Chest Pain Concerns: Should You Consider a CT Scan for Heart Issues?

Q: Chest Pain Concerns: Should You Consider a CT Scan for Heart Issues?

Hello Ms. <br>Chen： The sensation of vibration within the body is most likely related to the heartbeat, such as experiencing palpitations or a pulsating feeling in the scalp after consuming coffee or exercising, due to increased sympathetic nervous system activity and accelerated

Chest tightness or chest discomfort?

Hello Dr.
Huang: I am a 38-year-old male, 178 cm tall and weighing 78 kg.
I measure my blood pressure twice daily, with readings of 110-130/70-80 in the morning and before bed, and my heart rate ranges from 70 to 90 bpm.
I have a 20-year smoking history but quit smoking six months ago.
Last November, while traveling abroad in temperatures of 0-5 degrees Celsius, I experienced occasional chest tightness and pain on the left side for 2-5 seconds when sitting still in a vehicle.
After returning to Taiwan, I underwent examinations at a major hospital.
My total cholesterol was 182 (normal), low-density lipoprotein (LDL) was 110 (normal), high-density lipoprotein (HDL) was 38.7 (slightly low), and triglycerides were 155 (normal).
My fasting and postprandial blood glucose levels were normal.
However, my hemoglobin (Hgb) was elevated at 18.6, red blood cell count (RBC) was 6.22 (elevated), and hematocrit (Hct) was 54.3.

At night, when lying flat in bed, I feel a tightness in my chest, as if something is pressing down on it.
When I switch to sleeping on my side, I feel pressure from the chest muscles on both sides, and sometimes I experience shortness of breath for 1-3 seconds.
I also feel uncomfortable when lying on my stomach while using the computer.
Over the past six months, I have had persistent chest tightness and pain.
I underwent three electrocardiograms (ECGs) and two exercise stress tests at a cardiology department in a major hospital, all of which were normal.
I also had two chest X-rays done by a pulmonologist last year and recently, both of which were normal.

One night, between 12 and 1 AM, I experienced chest tightness and pain, and my blood pressure spiked to 160/100 in the emergency room.
An ECG performed there was normal, and the initial blood test for myocardial infarction was normal.
A follow-up blood test three hours later also returned normal results.
The emergency physician indicated that if it were a heart condition, it would be acute and not present as chronic pain for over six months.

I had ECGs performed by two different doctors at different hospitals.
One doctor reviewed the ECG and exercise stress test results, which were normal, and recommended that I pay out of pocket for a 640-slice coronary CT angiography, which costs over NT$20,000.
The other doctor also indicated that the ECG and exercise stress test results were normal and advised against the CT scan, suggesting that regular exercise for 30 minutes daily could improve my symptoms.

I would like to ask you, considering the high cost of the 640-slice coronary CT angiography, which is not covered by health insurance, based on my symptoms and test results, do you think my chest tightness and pain could be due to a cardiovascular issue? Is it necessary for me to pay out of pocket for the CT scan?

Alex, 30~39 year old female. Ask Date: 2018/10/11

Dr. Huang Yinghe reply Cardiology

Hello Ms.
Chen: The sensation of vibration within the body is most likely related to the heartbeat, such as experiencing palpitations or a pulsating feeling in the scalp after consuming coffee or exercising, due to increased sympathetic nervous system activity and accelerated blood circulation.
In fact, many factors can cause similar symptoms, commonly including life stress, tobacco and alcohol use, and even temperature changes.
Certain medical conditions are also associated with palpitations, such as arrhythmias, mitral valve prolapse, or hyperthyroidism.

Propranolol is a beta-blocker that primarily works by slightly reducing heart rate, which can help alleviate palpitations and may also lower blood pressure, potentially causing a sensation of lightheadedness.
Xanax is a benzodiazepine classified as a sedative, but the dosage is relatively low; occasional use for insomnia is unlikely to result in any long-term side effects.
However, long-term or excessive use of benzodiazepines may lead to tolerance, and discontinuation can result in withdrawal symptoms such as anxiety and irritability.
If long-term use is necessary, it should be discussed with a physician.
I recommend starting with lifestyle adjustments, such as managing and alleviating life stress, maintaining a regular schedule with exercise, and avoiding stimulants like tobacco, alcohol, and coffee.
Many people find that medication for symptom control is helpful, but if you continue to feel unwell despite taking medication, it is advisable to return to your doctor for further discussion on treatment options.
Wishing you all the best.

Reply Date: 2018/10/11

More Info

When considering whether to undergo a CT scan for heart issues, especially in the context of your symptoms and previous test results, it's essential to weigh the potential benefits and risks of the procedure against your clinical history and current condition.

Based on your description, you are a 38-year-old male with a history of chest discomfort, particularly on exertion or when in certain positions. You have undergone several tests, including multiple ECGs and exercise stress tests, all of which returned normal results. Your cholesterol levels are within normal ranges, although your HDL is slightly low, which is a risk factor for cardiovascular disease. The acute episodes of chest pain you experienced, particularly the one that led you to the emergency room, were ruled out for myocardial infarction (heart attack), which is reassuring.

The decision to proceed with a CT coronary angiography (CTCA) should be based on several factors:
1. Symptoms and Risk Factors: Your symptoms of chest tightness and discomfort, especially during physical activity, could suggest underlying coronary artery disease (CAD). However, the normal results from your stress tests and ECGs indicate that significant ischemia is unlikely. The presence of risk factors, such as a history of smoking (even though you've quit), and low HDL cholesterol, should also be considered.

2. CT Scan Benefits: A CTCA can provide detailed images of the coronary arteries and can help identify any blockages or narrowing that may not have been detected in previous tests. It is a non-invasive procedure and can be very useful in assessing coronary artery disease, especially in patients with atypical symptoms.

3. CT Scan Risks: The primary concern with a CT scan is exposure to radiation. While the amount of radiation from a CTCA is relatively low, it is still a consideration, particularly if you are concerned about cumulative exposure over time. Additionally, there is a small risk of contrast-induced nephropathy if contrast dye is used, especially in individuals with pre-existing kidney issues.

4. Cost Considerations: As you mentioned, the cost of a CTCA can be significant, especially if it is not covered by insurance. It is important to consider whether the potential benefits of the scan outweigh the financial burden, particularly if your symptoms have not worsened and previous tests have been normal.

5. Alternative Approaches: If you are hesitant about undergoing a CT scan, you might consider discussing other non-invasive tests with your healthcare provider. These could include a repeat exercise stress test, echocardiogram, or even a Holter monitor to assess for any arrhythmias that may be contributing to your symptoms.

In summary, while a CT scan could provide valuable information regarding your coronary arteries, the decision should be made collaboratively with your healthcare provider, taking into account your symptoms, previous test results, risk factors, and personal preferences. If your symptoms are manageable and not worsening, and if your healthcare provider believes that your risk for significant coronary artery disease is low, it may be reasonable to monitor your condition with lifestyle modifications and regular follow-ups rather than proceeding with an expensive and potentially unnecessary CT scan. Always ensure that you have a thorough discussion with your cardiologist to make an informed decision that aligns with your health goals and concerns.

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