Chest Pain: Is It Angina or Myocardial Ischemia?

Am I experiencing typical angina? Do I have myocardial ischemia?

Dr.
He: Hello, I asked a question on July 15, and today, since you haven't responded yet, I made some slight modifications to my question.
I apologize.
I am a 57-year-old male, weighing approximately 66 kg and standing 166 cm tall.
I do not smoke or drink alcohol, but I have periodontal disease.
My blood pressure is relatively low, with last year's record being 93/64, and my pulse is 76.
When I brisk walk for a few minutes or climb more than five flights of stairs, I feel significant discomfort and even pain in my chest.
Resting helps alleviate this.
Sometimes, when I stand up from a seated position, I experience discomfort in my chest for a few seconds.
I often feel anxious due to daily worries.
I only walk for exercise 2 or 3 times a week, for about 20 to 30 minutes each time, and I do not engage in other forms of exercise.
Last year, during a health check, my resting electrocardiogram report indicated abnormal Q waves.
In May of this year, I consulted a cardiologist, and the examination results were as follows: cholesterol = 204 mg/dl, triglycerides = 63 mg/dl, HDL = 66 mg/dl, LDL = 128 mg/dl.
The echocardiogram report showed: Anatomy AO root: 16, LA: 30, LVS: 8, LVEDD: 40, LVPW: 8, LVESD: 27, RA: normal, RV: normal, LVEF M-mode: 61%, Mitral Valve structure MR: mild, Tricuspid valve TR: mild.
The exercise electrocardiogram report indicated the primary diagnosis as mitral valve disorders, secondary diagnosis 1: chest pain, secondary diagnosis 2: dyspnea and respiratory abnormality.
The reason for the examination was that major systemic disease was denied, but ECG abnormalities were noted during the physical check-up.
I was informed of valvular heart disease in 2014.
I have knee osteoarthritis and cannot run.
The examination report indicated inadequate heart rate response and inconclusive results.
The doctor mentioned that I have mitral valve prolapse but did not provide further explanations and scheduled me for a myocardial perfusion scan.
Later, I found out that this test involves radiation, and I am hesitant to undergo it.
I would like to ask you: 1.
During the latter part of my exercise electrocardiogram, my chest discomfort increased, and I endured until the technician said my heart rate reached 85% of the maximum heart rate before stopping.
Can my exercise electrocardiogram report be used to determine if I have typical angina? Based on my physical condition and examination reports, do I have myocardial ischemia? Is it possible for someone with mitral valve prolapse to experience chest pain after brisk walking for a few minutes or climbing more than five flights of stairs? 2.
Since my heart rate reached exactly 85% of the maximum heart rate, is it still necessary to perform a myocardial perfusion scan? Both the myocardial perfusion scan and the 256-slice cardiac CT scan involve high radiation exposure and potential carcinogenic risks.
Given my situation, if further examination is needed, are there alternative methods to avoid these two tests? 3.
If these two tests cannot be avoided, which one should I undergo? Why? Thank you for your response.

Lao Chen, 50~59 year old female. Ask Date: 2015/07/18

Dr. He Dongjin reply Cardiology

Hello, a myocardial perfusion scan is like examining which area of the field has poor soil quality, while a 256-slice cardiac CT scan is used to check for blockages in the irrigation channels, essentially functioning as angiography.
If you're worried, getting a 256-slice cardiac CT scan can provide clear answers without the need for guesswork.
Both procedures involve radiation, but I haven't heard of anyone developing cancer just from undergoing a scan.
If you want a direct answer, you might choose the 256-slice cardiac CT scan, although there are pros and cons to both options.
Ultimately, it's your decision.
If it were me, I would choose the 256-slice cardiac CT scan.
Best regards from Changhua Hospital.

Reply Date: 2015/07/18

More Info

Understanding chest pain and its implications is crucial for identifying potential cardiovascular issues, particularly angina and myocardial ischemia. Based on your detailed medical history and the results of your previous tests, let's address your concerns systematically.

1. Chest Pain and Its Causes
Your symptoms of chest discomfort, especially during physical exertion like walking quickly or climbing stairs, raise the possibility of angina, which is typically caused by myocardial ischemia—when the heart muscle does not receive enough blood and oxygen. The presence of abnormal Q waves in your resting ECG could indicate a previous myocardial infarction or ischemia. Additionally, your history of mitral valve prolapse (MVP) can also contribute to chest pain, as it may lead to palpitations or even atypical angina-like symptoms.

2. Exercise Stress Test Results
The fact that you experienced increasing discomfort during the exercise stress test, which was terminated when you reached 85% of your maximum heart rate, suggests that your heart may be struggling to meet the oxygen demands during physical activity. This is a critical observation, as it can indicate underlying ischemic heart disease. While MVP can cause symptoms, the nature of your discomfort during exertion aligns more closely with angina, especially given your cardiovascular risk factors, including elevated cholesterol levels.

3. Need for Further Testing
Regarding the necessity of a myocardial perfusion scan (MPS), this test is often recommended when there is a suspicion of significant coronary artery disease (CAD) or when the exercise stress test results are inconclusive. Given your symptoms and the abnormal findings from your previous tests, an MPS could provide valuable information about blood flow to your heart muscle during stress and at rest.

4. Concerns About Radiation Exposure
You expressed valid concerns about the radiation exposure associated with MPS and CT scans. While both tests do involve radiation, the risk of radiation-induced cancer is generally low compared to the potential benefits of diagnosing a serious condition like CAD. The decision to proceed with these tests should be made in consultation with your cardiologist, who can weigh the risks and benefits based on your specific situation.

5. Alternative Testing Options
If you are apprehensive about MPS or CT scans, there are alternative non-invasive tests that can be considered. These include:
- Echocardiography: This ultrasound test can assess heart function and structure without radiation.

- Cardiac MRI: This imaging technique provides detailed images of the heart and can assess blood flow and heart function without ionizing radiation.

- Coronary CT Angiography: While it does involve radiation, it is less than traditional angiography and can provide detailed images of the coronary arteries.

Conclusion
In summary, your symptoms and test results suggest a potential for angina and myocardial ischemia, warranting further investigation. While the myocardial perfusion scan is a standard approach to assess for CAD, discussing your concerns about radiation with your cardiologist is essential. They can help you understand the necessity of the test in the context of your overall health and consider alternative testing methods if appropriate. Ultimately, the goal is to ensure your heart health while minimizing unnecessary risks.

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