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Q. Kindly advise regarding my chest pain as the test results are normal.

Answered by
Dr. Rishu
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Jan 23, 2017 and last reviewed on: Oct 09, 2018

Hi doctor,

I am a 29 year old female. I have been experiencing chest discomfort like an achiness for the past couple of months. It comes and goes. I cannot tell if it gets worse with certain foods or after I eat. Sometimes I think it does, but then I tell myself that I might just be making that up. It feels better when I get ready for bed. I do not feel it in my sleep, but it seems as soon as I start to think about it, I start to feel it. My EKG, chest x-ray, echo and blood work came back normal. I do have a heart murmur that is 3/6 and I also had a positive bubble study that suggests a PFO. However, I am getting a CT to rule out lung issues being the cause of the positive bubble study. I am also getting the CT to look at the vessels more closely. There are no associated symptoms. Also, this happened almost two years before.

Dr. Rishu

Cardiology
#

Hi,

Welcome to icliniq.com.

Cardiac origin of chest pain is highly unlikely in a 29 year old female. Female has a cardioprotective hormone called estrogen, which usually delays the onset of coronary artery disease till 65 years.

The pain you get is most likely because of high levels of your anxiety or overthinking.

Once shunt reversal in PFO (patent foramen ovale) is ruled out, then you can ask your cardiologist to start you with a low dose of SSRI (selective serotonin reuptake inhibitor) like Paroxetine along with low doses of anti-anxiety medicine benzodiazepine like Clonazepam for two to three months.

As echo and blood profile is normal, it is not cardiac. However, you have not mentioned if you are a smoker or alcoholic.

  • Is there any family history of early cardiac death? What is the shunt direction in PFO in 2D echo?
  • What are the symptoms of lung congestion? How long does the pain last? What is the frequency of your pain and is it associated with sweating?

A thorough history is a must before giving a cardiac clearance. Please answer the above.

For further information consult a cardiologist online --> https://www.icliniq.com/ask-a-doctor-online/cardiologist



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Hi doctor,

Well, that is what has always been said, but I have to disagree. I think age does not matter at all. My sister suffered from SCAD at the age of 25. I neither smoke nor drink. Yes, my mother had a heart attack brought on by heavy drinking. I am not sure about the shunt direction, but I think it as from right to left for some reason. I do not have any symptoms of lung congestion. Sometimes, the pain lasts for hours or on and off for the whole day and sometimes, for a few minutes. I am getting the pain almost daily. But, I felt nothing for the past two days. No, I do not sweat more during the episode of pain.

Dr. Rishu

Cardiology
#

Hi,

Welcome back to icliniq.com.

I have gone through your history.

The chest pain due to cardiac reason can either be,

  1. Stable angina.
  2. Unstable angina.
  3. Myocardial infarction (heart attack).

In all the three cases, the chest pain cannot remain throughout the day, In stable angina, it will settle down in 20 minutes,.However, in unstable angina, the chest pain will persist for more than 20 minutes and will lead to non-ST or ST-elevated myocardial infarction.

So, the only category of pain in your case if possible in rarest of a rare case is stable angina. A stable angina is a retrosternal (behind breast bone) chest pain. It was explained by most of the patients as a feeling of heaviness or chest discomfort rather than a frank pain. It lasts for a duration less than 20 minutes and is relieved on resting.

Angina is often associated with forehead sweating. So, with a normal ECG and echo, I do not think it as cardiac.

  • In a PFO, the normal direction of the shunt is from left to right. In a left to right shunt patient is asymptomatic;. If the shunt reverses from right to left, then it can lead to symptoms like chest pain and breathlessness. So, if possible, just see your echo or upload the picture of your echo as this is a very important point.
  • SCAD is a genetic disorder passes from parents to offsprings through genes. However, cardiac pain is not related to genetic. It can be a factor, but not a definitive cause.
  • You could go for a test called stress thallium. It is 98% sensitive, and if it is normal, then it cannot be a cardiac pain.

However, if everything is normal and your shunt is from left to right (contrary to what you wrote), then it can be costochondritis. Costochondritis is an inflammation of the cartilage that connects a rib to the breastbone (sternum).

  • A physical examination of the patient is necessary for its diagnosis. Usually, rebound tenderness is present at the junction of rib and sternum.
  • Please mention if you have ever taken benzodiazepines (anti-anxiety medication) or anti-inflammatory medications or any other medication, which has been tried by you or your doctor. Also, kindly mention the term of medication.

The Probable causes:

Costochondritis leading to anxiety if stress thallium is normal.

Investigations to be done:

Stress thallium.

Treatment plan:

The treatment can be suggested only after knowing the medications tried by previous cardiologists.

Regarding follow up:

Revert with the details to a cardiologist online.---> https://www.icliniq.com/ask-a-doctor-online/cardiologist


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Hi doctor,

I had a stress test done a year and a half ago, and it was normal. I do not think it was the thallium test, though. I do not yet have a copy of the echo, but I am waiting for my cardiologist to let me know the type of shunt. I have never taken anti-anxiety medicine, but I plan to. I have been taking Ibuprofen for about a week once a day, but it does not work. I started taking them on my own, and they were not prescribed. I was prescribed muscle relaxants from ER, but they do not work either.

Dr. Rishu

Cardiology
#

Hi,

Welcome back to icliniq.com.

My suggestion is as follows. Please consult your specialist doctor, discuss with him or her and take medicine with consent.

Ibuprofen is a preliminary NSAID (nonsteroidal anti-inflammatory drug).

  • Tablet Paracetamol, tablet Diclofenac and tablet Serratiopeptidase twice daily.
  • Tablet Methylprednisolone 8 mg thrice daily just for three days. In case the pain responds to low dose steroid, then it is costochondritis. Costochondritis shows a rapid response to oral glucocorticoids. However, if there is no response, then it is anxiety related chest pain.
  • Clonazepam 0.25 mg should be started with Escitalopram 5 mg, and the dose should be increased weekly for a month to see the result.

The Probable causes:

Costochondritis.

Regarding follow up:

For further information consult a cardiologist online.---> https://www.icliniq.com/ask-a-doctor-online/cardiologist


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