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QUESTION: Several months ago I developed a shortness of breath and chest pain with left arm involvement and thought i was having a heart attack and when to the hospital where they did tests and said it was not a heart attack and sent me home.

I decided to head to a doctor and do several tests which after getting the results have scared me and concerned me greatly.

Stress Test

Resting Data - HR 120 BP 120/75

ECG - Sinus tachycardia, right axes deviation and incomplete right bundle block.
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Stress Data - Protocol Bruce, Max HR 185, %Target Rate 104%,
Duration 9:00, Max BP 160/75

ECG - There were no significant ST segment changes over baseline during exercise.
Interpretation - Negative Stress Test
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Echocardiography Report:

The left ventricle was normal in size, There was overall Grade systolic function. Normal diastolic filling.
The right ventricle was normal in size and function.
The aortic valve was trileaflet and normal with no regurgitation. The ascending aorta was normal in size.
The mitral valve was normal.
The pulmonary valve was normal. There was trace physiological pulmonary regurgitation.
The tricuspid valve was normal. There was trace physiological tricuspid regurgitation. The right ventricular systolic pressure was estimated at 25 mmHg(RA=10)
There was no pericardial effusion.
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24 Hour Holter Monitor

HR - 85
ECG Normal sinus rhythm and Q waves in Leads V1 and V2

Normal Sinus Rhythm, heart rates between 56-161BPM and an average heart rate of 88BPM.
There was no ventricle premature beats.
There were 8 atrial premature beats. There was 1 atrial couplet.
There was no complex ectopy.
There were no pauses. There was no significant ST depression.
There were 2 symptoms of palpitations, 1 corresponding to no ECG abnormality and 1 corresponding to an atrial couplet. There were two symptoms of arm pain corresponding to no ECG abnormality. There was 1 symptom of chest tightness corresponding to sinus tachycardia. There was 1 symptom of thumping heart corresponding to no ECG abnormality.
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Reading all these its got my thinking something may be wrong as the doctor only went over the other tests and did not suggest anything about my heart tests. He only mentioned my vitamin b12 was low but did not suggest taking any supplements only prescribed clonazapam to help me relax which I am afraid to take in case i have a heart problem.

I am very concerned about the echocardiogram as i have sinus tachycardia and right axes diviation and incomplete bundle branch block- it sounds so serious and bad.  Along with grade 1 systolic function - i fear getting to stage 2 and 3 and the serious death.
Can you please explain what this means? I am trying to get a referral to cardiologists but i now have to wait a week to see PCP again and then maybe 2-3 months for cardio and while i wait I am so worried sick.

The other tests also concern me ot feels like i am getting heart failure.

What does all this mean please. Thank you so much for your time.

ANSWER: Hello Steve,

Sinus tachycardia is normal, part of the anxiety of a stress test.  Right axis deviation is part of the incomplete right bundle branch block, that is RBBB causes right axis deviation.  Incomplete RBBB is no threat.  The right bundle branch is a very thin ((maybe one fiftieth  of a millimeter) bundle of conducting fibers that can be interrupted by a tiny speck of dust from a normally dying heart cell. It does not interfere with the function of the heart and will never cause any trouble at all.  It may go away.  Grade 1 systolic function is normal.  Your heart will not deteriorate unless it's injured by auto accident or by heart attack when you're 55.  Your excellent exercise capacity shown on the stress test means you have no heart disease.  Just be sure to act appropriately to avoid heart attack when you're in your 50s.  

Chest pain in a young person is usually cramping of muscles in the chest wall.  If pushing on the painful area modifies the pain (makes it better or worse), or if the pain is relieved by bending the body away from the painful area, that proves the pain is from chest  wall.  Even if these maneuvers donít affect the pain, itís still probably chest wall.  Pain caused by narrowing of the coronary arteries that supply blood to the heart is extremely rare below age 40. Chest wall pain is no threat to life or health, just a big nuisance.  Safest management is just to ignore the pain, though Tylenol, aspirin or ibuprofren usually help.

Please write back if this note doesnít answer all your questions.

David Richardson

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QUESTION: Thank you very much for the reassurance. It helps put my mind at ease in regards to heart disease. Since sinus tachycardia and grade 1 systolic function is normal and incomplete RBBB is not a threat I am wondering if any of the other stuff in regards to regurgitation on the tests were normal and the various palpitations i had during the Holter.

One last thing that concerns me - my doctor suggested i take a medication for anxiety called celexa - lexapro. I am concerned because it stats there is potential for heart rhythm issues, especially if you have a heart condition. I am just so super worried I will have a heart attack or my heart will go into heart failure or rhythm issues.

Based on my test results would you think i am safe to to take a medication like this for anxiety?

Could anxiety give me all these chest pains and heat palpitations and worries about my heart?

Thanks so much for your time.

Answer
Trace regurgitation is normal.  Valves leak a little after the ventricle contracts before the leaflets completely close.  The palpitations were your feeling 2 atrial premature beats, which are normal heart activity and no threat.  Celexa-Levapro will not cause rhythm troubles or heart failure.  You're safe taking it.  The exact cause of chest wall pain is unknown.  Anxiety may worsen it.  Let me know please if Lexapro-Celexa relieves your chest pain.

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David Richardson

Expertise

Adult heart function and disease. Not very good about children lesss than 12. Hypertension is o.k. Heart rhythm a special interest.

Experience

Certified in cardiology by the American Board of Internal Medicine. Was chairman of division of cardiology at the Medical College of Virginia. Am now mostly retired.

Organizations
Fellow of American Heart Association and American College of Cardiology and member of American Physiological Society..

Publications
Circulation, American Heart Journal, Hypertension.

Education/Credentials
M.D. from Harvard Medical School. Residency training at Yale Uhniversity School of Medicine and Medical College of Virginia.

Awards and Honors
Gold Heartt Award from American Heart Association in 1995.

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