Persistent Left Chest Pain: Insights and Next Steps

Persistent left chest pain for seven years?

Hello, Doctor.
I have some questions I would like to ask.
I have undergone several tests, and here are my basic details: height 177 cm, weight 83 kg, BMI 26.4.
My blood pressure, blood lipids (triglycerides, cholesterol, etc.), echocardiogram, X-ray, and electrocardiogram are all normal.
I do not have diabetes.
I have undergone a gastroscopy, which showed mild gastroesophageal reflux and gastritis; the doctor said medication would help, and I am currently on medication.
A myocardial perfusion scan indicated "significant" ischemia during exercise, and the doctor recommended a CT scan or cardiac catheterization, suggesting the former due to associated risks.
I have a history of psoriasis, and in my family, my father has arrhythmia and hypertension, my aunt has arrhythmia, and my uncle has arrhythmia and angina.
I quit smoking two years ago after a six-year smoking history and rarely drink alcohol.
I have a more anxious Type A personality.
I have had poor endurance since childhood, although I have good explosive strength; however, my long-distance running ability is very poor, despite being active as a child, so it is not due to a lack of exercise.

Symptoms description: I may experience left chest tightness or pain while sitting, standing, lying down, sleeping, having stressful dreams, sleeping on my left side (which I no longer do), waking up, walking, climbing stairs, feeling anxious, lacking sleep, after a large meal, or when fatigued.
The location and timing are unpredictable, and it occurs almost daily under various conditions.
The discomfort is not severe, just mild tightness or pain.
There was a period when I felt pain while taking deep breaths or exhaling fully.
This has persisted for several years.
However, I do not experience discomfort while running; in fact, I feel fine during and immediately after running.
Yet, within 20 hours after running 3000 meters, I experience slight palpitations, body tremors, and left chest tightness.
Given my poor stamina, this is considered high-intensity exercise for me.
Sometimes, even if I feel chest tightness before exercising, I still proceed with my planned workout without experiencing significant discomfort.
I took CanCun 1.25 mg for a few days, which slowed my heart rate, but the chest tightness persisted, and due to fatigue and weakness, I stopped taking it.
I would like to ask a few questions:
1.
Based on this description, what issues am I more likely to have?
2.
Does the myocardial perfusion scan indicating ischemia during exercise mean I have coronary artery disease? I have this doubt because the myocardial perfusion scan is not entirely accurate; another doctor even told me it is not reliable.
If there is significant ischemia during exercise, why do I not feel pain while exercising? Does the myocardial scan not reflect the actual exercise state?
3.
The cost of a CT scan is high; if I choose a 256-slice or higher scan, can it accurately diagnose coronary artery disease?
4.
I once felt left chest pain during an electrocardiogram, but the ECG results were normal.
Does this indicate that the problem may not be with the heart?
5.
I plan to undergo a 24-hour Holter monitor and an exercise ECG.
Although these tests are not 100% accurate, if they show myocardial ischemia, it could corroborate the results of the myocardial scan, and then I should consider cardiac catheterization.
If they show no ischemia, I can wait until I am more financially stable to undergo a CT scan for confirmation.
I may have to pay for these tests out of pocket, as most doctors have dismissed me after reviewing my ECG and X-ray results, only one doctor was willing to perform the myocardial scan.

Chen Shih-Hsien, 30~39 year old female. Ask Date: 2017/12/11

Dr. He Dongjin reply Cardiology

Hello, if you have been experiencing left chest discomfort for seven years without any serious issues, it should be okay, right? A CT scan is expensive, and the accuracy of a 24-hour Holter monitor and exercise stress test is not 100%.
The symptoms are also atypical angina, so it might be sufficient to just monitor the situation.
Any tests you do are mainly for peace of mind.
Once your financial situation improves, you can consider getting a CT scan to confirm your condition.
Take care from Changhua Hospital.

Reply Date: 2017/12/11

More Info

Based on your detailed description of persistent left chest pain and the various tests you have undergone, it is essential to approach this situation with a comprehensive understanding of potential underlying issues. Your symptoms, which include left chest discomfort that occurs during various activities and states of rest, warrant careful consideration and further investigation.

1. Possible Conditions: Given your history and symptoms, several conditions could be contributing to your left chest pain. While you have undergone numerous tests that have returned normal results, the presence of symptoms during specific activities suggests that there may be underlying issues that have not yet been identified. Conditions such as anxiety-related chest pain, musculoskeletal issues, or even gastroesophageal reflux disease (GERD) could be contributing factors. Your mention of mild gastroesophageal reflux and gastritis could indicate that some of your symptoms may be related to acid reflux, which can cause chest discomfort that mimics cardiac pain.

2. Myocardial Ischemia and Coronary Artery Disease: The results from your myocardial perfusion scan indicating significant ischemia during exercise raise concerns about potential coronary artery disease (CAD). However, it is important to note that not all patients with CAD experience chest pain during exertion, particularly if they have a high level of fitness or if their ischemia is not severe enough to trigger pain. The variability in your symptoms—where you feel fine while running but experience discomfort afterward—could suggest that your heart is able to compensate during exercise but struggles during periods of rest or stress.

3. CT Angiography: A CT scan, particularly a coronary CT angiogram, can provide valuable insights into the state of your coronary arteries. While it is not 100% definitive, a high-quality scan (256 slices or more) can effectively visualize coronary artery blockages or abnormalities. If you are considering this option, it is advisable to discuss the potential benefits and limitations with your healthcare provider, especially in light of your financial concerns.

4. Electrocardiogram (ECG) Findings: The fact that your ECG was normal during an episode of chest pain does suggest that the issue may not be directly cardiac in nature. However, it is crucial to understand that a normal ECG does not completely rule out cardiac problems, especially if the symptoms are intermittent. Continuous monitoring through a Holter monitor or an exercise stress test can provide additional data on how your heart responds during episodes of discomfort.

5. Further Testing and Management: Your plan to undergo a 24-hour Holter monitor and an exercise stress test is a prudent step. If these tests indicate myocardial ischemia, it would indeed support the findings from your myocardial perfusion scan and may necessitate further evaluation, such as coronary angiography. Conversely, if these tests do not show ischemia, it could suggest that your symptoms are not related to coronary artery disease, allowing you to explore other potential causes, such as anxiety or musculoskeletal issues.

In summary, while your symptoms are concerning, the combination of normal tests and the nature of your pain suggests that a multifactorial approach may be necessary. It is essential to maintain open communication with your healthcare provider, who can help guide you through the next steps based on the results of your upcoming tests. Additionally, consider lifestyle modifications, stress management techniques, and possibly consulting with a cardiologist who specializes in non-invasive cardiac testing to further clarify your condition. Your health is paramount, and ensuring that you receive comprehensive care is crucial in addressing your persistent symptoms.

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