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Chest pain, TACHYCARDIA when stressed. HEART PROBLEM?

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For the past 2 months I've been experiencing on and off chest pains and tachycardia when emotionally stressed. Even the slightest stress would trigger it, such as engaging in an argument or eating a heavy meal. These symptoms also included constant lightheadedness which put me in a panic attack cycle. I would get chest pains to the point where I'd go to the ER almost on a weekly basis, and then they'd send me back home saying it was nothing but a panic attack.

I went to see my internal medicine doctor and after plenty of tests, including cholesterol, echo-cardiogram, 24hr urine and 48 hour holter monitor(which showed only 1 PVC), she assured me I was in good shape and my symptoms seem to be caused by stress without any final diagnosis.

The problem is I never felt there was something stressing me, but I admit that I've always been a person who got angry quickly, so it could be possible that with age now it could have put its toll on my body. (I just turned 30)

I've told my doctor that I was experiencing heart pounding before asleep and after meals. She told me to try to manage my stress for 6 weeks and see if that helps. The good news is I've been getting better and better but seemed to have stopped. After my recent visit to her last week I told her about my on and off chest pain and how it came when I was in panic (when taking my college exams) and she prescribed me Inderal. Ever since, the chest pain episodes have been minimized greatly and I feel like I'm getting better again. Best of all I don't feel that heart pounding before going to bed.

My question here is:

Is heart disease ruled out? What more tests should I do? Why has my fitness suddenly dropped for almost no reason at all? When should chest pain be a source of concern? Should I take a gene tests to rule out heart problems in the future even though my immediate family hasn't had a history of heart disease?

Category: Family Physician-GP

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Dr. Deepu Sebin Sebastian is online now

Expert:  Dr. Deepu Sebin Sebastian replied 4 Days.

Thank you for your query at DoctorSpring.com
The tachycardia, and the heart pounding indeed can be found in episodes of anxiety/ stress.
Since you yourself feel you're getting better, that is a good sign.
Since you're saying your fitness has dropped all of a sudden you can go for the treadmill stress test, and that will give us a better idea. Also a 2D- ECHO and stress test will be helpful. Any minor cardiac ailments will be picked up, and if both these tests come out to be normal, then there is nothing to worry about.
Chest pain will become a cause of concern, when it is associated with severe nausea, palpitations, and breathlessness. Right now it seems like you're having intermittent chest pains and palpitations due to anxiety.
But 2D ECHO with stress test is the best way to go about it. If you have the echo reports kindly share or mention the Ejection Fraction.

Patient replied :

I have done my echo at cleveland clinic (known to have the best cardiology facility in the world). I asked my doctor about a stress tests but she quickly became dissmisive after seeing my other test results. She said I have nearly impossible risk factors and a stress tests will not help with anything. This upset me, but then again she is an Internal Medicine doctor with a specializiation in heart failure so I wasn't going to be presistent on the subject.
Should I go back and ask her to do a stress test? How about a chest CT scan? When is that a viable option?
Below is my echo results from early August:
Date of service: 9/11/2014 11:39:17 AM
Indication: Palpitations
PATIENT: Age: 29 years Gender: M
Primary rhythm: sinus. Height: 175.26 cm BSA: 2.06 m² Weight: 87.09 kg BMI: 28.4 kg/m²
Heart rate 72 bpm Blood pressure 125/88 mmHg
Color Doppler was utilized to interrogate the cardiac valves assessed and spectral Doppler was utilized to determine the flow velocities and pressure gradients reported in this exam.
MEASUREMENTS: Value Indexed Value Max aortic dimension 2.6 cm 1.26 cm/m² Left atrium diameter 3.3 cm (M-Mode) Left atrial volume 46.8 ml (Area-Length) 22.8 ml/m² LV ID (diastole) 4.6 cm (M-Mode) LV ID (systole) 3.3 cm (M-Mode) IVS, leaflet tips 0.9 cm (M-Mode) Posterior wall thickness 1.0 cm (M-Mode) Left ventricular mass 147 g 71.3 g/m² LV stroke volume 69 ml (2D biplane) LV end diastolic volume 115 ml (2D biplane) 55.9 ml/m² LV end systolic volume 46 ml (2D biplane) 22.3 ml/m² Ejection Fraction 60 % (2D biplane)
LEFT VENTRICLE The left ventricle is normal in size. Left ventricular systolic function is normal. Baseline left ventricular diastolic function is normal. Mitral annular lateral E/e': 5.1. Mitral annular septal E/e': 7.4.
RIGHT VENTRICLE The right ventricle is normal in size. Right ventricular systolic function is normal. Estimated right ventricular systolic pressure is 28 mmHg consistent with normal pulmonary artery pressures. Estimated right atrial pressure is 5 mmHg.
LEFT ATRIUM The left atrial cavity is normal in size. Pulmonary Veins: The pulmonary venous pattern showed blunted systolic flow.
RIGHT ATRIUM The right atrial cavity is normal in size. Inferior Vena Cava: The inferior vena cava appears normal measuring 1.8 cm. The vessel decreases greater than 50 percent with inspiration.
MITRAL VALVE The mitral valve leaflets are structurally normal. There is trivial mitral valve regurgitation. The pressure half time is 60 msec. The peak mitral E/A ratio is 1.64. The average mitral E/e' ratio is 6.3. The mitral flow deceleration time is 208 msec.
TRICUSPID VALVE The tricuspid valve leaflets are structurally normal. There is trivial tricuspid valve regurgitation.
AORTIC VALVE There is no aortic valve regurgitation. Tricuspid aortic valve.
PULMONIC VALVE There is no pulmonic stenosis. There is trivial pulmonic valve regurgitation.
AORTA The visualized aorta is normal in size. Measurements - Sinus 2.6 cm. Sinotubular junction 2.4 cm. Mid ascending aorta 2.5 cm.
PULMONARY ARTERIES The pulmonary arteries are normal.
CONCLUSIONS: - Exam indication: Palpitations - The left ventricle is normal in size. Left ventricular systolic function is normal. EF = 60 ± 5% (2D biplane) Baseline left ventricular diastolic function is normal. - The right ventricle is normal in size. Right ventricular systolic function is normal. - No prior echocardiographic exam available for comparison.

Expert:  Dr. Deepu Sebin Sebastian replied 3 Days.

I have gone through your entire 2D ECHO report, and have reviewed it with our cardiologist in the panel too.
There is nothing wrong in your report and your heart seems to be in great shape.
Seeing this report, even i won't advocate unnecessary stress testing.
Chest CT SCAN won't reveal anything. The best diagnostic modality is always ECHO.
So safely we can heart disease has been ruled out.
So the palpitations are mostly due to your recent stress/ anxiety. Once you can overcome that, you will have no such problems. Also slight reduction in weigh will be helpful. I will advise rest for a few days.

Dr. Deepu Sebin Sebastian
Category: Select Speciality
MD, Internal Medicine - Stanley Medical School
Medical School - MBBS - Govt. Medical College, Kottyaam

Diagnostic Prediction - Stanford School of Medicine
Received Specialty training in Critical Care, Cardiology, Neurology, Gastroenterology, Nephrology from Stanley Medical College and in Endocrinology, Rheumatology.

Hematology and Geriatrics from Madras Medical College.
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