Expert: Charles V Allen Jr., RN, BSN - 6/10/2009

Question
QUESTION: Hi I've been having chest pains for almost 2 months now.  Sometimes it's the middle of my chest sometimes upper towards my collar bone sometime on either side.  It's like a dull pain sometimes it will hurt worse when I bend over.  I've had EKG, echo at rest, stress test max heart rate reached, and echo after exercise all were perfectly normal!  I have history of heart attack on my dad's side of the family but not young deaths.

I'm 30 yr. old Female
quit smoking over 10 yrs. ago
occasionally drink
have depression and anxiety which the doctors seem to think it is.
I've also been experiencing horrible back pain for months as well before the chest pain started.  Sometimes I think the pain from back is radiating to my chest or vice/versa.

Should I not be as concerned with this being my heart since the test I had came back great I have no insurance now which I think adds to the stress...sometimes this is all I can think about is my chest pain.  Am I losing my mind am I causing the pain myself?  I exercise at least 4 days a week and have no problems during exercising either.  Your answer would be greatly appreciated I feel like a dumby b/c this is interfering with my life so bad.  Thank you for your time.

ANSWER: Hi Bre,

    I'm glad that your cardiac tests came back negative. The stress test was the big one. They probably used a contrast dye and can see the blood flow to the heart and the coronary arteries light up with the contrast showing them if you have any blockages. It is a good tool for ruling out a heart catheterization or confirming that one needs to be done. You didn't mention any lab tests although I'm sure they had to have been done, probably immediately or very soon after admission to the ER. These lab tests are looking elevated for cardiac enzymes such as Creatine Kinase (CK's) and (CK-MB) Creatine Kinase-Myoglobin. Elevated levels of CK only show damage to muscle so they could be elevated after you worked out even. CK-MB's are more specific to the heart as they will show muscle damage to the heart tissue if elevated. The latter two are not as nearly specific of your Troponin I levels. Only your heart, when damaged will produce high levels of Troponin I. This is enzyme, if elevated is about 97% accurate in telling us that you have had a heart attack. They normally draw three sets at 8 hour intervals because these enzymes peak at different times.
    Sounds like you have chronic chest pain and the heart is the first most important thing to look at as the cause. However, if all heart tests came back negative we have to look at other causes of chest pain of which there are many. Chest pain unrelated to a heat attack is one of the most difficult diagnoses for doctors to make. The reason is that there are dozens and dozens of causes. I'll go over a few of the common ones that can feel like a heart attack:

(1) A condition known as Costochondritis is an inflammation of the cartilage that connects a rib to the breastbone (sternum). It causes sharp pain in the costosternal joint — where your ribs and breastbone are joined by rubbery cartilage. Pain caused by costochondritis may mimic that of a heart attack or other heart conditions. It usually resolves over 1-2 months, (2)Anxiety/panic attacks, (3) Heart burn/GERD (Gastroesophogeal Reflux Disease), (4) musculoskeletal conditions which account of 36% of all chest pain not involving the heart, (5) gastrointestinal disease, (6) stable coronary artery disease (CAD), (7) pulmonary disease and (8) Pneumonia. This is only a partial list.
    Just because your chest pain was non-cardiac in nature base on your negative test results DOES NOT MEAN THAT IT SHOULD BE IGNORED. In my opinion, you need to see your primary care doctor to have your chest pain diagnosed. "The key to diagnosis remains accurate patient history. Learning about the nature of the pain will give the healthcare provider direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the care provider assess the probability of what potential diagnoses should be considered and which should be discarded.
     A differential diagnosis is a thought process that healthcare providers use to consider and then eliminate potential causes for an illness. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved."(MedicineNet.com)
    So that you don't have to suffer with this anymore, this is my suggestion. Even though you have no health insurance, the doctors and hospitals will work with you and possibly help you get financial aid. You really should get this further checked out so you can go on living a normal pain free life. I would however keep up with a healthy living style and you should be checked out at least every 5 years for cardiac health since you have a family history of it. I most often see patients who have suffered a heart attack that are between the ages of 40-50 yrs. Many of the older patients are in this group as well but we see more heart failure and conduction disorders such as Atrial Fibrilation in the older population.
    I hope my answer has sufficiently given you the information you needed. Top priority for you is to see a competent physician and let him know that you are there for one reason, to have your chronic chest pain diagnosed and treated. You will obviously tell him all cardiac tests came back negative or he will send you straight to the ER. Let me know how it turns out and best wishes for having it resolved.

Sincerely, Charles V Allen Jr., RN, BSN



---------- FOLLOW-UP ----------

QUESTION: First off thanks for such a quick response. My primary doc is the one who sent me for the test I'm also having a recheck with him tomorrow morning. My follow up would be that they did not do the nuclear dye stress test which I've read is more correct. I've had chronic chest pains off and on for 3 yrs and even seen by a cardiologist 3 yrs ago who also ruled out heart problems but just by looking at holter moniter results and echo results. And to answer your question about lab work at the ER the only things I had done was xrays and EKG no bloodwork which I thought was strange. I've had a normal workup at my docs office but I'm sure they don't check for heart attack enzymes. My primary is the one who said he's not worried about my heart but I can not live like this and I'm glad you agree. Also would you have chest pains this long if it is heart related. I thought I would be dead by now. Again thank you.

Answer
Bre,

I am astonished that blood work was not done in the ER. Testing for elevated cardiac enzymes, Troponin I and even electrolytes should always be done. You probably should have been admitted, if you weren’t, so that they could do all three checks of your enzymes before clearing you. You could possibly have angina. An episode of angina is not a heart attack. Angina is due to a temporary reduction in the flow of blood to part of the heart muscle and does not damage the heart itself. They should have given you a sublingual nitroglycerin tablet to attempt to relieve the chest pain. Nitro temporarily dilates the coronary arteries restoring blood flow to the heart. Cardiac enzymes would not be elevated with angina because it does not damage the heart. They should have checked for that but I personally would rule that out since angina gets very bad during even mild exercise and you don't have that problem. Get lab work done to look for elevated cardiac enzymes, Troponin I and electrolytes. Tell you Dr that they didn't do them in the hospital. I'm still in shock that they didn't do that. In our hospital it is done on anyone coming in for chest pain and three full sets are done.
   Good luck with everything.

Sincerely, Charles V Allen Jr., RN, BSN