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

Hello,

Welcome to icliniq.com.

I thoroughly read your query and understand your concern. Please tell me the following details so that I can help you with the concern. Did NSTEMIs (non-ST segment elevation myocardial infarction) occur after exertion or at rest? What were the symptoms during NSTEMIs, like transient or prolonged chest pain more than usual? 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. Secondly, 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 abnormalities during NSTEMI, so I doubted it not 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? I suggest you try 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, you change the tablet from 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, it is 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 problems. To get relief, you should request your doctor for diuretic medications like Torsemide, which will increase the urine output, remove excess fluid from the lungs, which occurs in diastolic dysfunction, and help relieve breathlessness. I hope this helps you. Get back if you have any doubts or more information to share. Regards.

Hello,

Welcome back to icliniq.com.

I understand your concern. 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 problems. 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 an ECHO. 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, I suggest you do a 24-hour Holter monitoring since 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. Hope this helps. Regards.

Hello,

Welcome back to icliniq.com.

I understand your concern. I saw your attached reports (attachments are hidden to protect the patient's identity). Holter monitoring does not show any significant abnormalities except some slow heart rate (bradycardia). So besides the superficial bridge, moderate diastolic dysfunction (which can be age-related), and some minor bradycardia, there are no significant cardiac abnormalities. Now, fatigue, if it is there throughout the day, is certainly not cardiac. However, in your case, since your heart rate is lower possibility of hypothyroidism should be ruled out, which can cause fatigue. Fatigue can be related to deconditioning due to an inactive lifestyle or psychological issues like stress, lack of interest, etc. Moderate diastolic dysfunction can cause breathlessness on exertion, so you should get prescribed medicine for it, a diuretic like Torsemide for a week or two, and see the response. If there is no response after diuretics, then this breathlessness might not be related to the heart as well. As chest discomfort or pain does not relate to exertion, it is unlikely to be caused by a bridge. If there are gastric symptoms that can cause intermittent chest pain, like bloating, burping, upper abdominal pain, or heaviness, then I suggest you take antacids like Rabeprazole before breakfast. So in a nutshell, a trial of diuretics like Torsemide should be taken to see the response, and a thyroid profile should be done (in view of bradycardia over the Holter monitoring report) if not done in the recent past. Also, such symptoms may be related to deconditioning due to a sedentary lifestyle. To overcome this, one needs to resume gradually escalating physical activities like walking, brisk walking, etc. Hope this has answered your query. Regards.

Hello,

Welcome back to icliniq.com.

I understand your concern. In the first query, you mentioned it is not always exertional. Anyways considering exertional symptoms, it is probably caused by the myocardial bridge, as there are no significant blockages on the angiography. Have you tried any treatment for the myocardial bridge yet? Is there any relief in the symptoms with medications? Do you have TMT (treadmill test) including tracings available with you? You should request your local cardiologist for medical treatment for the bridge, and if not helpful, then you are a candidate for revascularization. Holter is not used for detecting ischemic changes, and T-wave inversions are seen even at a slow heart rate. So this is not reliable. TMT is used for this purpose. Hope this helps. All the best.