at 5 pm all within 24 hours.
– I used Ativan for two of the three episodes. Ativan had zero effect on my breathing and very little on the pain.
– This was the first time I’d had more than one episode at a time.

PAIN CHANGED
– Psychiatrist doubled my propranolol and prescribed Cipralex. Two days later I took a long haul flight overseas.
– The episodes became daily then hourly.
Pain and shortness of breath, fatigue, sleeping 14 plus hours a day in four hour stints. Climbing or lifting seems to bring on an episode more quickly than just walking. I learned to sleep sitting up and to avoid triggers as I discovered them. Cold clammy sweats a few minutes after each episode. Appetite dropped off. I discontinued Cipralex after two weeks. Episodes lessened slightly after two days but I stopped sleeping so much.
– I foolishly ate a large meal with wine after a relatively active day. That evening I had episodes one after another, nearly continuous. Ambulance called and they gave me nitroglycerin. Afterwards I could breath even laying on my back on the gurney. The chest pain slowed down and stopped within a few minutes. ECG and blood tests normal. I asked if I could wait until I got back home for more tests.
– I need to take a short walk every morning to clear my lungs.

What makes it worse?
– Cipralex
– Laying on my back
– Flying
– Car sickness
– Stress
– Big meals
– Alcohol
– Chiropractor
– Sex

What makes it better?
– Sitting up
– Leaning forward
– Resting
– Concentrate on breathing deeply
– Nitroglycerin (sometimes it takes 2)
– Hot bath

DIAGNOSIS TO DATE
GP #1 – Costochondritis – prescribed physio which helped with muscle pain. Physiotherapist after two months says the muscle pain was from ‘gaurding’ my chest due to an underlying issue. This GP ordered an echocardiogram which was negative and blood tests and he referred me to Internist. He doesn’t feel the issue is anxiety.
Psychiatrist 1 – absolutely convinced its anxiety, doesn’t want to discuss alternatives.
Psychiatrist 2 – (filling in for the referred psychiatrist) told me that the only conclusive way to rule out heart was with an angiogram.
Internist – does not feel its heart related but has ordered a stress test to be sure. Very clear that if the stress test is normal he will not pursue further potential heart issues. He says Psychiatrist 2 was in error telling me that an angiogram was the only conclusive test. He mentioned that the ultrasound technician did not look at my heart lining. He feels that the reason my symptoms worsened with Cipralex was due to an allergic reaction. He suggested that we may be looking at costochondritis, esophageal spasms or anxiety.
He gave me nitroglycerin .3 mg and ventolin in the meantime which is helping immensely. I can even sleep on my back a bit.

I don’t know whether I should ask to see a cardiologist or whether I should accept what I’m hearing from the psychiatrist and Internist.

I looked up the DSM V for panic attacks and I do not meet the criteria. I am emotionally calm during episodes and actually had one episode at a west end musical because the music was exciting.

Advice please.

Hello @beahind and welcome to Connect. Thank you for providing such a detailed description of what you are experiencing. It all sounds both scary and frustrating. While we cannot give medical advice on Mayo Clinic Connect, I would advise taking the direction of your physician. Was it suggested that you see a cardiologist?

I would like to introduce you to @dawn_giacabazi, one of our volunteer Connect mentors who has experience with costochondritis. Dawn, do you have any insight to provide @beahind with your experiences with costochondritis?

@beahind, a lot of our members on Connect are very adiment about advocating for your own health and seeking input from physicians until you find the answers you are looking for. Do you plan to get checked for costochondritis, esophageal spasms, and anxiety?

Which doctor do I listen to? The cipralex made the chest pain much worse so I’m reluctant to take anything else for anxiety until we have conclusively ruled out heart issues. I am going to physio in case it’s costochondritis and will continue to do so.
If the stress test is negative the internist was clear that he will not pursue heart issues further.
As long as he keeps prescribing nitrogen I can function so maybe that’s good enough? I’m finding that if I take two in the morning I’m pretty good as long as I sleep sitting up. If I fall over in my sleep and wind up on my back the pain and breathlessness is bad enough to wake me up and I need nitro and Ventolin. The next day is a train wreck and I have to stop frequently and rest (sitting up and leaning slightly forward). Sorry for the long winded messages, just trying to sort out the various diagnosis’.
Is an internist the same as a cardiologist?

Could it be prinzmetals Angina or am I just spending too much time on the internet?

Hello @beahind!! I am very sorry you are going through such a difficult time. As I ready your introduction, I found a flood of questions and comments come to mind.

Based on my experience with my own chest pain.. Here are some resources and suggestions if I had to go through it again (pray I never do!! HORRIBLE PAIN)

I highly recommend sternal MRI and or bone scan. If there is increased activities in the isotopes then you would confirm Costochondritis. Here is some information on this dx http://www.mayoclinic.org/diseases-conditions/costochondritis/basics/symptoms/con-20024454

2nd I went through 27 doctors before going to Mayo Clinic and waisted over $100,000.00 and 3 years of pain and suffering. I always recommend going directly to Mayo Clinic for any case that seems complicated. You certainly have tried many options. Here is a link on Mayo Clinic. http://www.mayoclinic.org/patient-visitor-guide/why-choose-mayo-clinic

3rd I went through the Pain Rehabilitation Clinic which is how we ultimately discovered the correct diagnosis and treatment plan. Now I am 100% Pain and symptom free!! http://www.mayoclinic.org/departments-centers/pain-rehabilitation-center/overview

Lastly cardiologist is it’s own specialty.
http://www.mayoclinic.org/departments-centers/cardiovascular-diseases/home/orc-20121930

Hope this helps!!
Dawn

Thankyou

I tried to sleep horizontally again and no luck. Woke up at 3 am with chest pain radiating into my shoulders and back, occasionally up the right side of my neck, .6 mg nitro gave me enough relief to be able to sleep, I woke up at nine with another bad spell. If past history is any indication I’ll be sore for some of today with any excitement setting off milder chest pain. As I’ve said before, the Internist is looking at Costochondritis, esophageal spasms, anxiety, or pericarditis. My question regards the medication I take. I’ve been on lamotrigine (lamictal) and propranolol for 25 years. Could they have caused this?

Hello @beahind,

I moved your message to this discussion, so that all the messages can be together.
There are so many causes for chest pain, and a heart condition is one of the more significant factors. Consulting a cardiologist would be the best avenue to rule out any heart conditions.

I’d also like to connect you with members who have taken Lamictal (lamotrigine) and/or propranolol; @thoferer81017 @lucky12 @debburrington @sharin @mfelton @sheetrock0131 @trainwreck54 @macarl @trouble4343 @19aleckelly, do you have any insight or suggestions for @beahind?

@beahind , hello! I read your story twice and immediatedly I remembered the story of a close relative in the 90s. She had attacks of chestpain with radiation to her shoulder and her jaw. she was young, maybe 25 years old. the family doctor suggested stress and perscribed a b-blocker. 15 years later she had severe pain behind her sternum. a gastroendoscopy was done.diagnosis : inflammation and bleeding of her esophagus.(GERD stage III) she got omeprazol. this medicin was only partially effective, her chestpain attacks were still there although a second gastroendoscopy showed healing of inflamed esophagus. a year later she asked for a second opinion, the university gastroenterology department asked her to participate in a pilote study “non-cardial angina pectoris”. there was a scientific paper, which said that 50% of the patients, who came to the emergence room because of chestpain, had no cardial
abnormaties.test were done, negative. she continued her visits to the gastroent. physician. a couple of years later he suggested an operation (fundoplastica) and sent her to a surgeon. he said to her,: you have the same problem like me: a neurological disorder, called esophageal spasm, maybe correlated with GERD in the past. he said: I don’t know what you do. I carry always a small bottle of water with me, even in theater etc. no surgery .she was so relieved , a long time (20-25 years) with missed and false diagnoses came to an end. (1996 or 1997). a couple of years ago she stopped the medication with PPI (protonpump-inhibitor), she still has the pain after her sternum with radiation sometimes, not very often.. she cannot tell what provokes such a spasm. she only knows that she should not drink wine with an empty stomach.and after the meal + wine she always drinks a glass of water.
the essence of this story is that several physicians never suggested the involvement of the esophagus, cardiologists mentioned a cardiac disorder, gastroenterologists focussed on GERD.
would you agree with me, that her story is similar and why your story reminds me of her?

@yoanne

@beahind , hello! I read your story twice and immediatedly I remembered the story of a close relative in the 90s. She had attacks of chestpain with radiation to her shoulder and her jaw. she was young, maybe 25 years old. the family doctor suggested stress and perscribed a b-blocker. 15 years later she had severe pain behind her sternum. a gastroendoscopy was done.diagnosis : inflammation and bleeding of her esophagus.(GERD stage III) she got omeprazol. this medicin was only partially effective, her chestpain attacks were still there although a second gastroendoscopy showed healing of inflamed esophagus. a year later she asked for a second opinion, the university gastroenterology department asked her to participate in a pilote study “non-cardial angina pectoris”. there was a scientific paper, which said that 50% of the patients, who came to the emergence room because of chestpain, had no cardial
abnormaties.test were done, negative. she continued her visits to the gastroent. physician. a couple of years later he suggested an operation (fundoplastica) and sent her to a surgeon. he said to her,: you have the same problem like me: a neurological disorder, called esophageal spasm, maybe correlated with GERD in the past. he said: I don’t know what you do. I carry always a small bottle of water with me, even in theater etc. no surgery .she was so relieved , a long time (20-25 years) with missed and false diagnoses came to an end. (1996 or 1997). a couple of years ago she stopped the medication with PPI (protonpump-inhibitor), she still has the pain after her sternum with radiation sometimes, not very often.. she cannot tell what provokes such a spasm. she only knows that she should not drink wine with an empty stomach.and after the meal + wine she always drinks a glass of water.
the essence of this story is that several physicians never suggested the involvement of the esophagus, cardiologists mentioned a cardiac disorder, gastroenterologists focussed on GERD.
would you agree with me, that her story is similar and why your story reminds me of her?

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To a man whose prime tool is a hammer, every problem looks like a nail.

Liked by beahind

Thankyou. It’s true that doctors look at patients through the lens of their specialty. When your mentally ill it’s hard for them to look at you without that bias as well. I’m frustrated that the internist plans to rule out heart related issues based on an exercise stress test done during the day when he knows that the episodes are always more severe at night. Of the first six episodes I had, five happened flat on my back after midnight. The good news is that nitroglycerin is a wonder drug. If I take .6mg when the pain wakes me up I can go back to sleep, and then if I take .3mg in the morning I don’t get much pain at all during the day. Trial and error I guess.

Cardiologist if you don’t have one find one that knows about Pulmonary Hypertension

I have similar chest pain to what you describe. The only difference is I have had genetic heart defects repaired and a genetic defect for eliminating cholesterol so I have high cholesterol. After many ER trips and no occlusive disease or elevated tropinonins or EKG problems and multiple cardiac caths that were normal, I was finally referred to Mayo in Rochester Minnesota. They diagnosed me with endothelial dysfunction and Coronary Artery spasms. They put together a treatment plan for me that helped quite a bit. It took some trial and error tweaking, but they really helped me with all of my problems. The also helped with all my genetic defects. While I still have mild to mod chest pain , at times, I am so much better. I can’t thank Mayo enough. I haven’t been in the ER with chest pain since November if 2016 and I used to have to go every month to every other month. I am also now on Repatha which has also made a huge difference for me.

@vthatch

I have similar chest pain to what you describe. The only difference is I have had genetic heart defects repaired and a genetic defect for eliminating cholesterol so I have high cholesterol. After many ER trips and no occlusive disease or elevated tropinonins or EKG problems and multiple cardiac caths that were normal, I was finally referred to Mayo in Rochester Minnesota. They diagnosed me with endothelial dysfunction and Coronary Artery spasms. They put together a treatment plan for me that helped quite a bit. It took some trial and error tweaking, but they really helped me with all of my problems. The also helped with all my genetic defects. While I still have mild to mod chest pain , at times, I am so much better. I can’t thank Mayo enough. I haven’t been in the ER with chest pain since November if 2016 and I used to have to go every month to every other month. I am also now on Repatha which has also made a huge difference for me.

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@vthatch How wonderful that you found such quality help at Mayo! I’m happy to hear that you are feeling so much better. It sounds like you have a difficult to diagnose problem. Thanks for sharing your story and for being so proactive in finding the help you needed. Teresa

Hello @vthatch,

I’d like to echo Teresa’s thanks, and welcome you to Connect. We have to be advocates for our own health, and it seems you’ve done exactly that, and found some relief.

For @beahind, and other Connect members on this discussion, here’s some information from Mayo Clinic, about coronary artery spasm:
http://mayocl.in/1niap3N

@vthatch, would you be comfortable giving us a brief overview of your treatment plan?

I am having some of these issues. I also go to Mayo. I had my surgery back in 2015 Dec. Recently I have been so tired…having odd pains, tightness in my chest, shortness of breath,pain in my arm pit, pain in my left shoulder going down to my fingers and they become achy and numb. I have racing heart sometimes as I lay down in bed and takes awhile to breath normally. I have been having problems with my left eye losing vision as a dark curtain comes across it, but lasting only a minute or two. It doesn’t matter if I am driving, or sitting in a chair or standing- I even have some fevers, chills, and going thru sweats. My sternum and chest wall is sensitive .I had a hysterectomy when I was 35 and have my ovaries, thoracotomy to to take out some lymph nodes as I had stage 4 melanoma in 2010 ( cancer free after immunotherapy) Last infusion was 2013. I remain cancer free. I had a myectomy and repair of aortic stenosis and kept all of my valves…Dr Schaff removed the scar tissue on my aorta in Dec 2015. I have been going through a battery of tests since last Friday..So far my scans show everything is basically working great…I do have slight leakage of the aortic valve but nothing to worry about. My labs look basically fine except NT-proBNP,s is 657 pg/mL up about 150 from presurgery labs from 2015. My platelets are low, but they have been low for years since I was in cancer treatment. Echo is fine…MRI appears fine…I had a 48 hr halter and the Dr didn’t comment. He is running cultures to see if there is a bacteria…but all my blood work appears within the normal range…even my white count….So all I have left to wait on are the cultures and an eye app’t with an ophthalmologist. I am beginning to feel like a hypochondriac…I don’t know whats wrong with me

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