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.

@kanaazpereira

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?

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It has changed a lot but currently I tak Ranexa 500 mg twice a day/ Lovaza 4000 mg a day/ D3 /coq 10 /amlodipine 2.5 mg /
Aspirin 81 mg/ reapath once a month infusion. I am on other meds for other things, but this are my heart meds. I had to wear a nitro patch at night for quite awhile and was on higher doses of amlodopine and Ranexa, but have been able to wean off nitro patch and lower Ranexa and amlodipine once spasms got under control.
I have a rescue Med bag with various forms of nitro, morphine, tramadol, and amlodipine if spasms get bad or increase. I haven’t use any of those meds for several months.
When Mayo tested me, nitro didn’t work completely, fentanyl didn’t work completely, but Verapimil finally released the spasms.?his was determined during a special test the did for endothelial dysfunction. I think it was called aceticholine test. Not sure I remember correctly.

@lynnkay1956

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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You’ve really been through the mill health wise, lynnkay. I don’t think hypochondriacs are self aware enough to question whether they are hypochondriacs or not. I hope you get some answers soon. Take care.

I have three kinds of chest pain. Big ones happen every couple of months and are your standard crushing, radiating, can’t breathe curl up in a ball episodes. They last five minutes tops. ECG etc negative. Nitro stops them cold. The second kind of pain happens every night while I’m resting and feels like pressure and make it hard to breathe but I still can. Sweats, blurry vision and occasionally radiating pain accompany them. Can last up to half hour. If I take one or two shots of nitro when they start I can sleep through them but I feel like a train wreck the next morning. If I have a bad night I get random aches through the day that catch my breath. They seem to be triggered by anything or nothing at all although stress doesn’t help. They are fleeting and I try to power through them or just sit quietly till they stop. The GP says I may have an unusual kind of angina and I see the cardiologist next month. I just wondered if this is common.

@beahind

I have three kinds of chest pain. Big ones happen every couple of months and are your standard crushing, radiating, can’t breathe curl up in a ball episodes. They last five minutes tops. ECG etc negative. Nitro stops them cold. The second kind of pain happens every night while I’m resting and feels like pressure and make it hard to breathe but I still can. Sweats, blurry vision and occasionally radiating pain accompany them. Can last up to half hour. If I take one or two shots of nitro when they start I can sleep through them but I feel like a train wreck the next morning. If I have a bad night I get random aches through the day that catch my breath. They seem to be triggered by anything or nothing at all although stress doesn’t help. They are fleeting and I try to power through them or just sit quietly till they stop. The GP says I may have an unusual kind of angina and I see the cardiologist next month. I just wondered if this is common.

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Hello @beahind. I merged your most recent discussion with your previous discussion on your chest pain. I did this so all of the members you previously connected with would receive a notification and your recent symptoms.

What did your GP mean by unusual type of angina? Is there a rare type that he or she may think you have?

Possibly some sort of spasm. I’ll know more after Cardiologist. GP assures me that it won’t kill me so I just have to wait out the time until I can get into a cardiologist. The Diltiazem has helped a bit and I went a whole day without nitro which feels pretty dang good.

@beahind

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?

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No an Internist is a regular Doctor. A Cardiologist specializes in the heart .

@beahind

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?

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an internist is a Dr. that specializes in Internal Med. usually a regular Dr. is referred to as a family practice Dr.

@beahind

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?

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See a hematologist. Check for protein in your plasma, your serum, your urine. Your pain sounds more like spleen and/or other organ enlargement, as mine is. There are over 1,000 different types of mis-folded protein deposit disease, and you will rarely find either a cardiologist or hematologist or even gastroenterologist who knows anything about any of them. Could even be myeloma or sarcoidosis. Not one in 1,000 docs know about any of it. Talk to a top specialty clinic such as Mayo-Rochester, Sloan Kettering, Stanford, Mass General. Read “Heart Like Stone”, John (Jay) Helwig, and/or Dr. Kee’s little book about amyloidosis.

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