What could be the causes of continuous chest pain?

Question

Hello doctor,

I have been suffering from chest pain for the last three years. About two weeks back, I felt uneasiness, shortness of breath, and mild chest pain. The ECG was abnormal. I was admitted to the hospital and was on Lomo injections. They advised me for an angiography and the reports were normal. But, CPK-MB was 35 and creatine level was 1.08.

After angiography, my doctor discharged me and prescribed Met XL 25 and Mactor ASP 75 for one month. I am still not convinced that they got the actual issue as I am still facing mild chest pain. They told me that I have MVP (mitral valve prolapse) as shown six months back in my 2D echo. But, I am not sure why CPK-MB was affected by that.

Please help.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

Creatine phosphokinase-MB (CKP-MB) is an indicator of the cardiac event, but it is not very specific. There are a number of conditions in which CPK-MB could be raised apart from cardiac issues. Troponin I is a better indicator. Troponin I has a very high sensitivity level and is much superior to CPK-MB in detecting a cardiac event.

The doctor prescribed you Mactor ASP 75 (a combination of Atorvastatin and Aspirin) after angiography, which means that there is a blockage in one of the arteries though it can be less than 75 percent, so stents were not placed. But in case, if your angiography is normal as you have written, then no drugs would have been given.

Suppose angiography shows that blockage is less than 75 percent, in that case, chest pain can also be because of an entity called Prinzmeta angina (pain due to spasms in heart vessels) for which the treatment totally differs. You said 2D echocardiography showed mitral valve prolapse.

To comment on the severity, I need to see the 2D echo report and the level of regurgitation (blood backflow). MVP can also cause breathlessness and shortness of breath as described by you. You said that the ECG was abnormal, but an ECG can have a number of abnormalities ranging from T-wave inversion to ST segment depression in case of ischemia. The ECG abnormality can also be because of mitral valve prolapse.

I would like to know a few more details regarding your personal history.

1. Are you a smoker or alcoholic?

2. Do you feel pain on walking fast and does it relieve on resting?

I hope this has helped you.

Thanks and regards.

Answer 2

Hi,

Welcome back to icliniq.com.

I have gone through all your reports (attachments removed to protect patient identity). Your angiogram and echocardiogram findings are normal. Your left ventricular ejection fraction (LVEF) is perfectly normal. The mild mitral valve incompetency should not be a case of concern. Your echocardiogram showed apical mild hypokinesia, which is not a thing to worry about. CPK-MB is a highly unspecific enzyme. A mild elevation of this enzyme can be seen in a number of disorders. Your ECG shows the right bundle branch block and all the ST-T changes are because of this. In the presence of a right bundle branch block, ST-T changes are insignificant. The right bundle branch block is normal in 90 percent of the cases. If your echocardiogram and angiogram are normal, then the right bundle branch block is not a problem to be worried about.

As of now, mostly your pain is not of cardiac origin. I suggest you tablet Clonotril 0.5 mg (Clonazepam) once a day at bedtime along with tablet Pexep CR 12.5 milligrams (Paroxetine) once a day in the morning and Pan DSR capsule (combination of Pantoprazole and Domperidone) once a day in empty stomach. As your anxiety levels are high, anxiety can often mimic the symptoms of cardiac pain. I think it is either anxiety-related or because of acid peptic disorders. Start exercising 45 minutes a day. Eat less fat. Start the medicines. Please discuss my opinion with your doctor and stop taking Aspirin and Metoprolol for the time being.

I hope this has helped you.

Kindly consult a specialist, talk with them, and take medicines with their consent.

Thanks and regards.

Answer 3

Hi,

Welcome back to icliniq.com.

The uneasiness can be because of palpitation, in which the heart rate increases for a few seconds and after that it becomes normal. As of now, the most important cause of all your problems can be anxiety. Anxiety can be hidden also. A very important test, which I would like to suggest to you, is 24-hour Holter monitoring. It is a small machine that will be attached to your body for 24 hours and will record your 24-hour heartbeats. Anything wrong with your rate and rhythm in the next 24 hours will be recorded. You can even note the time in your logbook and we can see the rhythm of your heart till the time Holter is done. Please follow the medications suggested by me.

I hope this has helped you.

Thanks and regards.

Answer 4

Hi,

Welcome back to icliniq.com.

It is good that you are not having pain now. Anxiety will take time to settle down for at least 21 days to show an initial response. Keep on taking the three medicines as advised by me. After seven days, increase the dose of Tablet Pexep to 25 mg. Take Tablet Clonotril 0.5 mg once before going to bed, and Capsule Pan DSR once daily (empty stomach). Take them for 14 days and review them after 14 days. You can join the office. Do not overthink about palpitations because anxiety is the main reason in your case. Try to divert your mind by keeping yourself busy at work. Get a holter done whenever possible, it takes one day, so you can go to the nearest place with this facility for a day. Take medicines as advised by me.

I advise follow-up after 14 days.

Thanks and regards.