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Q. I have severe peripheral neuropathy and obstructive sleep apnea. Please give an opinion.

Answered by
Dr. Sagar Ramesh Makode
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on May 22, 2021

Hi doctor,

I am suffering from chest pain on and off for quite some time now. The frequency of chest pains has been increasing over the last few months. I had chest pain twice last year before 7 and 14 months. I was hospitalized with chest pain and with mildly elevated Troponin T. Discharge summary says NSTEMI. But angiogram shows only smaller blocks, which the cardiologist felt were not likely to cause symptoms. A CT angio taken before three years also showed superficial myocardial bridging in mid LAD (of 6 cm length). Angio taken last year shows minor plaques in LAD and 60 % lesion in RCA. Symptoms include: recurrent, continuing chest pains - compressive or squeezing type of pain in the center of the chest at any time (not always related to exertion). Palpitations some times. Discomfort (breathlessness and general discomfort) on even routine activity, inability to exert much. Lightheadedness on exertion; also on standing up from sitting on the floor. General fatigue. Symptoms seem to be gradually worsening. Other investigations include lipid profiles and other blood tests largely within normal limits. The stress test before six years was positive. Last month, I did a cardiac MRI, the reports of which are enclosed. Main findings include dilated left atrium, left atrial ejection fraction of 32 %. Also, a couple of ECGs done recently showed a QTC prolonged (over 500 ms, one 583 ms). Other health issues include some ataxia under neurological follow-up. It is not definitively diagnosed. I have taken a genetic test, and I am waiting for the results. Also, I have severe peripheral neuropathy (altered sensations, numbness, pain in the foot) and obstructive sleep apnea. I am seeking a doctor's opinion on what could be the cause of my symptoms or NSTEMI? Since it is felt that the blocks are minor and not likely to impede blood flow. Also, is the finding of the dilated left atrium with left atrium ejection fraction 32% concerning? Will it be the cause of chest pain or breathlessness? Anything to do for it? Do I need any medication change in addition to alleviate my symptoms? (I am currently on tablet Clopidogrel, tablet Flavedon, tablet Ranozex, and tablet Ciplar LA).

#

Hello,

Welcome to icliniq.com.

Please tell me the following details so that I can help you with the conceern:

1) Did NSTEMIs (non-ST segment elevation myocardial infarction) occur after exertion or at rest?

2) What were the symptoms during NSTEMIS, like transient or prolonged chest pain more than usual?

3) Do you have the reports of cardiac markers done during NSTEMIS?

There are two possibilities with the available information; one is that those were not NSTEMIS, and the second is, there was a transient block or myocardial bridge that had caused it (obstruction is transient in this case and will not be evident on angiography). Also, echo (echocardiography) was normal during NSTEMI admission, and usually, echo shows the abnormalities during NSTEMI, so I doubted it not to be NSTEMI. Anyways, it does not matter now because the same medications will have to be continued.

Regarding your current chest pain, it may not be cardiac at present, as the pain due to blockages and bridge causes exertional pain. Now for other causes, do you have any gastric symptoms like bloating, burping, or epigastric pain as acid reflux can cause similar symptoms? It would be best if you had a trial of antacids like capsule Cyra D (Domperidone 30 mg and Rabeprazole 20 mg) and locally acting antacids like Sucral O suspension (Sucralfate 1000 mg and Oxetacaine 10 mg). Also, you should avoid oily fatty meals, avoid heavy meals, have a light dinner, and have a regular walk after meals for some time. If this is not helpful, the tablet should change Ciplar-LA 40 mg (Propranolol) to other beta-blockers like Metoprolol, and the doctor should try dose adjustment.

Regarding the left atrial issue, this can create problems in the future, however not very concerning. However, symptoms of breathlessness can be due to left ventricular diastolic dysfunction (which is probably related to high blood pressure, and the same thing may be responsible for left atrial problem).To get relieved, you should request your doctor for diuretic medications like Torsemide, which will increase the urine output (remove excessive fluid from the lungs, which occurs in diastolic dysfunction) and help relieve breathlessness.

I hope this helps you and get back if you have any doubts or more information to share.

Thank you for the response doctor,

My symptoms during the NSTEMI episodes - chest pain for 30 minutes, palpitations for one hour, dizziness - during the first episode, and mainly chest pain with some left arm and neck pain for about two to three hours during the second one. Both these episodes happened at rest, one late night around 1:30 AM or so (before I went to sleep), the other in the morning hours. There was no echo taken during either NSTEMI admission. I think the echo I have attached was taken separately a few months after the first episode. I do not notice any specific gastric issues mentioned, like acid reflux, etc. The cardiac markers were only mildly elevated. Troponin T was 21 (normal limits 14) during the first time. And around 24 or 26 in the second episode. When retaken, it came down to 17. I am very keen on understanding if these two episodes and my regular symptoms (mainly inability to exert without discomfort) are caused by the myocardial bridge (MB). Since these symptoms are exertional, and angiography (done while at rest) may not show them. What can be a test to see if there is any blood flow limitation directly due to the MB during exertion? I am keen to understand this to improve my current symptoms and also avoid further such episodes. Also, I am trying to understand the implication of the left atrial ejection fraction of 32 %. What is the normal value for this? I think this means that only 32 % (about one-third) of the blood in the left atrium is squeezed out during each heartbeat. Is that correct? And since this blood goes to the left ventricle, does it mean that there would be an inadequate supply of blood to the left ventricle? If so, what kind of problems can this lead to?

Thank you.

#

Hello,

Welcome back to icliniq.com.

There are two sets of symptoms one is at rest (during NSTEMIS), and the other is exertional. The myocardial bridge is responsible for symptoms during exertion but not during rest. And during exertion as well, there are two sets of symptoms like heaviness on exertion or breathlessness on exertion.Chest heaviness on exertion may be related to myocardial bridge, and breathlessness on exertion may be related to diastolic dysfunction or left atrial problem.

To detect blood flow issues, you should be subjected to stress tests like stress thallium or treadmill test. As it was positive earlier, there is certainly some decreased blood supply during exertion, which may be due to the myocardial bridge. So the doctor may adjust medications for it.NSTEMI occurs due to clot formation, which is usually evident on angiography. And it usually has some component of permanent damage, seen on echo (echocardiography).

Also, troponin levels were marginally elevated, so NSTEMI diagnosis is doubtful.Normal left atrial ejection fraction is usually more than 45 percent, so it is moderately deranged. It can cause shortness of breath, but other problems are unlikely (which you mentioned). Because even in the absence of atrial contraction, blood continues to go to LV (left ventricle) without any issues. Another problem it can lead to in the long term is atrial fibrillation.

So you should do 24-hour holter monitoring (you had palpitations during the first NSTEMI episode, so the possibility of arrhythmia should be ruled out as well as a cause for these episodes). Also, you should request diuretics (like Torsemide), antacids trial, and request medications adjustment for the myocardial bridge.

Regards.


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