Chest Pain: Insights on Myocardial Ischemia and Treatment Options

Chest pain, coronary artery obstruction, myocardial ischemia, myocardial bridge?

Hello, please help me interpret the report and advise on further treatment or examination directions.
Thank you, doctor.
A few years ago, I underwent radiofrequency ablation for PSVT and have a myocardial bridge over the left anterior descending artery.
For the past two days, I have been experiencing pain near my left chest close to the armpit that worsens at night.
The next day, when I woke up and yelled at my child, the pain returned immediately.
Usually, when I speak loudly, walk uphill, or go grocery shopping, I feel chest pain or tightness, and I have to stop to relieve the pain.
After each meal, I experience palpitations that last a long time and can also be painful, especially when I eat rice.
Walking and talking makes me short of breath, significantly affecting my daily life.
During a stress test, there was significant ST segment depression in leads II, III, and AVF, which was positive for ischemia.
The portable ECG monitoring showed sinus rhythm with a rate of 60-163/min and a mean of 85/min.
2.
There were intermittent first-degree AV blocks.
3.
Rare atrial premature contractions (total of 4).
4.
One ventricular premature contraction.
5.
No pauses longer than 2.0 seconds.
6.
No ST segment deviation greater than 2mm.
7.
No entries of symptoms were made in the patient diary.

Irene, 40~49 year old female. Ask Date: 2022/05/04

Dr. He Dongjin reply Cardiology

Hello, at this age, it is common to experience chest pain due to autonomic nervous system issues during menopause.
However, a positive result from an extreme cycling exercise test still raises suspicion for angina, particularly with the presence of a myocardial bridge in the left anterior descending artery.
How long ago was this discovered? It may be worth considering a CT angiography for further evaluation.
In the meantime, medications can be adjusted to enhance the stability of the autonomic nervous system.
Changhua Hospital cares about your well-being.

Reply Date: 2022/05/04

More Info

Understanding chest pain, particularly in the context of myocardial ischemia, is crucial for both diagnosis and treatment. Your symptoms and the findings from your recent tests suggest that you may be experiencing significant cardiac issues that warrant further investigation and management.

Overview of Your Symptoms and Findings
You have reported left chest pain, particularly near the axilla, which worsens with physical activity, such as talking loudly or walking uphill. This type of pain, especially when associated with exertion, is often indicative of myocardial ischemia—a condition where the heart muscle does not receive enough blood and oxygen, typically due to narrowed coronary arteries.

Your history of having undergone a procedure for paroxysmal supraventricular tachycardia (PSVT) and the presence of a myocardial bridge over the left anterior descending artery (LAD) could contribute to your symptoms. A myocardial bridge can cause intermittent compression of the coronary artery during heart contractions, potentially leading to ischemia, especially during physical exertion.

Diagnostic Findings
The results from your exercise stress test indicate significant ST segment depression in leads II, III, and AVF, which is a classic sign of myocardial ischemia. Additionally, the portable ECG monitoring revealed sinus rhythm with a heart rate ranging from 60 to 163 beats per minute, intermittent first-degree AV blocks, and occasional premature atrial and ventricular contractions. While these findings are not uncommon, they do suggest that your heart is under stress, and the presence of ischemic changes during exertion is concerning.

Risk Factors and Considerations
Your risk factors, including a history of hypertension and dyslipidemia, further elevate your risk for coronary artery disease (CAD). The combination of your symptoms, stress test results, and risk factors suggests that you may have underlying CAD, which could be exacerbated by the myocardial bridge.

Treatment Options
1. Medical Management: The first line of treatment typically involves medications to manage symptoms and reduce the risk of further ischemic events. This may include:
- Beta-blockers: To reduce heart rate and myocardial oxygen demand.

- ACE inhibitors: To manage blood pressure and improve heart function.

- Statins: To lower cholesterol levels and stabilize plaque in the arteries.

- Antiplatelet agents: Such as aspirin, to reduce the risk of clot formation.

2. Lifestyle Modifications: It is essential to adopt heart-healthy lifestyle changes, including:
- A balanced diet low in saturated fats, cholesterol, and sodium.

- Regular physical activity, as tolerated, to improve cardiovascular health.

- Smoking cessation, if applicable.

3. Further Diagnostic Testing: Given the significant symptoms and stress test findings, further evaluation may be warranted. This could include:
- Coronary Angiography: To visualize the coronary arteries and assess for blockages.

- Cardiac MRI or CT Angiography: To evaluate the structure and function of the heart and coronary arteries.

4. Interventional Procedures: If significant blockages are found, options such as angioplasty with stenting or coronary artery bypass grafting (CABG) may be considered.

Follow-Up and Monitoring
Regular follow-up with your cardiologist is crucial. They can help monitor your symptoms, adjust medications as needed, and determine if further interventions are necessary. Keeping a diary of your symptoms, including when they occur and their severity, can be helpful for your healthcare provider in managing your condition.

Conclusion
Your symptoms and test results indicate a need for careful evaluation and management of potential myocardial ischemia. It is essential to work closely with your healthcare team to develop a comprehensive treatment plan tailored to your specific needs. Don't hesitate to reach out to your cardiologist for further discussions about your symptoms and the best course of action moving forward.

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