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Mild Sensation In Chest, Advised Combiflam If Pain Is Intolerable. ECG Normal. Advice ?
Question: I am 24 Years old. I am having mild sensation like feeling in the chest since October, 2011. The discomfort is irregular and often not noticed by me if I get busy with some work. The discomfort does not increase with exertion. There is no discomfort in the shoulder, back etc. I had severe pain the mornings in October, 2011 during sleep in an air-conditioned room which reduced significantly when an NSAID - Combiflam was taken. I started using warm blankets later on and the morning pain/pain after a few hours of sleep in a cold room disappeared. I walk on the treadmill at 6 Kms/hour speed for 30 minutes 5 days a week. I do not feel any pain or trouble walking on the treadmill. I also play casual Cricket once in a week and also climb stairs several times in a day without any trouble. The discomfort is not affected by breathing. I have a doubt that this pain might be caused due to my taking treadmill from one room to the other due to the situation in my house which may be straining the muscle but as a long time has passed since this discomfort began, I am worried.
I consulted my Family Doctor, an MD and vastly experienced in October 2011 and he examined me thoroughly. He also did an ECG which I am uploading for your reference. He told me that everything is normal and there is no need to worry. He asked me to take Combiflam if pain is not tolerable which I have not taken since then as it has always been very mild and tolerable and almost unnoticeable.
I consulted my Family Doctor, an MD and vastly experienced in October 2011 and he examined me thoroughly. He also did an ECG which I am uploading for your reference. He told me that everything is normal and there is no need to worry. He asked me to take Combiflam if pain is not tolerable which I have not taken since then as it has always been very mild and tolerable and almost unnoticeable.
Hello
Thank you for the query.
Given your history and having seen the ECG, I agree with your physician that it is likely to be of musculo-skeletal origin. The possibilities include pain from the intercostal muscles, costochondritis (inflammation of the costochondral joints), pectoral muscle inflammation, intercostal neuralgia etc.
The ECG shows a normal sinus rhythm, normal axis, normal intervals. There is no chamber enlargement. There is no evidence of any ischemia.
Other possibilities include gastritis, esophagitis, reflux problems etc. If there is no improvement with analgesics, you could consider an endoscopy. Empirical trial of antacid or a drug like pantoprazole is also acceptable.
If the discomfort is mild, you can simply use a topical analgesic spray, ointment or gel. This should provide adequate relief without the associated side effects of NSAIDs.
I hope this answers your query. Feel free to ask me for any specific clarifications.
With regards,
Dr R S Varma
Thank you for the query.
Given your history and having seen the ECG, I agree with your physician that it is likely to be of musculo-skeletal origin. The possibilities include pain from the intercostal muscles, costochondritis (inflammation of the costochondral joints), pectoral muscle inflammation, intercostal neuralgia etc.
The ECG shows a normal sinus rhythm, normal axis, normal intervals. There is no chamber enlargement. There is no evidence of any ischemia.
Other possibilities include gastritis, esophagitis, reflux problems etc. If there is no improvement with analgesics, you could consider an endoscopy. Empirical trial of antacid or a drug like pantoprazole is also acceptable.
If the discomfort is mild, you can simply use a topical analgesic spray, ointment or gel. This should provide adequate relief without the associated side effects of NSAIDs.
I hope this answers your query. Feel free to ask me for any specific clarifications.
With regards,
Dr R S Varma
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you very much for your response. Below are the symptoms of the possible diseases you have mentioned in your email which I do not have:
1) Pain from the Intercostal muscles: I do not feel any Sharp, Stabbing pain. The pain is not affected by breathing, side bending and twisting. I felt stabbing pain in the month of October, 2011 after a few hours of sleep but it was effectively controlled by Combiflam (NSAID). I started using warm blankets and the pain has reduced significantly and I do not feel any pain now for the past few months.
2) Costochondritis: The pain is not severe at all. It is very mild and often unnoticeable if I am busy with some work. I do not feel wheezing, fever, excessive sweating, nausea, palpitations, weakness, faintness, difficulty in breathing, cough, back pain, jaw pain, arm pain, etc. The chest pain is not affected by taking a XXXXXXX breath or coughing.
3) Pectoral muscle inflammation: This can be the cause of the pain but the pain is not continuous. It is not felt all the time. It is also not affected by movement or breathing etc.
4) Intercostal Neurelgia: The pain is not stabbing, sharp, spasm-like, tearing etc. The pain does not wrap around the chest or radiate from the back toward the front of your chest in a band-like pattern. The pain is not felt uniformly along the length of the ribs. The pain does not intensify with exertion, lifting heavy objects, twisting or turning the torso, coughing, sneezing, or laughing. There is no Abdominal Pain, fever, itchiness, numbness, pain in the arm, shoulder or back. The pain does not restrict the mobility of my shoulders. Although the pain might be described as tingling. I do not have any respiratory problems. I also do not have any abdominal pain.
5) Gastritis: There is no recognizable abdominal pain and it does not get worse after eating.
6) Esophagitis: I do not have any difficulty in swallowing, mouth sores, feeling of something being stuck in the throat, nausea or vomiting (unless I travel a long distance by road as I have Migraine which is generally related to Motion sickness which I have mentioned in my original question).
7) Gastroeasophageal Reflux: My pain is not affected after eating a heavy meal, Bending over, Lifting, Lying down etc.
The above are the symptoms of the diseases mentioned by you which are known to me which are not occurring except for Pectoral muscle inflammation but the pain is not felt all the time and is also not affected by movement or breathing.
My symptoms are matching more with Unstable Angina as the discomfort is random and unpredictable. It occurs even at rest and it woke me up 2-3 times in October, 2011 from my restful sleep but which was later controlled by NSAID and the usage of warm blankets while sleeping in a cold/airconditioned room. It lasts more than 15-20 minutes. I do not know what is the effect of nitroglycerin on the discomfort as I have not taken it ever. Inspite of these symptoms, as I have mentioned in my original question, I feel very healthy except for my migraine which I am having since the age of 10. Even after developing such symptoms, I walk on the treadmill 30 minutes a day at a speed of 6 KMS/hour, play casual cricket for 2-3 hours once in a week, climb stairs 5-6 times a day atleast and so on. I do not feel any pain in the shoulder, back, jaw etc.
The ECG you saw was done in October 2011 when the pain began but it is said that in angina patients who are momentarily not feeling chest pain, an electrocardiogram is typically normal, unless there have been other cardiac problems in the past.
Kindly advise.
Thank you
1) Pain from the Intercostal muscles: I do not feel any Sharp, Stabbing pain. The pain is not affected by breathing, side bending and twisting. I felt stabbing pain in the month of October, 2011 after a few hours of sleep but it was effectively controlled by Combiflam (NSAID). I started using warm blankets and the pain has reduced significantly and I do not feel any pain now for the past few months.
2) Costochondritis: The pain is not severe at all. It is very mild and often unnoticeable if I am busy with some work. I do not feel wheezing, fever, excessive sweating, nausea, palpitations, weakness, faintness, difficulty in breathing, cough, back pain, jaw pain, arm pain, etc. The chest pain is not affected by taking a XXXXXXX breath or coughing.
3) Pectoral muscle inflammation: This can be the cause of the pain but the pain is not continuous. It is not felt all the time. It is also not affected by movement or breathing etc.
4) Intercostal Neurelgia: The pain is not stabbing, sharp, spasm-like, tearing etc. The pain does not wrap around the chest or radiate from the back toward the front of your chest in a band-like pattern. The pain is not felt uniformly along the length of the ribs. The pain does not intensify with exertion, lifting heavy objects, twisting or turning the torso, coughing, sneezing, or laughing. There is no Abdominal Pain, fever, itchiness, numbness, pain in the arm, shoulder or back. The pain does not restrict the mobility of my shoulders. Although the pain might be described as tingling. I do not have any respiratory problems. I also do not have any abdominal pain.
5) Gastritis: There is no recognizable abdominal pain and it does not get worse after eating.
6) Esophagitis: I do not have any difficulty in swallowing, mouth sores, feeling of something being stuck in the throat, nausea or vomiting (unless I travel a long distance by road as I have Migraine which is generally related to Motion sickness which I have mentioned in my original question).
7) Gastroeasophageal Reflux: My pain is not affected after eating a heavy meal, Bending over, Lifting, Lying down etc.
The above are the symptoms of the diseases mentioned by you which are known to me which are not occurring except for Pectoral muscle inflammation but the pain is not felt all the time and is also not affected by movement or breathing.
My symptoms are matching more with Unstable Angina as the discomfort is random and unpredictable. It occurs even at rest and it woke me up 2-3 times in October, 2011 from my restful sleep but which was later controlled by NSAID and the usage of warm blankets while sleeping in a cold/airconditioned room. It lasts more than 15-20 minutes. I do not know what is the effect of nitroglycerin on the discomfort as I have not taken it ever. Inspite of these symptoms, as I have mentioned in my original question, I feel very healthy except for my migraine which I am having since the age of 10. Even after developing such symptoms, I walk on the treadmill 30 minutes a day at a speed of 6 KMS/hour, play casual cricket for 2-3 hours once in a week, climb stairs 5-6 times a day atleast and so on. I do not feel any pain in the shoulder, back, jaw etc.
The ECG you saw was done in October 2011 when the pain began but it is said that in angina patients who are momentarily not feeling chest pain, an electrocardiogram is typically normal, unless there have been other cardiac problems in the past.
Kindly advise.
Thank you
Hello,
Thank you for the reply.
Please understand that the character of the pain (stabbing, pricking, band-like, etc) is only a very general guide. It is not reliable enough to confirm or exclude any diagnosis. There is a spectrum of severity and mild forms need not have any of the classical symptoms or associated features.
Costochondritis can present only with chest discomfort and minimal local tenderness if you press on the affected site. None of the other features that you mentioned need be present.
It is also wrong to suppose that all gastric and esophageal pain should be related to food. It is not always the case. Also, symptoms like difficulty in swallowing, feeling of food stuck in the throat occur very late in the course of the disease and mostly such symptoms are rare in esophagitis without obstruction/strictures, and in cases of esophageal muscle spasm. An endoscopy is a simple, and relatively inexpensive test to confirm or rule out these problems.
At 24 years of age, in the absence of risk factors like smoking, diabetes, hypertension, abnormal cholesterol levels, strong family history of heart disease, it is highly unlikely that you have atherosclerotic coronary artery disease. Unstable angina is an acute process and, since this pain has been present since October 2011, if it was unstable angina, you would have had a myocardial infarction by now. Unstable angina at this age usually occurs in heavy smokers, familial dyslipidemia, thrombophilia syndromes, diabetics, and drug (like cocaine) abusers. Usually, the pain is severe like an acute heart attack and ECG changes are prominent.
There is the possibility of vasospastic angina. You will need to take an ECG during the chest discomfort to diagnose this condition. The other option is to do a coronary angiogram with intra-coronary injection of a drug to provoke coronary spasm.
You can always take another ECG (preferably when you have ongoing chest discomfort) and ensure that there has been no further/serial changes in the ECG. If you are worried still about a cardiac cause of chest discomfort, you could get a stress test done in the form of a treadmill test or a dobutamine stress echo. A CT coronary angiogram can tell you the exact anatomy and if negative, it will conclusively rule out coronary artery disease. But, such an extreme step is really not necessary in your case.
Other non-ischemic but cardiac causes of chest pain like mitral valve prolapse, ventricular hypertrophy, aortic/pulmonary valve stenosis, pulmonary hypertension, etc can be ruled out by clinical examination and an echo-cardiogram.
Pleuritic and pericardial pain are unlikely in the absence of postural/respiratory variation, long duration and lack of any other positive findings in x-ray.
The fact that the pain is very mild and that there is reduction of the pain with NSAIDs is a strong pointer to a musculoskeletal origin of the pain. Cardiac pain does not come down with analgesics. Also, in the presence of mild discomfort, it is not necessary to have any other associated symptoms or signs that you have mentioned, and it would not be wise to rule out any of these causes for the reasons that you have mentioned. Also, it is well known that cold temperatures worsen a musculo-skeletal pain.
Thus, you could do a repeat ECG during ongoing chest pain, do blood tests for cardiac troponin/CK MB 6 hours after the onset of pain, elective stress test and echo of the heart. If all the above are normal, you can safely disregard cardiac causes.
I have not discussed the possibility of psycho-somatic pain syndromes since it is necessary to consider all organic causes of pain first. The pain, however, is real pain though the cause may be stress/anxiety, etc.
I hope this answers your query.
With regards,
Dr RS Varma
Thank you for the reply.
Please understand that the character of the pain (stabbing, pricking, band-like, etc) is only a very general guide. It is not reliable enough to confirm or exclude any diagnosis. There is a spectrum of severity and mild forms need not have any of the classical symptoms or associated features.
Costochondritis can present only with chest discomfort and minimal local tenderness if you press on the affected site. None of the other features that you mentioned need be present.
It is also wrong to suppose that all gastric and esophageal pain should be related to food. It is not always the case. Also, symptoms like difficulty in swallowing, feeling of food stuck in the throat occur very late in the course of the disease and mostly such symptoms are rare in esophagitis without obstruction/strictures, and in cases of esophageal muscle spasm. An endoscopy is a simple, and relatively inexpensive test to confirm or rule out these problems.
At 24 years of age, in the absence of risk factors like smoking, diabetes, hypertension, abnormal cholesterol levels, strong family history of heart disease, it is highly unlikely that you have atherosclerotic coronary artery disease. Unstable angina is an acute process and, since this pain has been present since October 2011, if it was unstable angina, you would have had a myocardial infarction by now. Unstable angina at this age usually occurs in heavy smokers, familial dyslipidemia, thrombophilia syndromes, diabetics, and drug (like cocaine) abusers. Usually, the pain is severe like an acute heart attack and ECG changes are prominent.
There is the possibility of vasospastic angina. You will need to take an ECG during the chest discomfort to diagnose this condition. The other option is to do a coronary angiogram with intra-coronary injection of a drug to provoke coronary spasm.
You can always take another ECG (preferably when you have ongoing chest discomfort) and ensure that there has been no further/serial changes in the ECG. If you are worried still about a cardiac cause of chest discomfort, you could get a stress test done in the form of a treadmill test or a dobutamine stress echo. A CT coronary angiogram can tell you the exact anatomy and if negative, it will conclusively rule out coronary artery disease. But, such an extreme step is really not necessary in your case.
Other non-ischemic but cardiac causes of chest pain like mitral valve prolapse, ventricular hypertrophy, aortic/pulmonary valve stenosis, pulmonary hypertension, etc can be ruled out by clinical examination and an echo-cardiogram.
Pleuritic and pericardial pain are unlikely in the absence of postural/respiratory variation, long duration and lack of any other positive findings in x-ray.
The fact that the pain is very mild and that there is reduction of the pain with NSAIDs is a strong pointer to a musculoskeletal origin of the pain. Cardiac pain does not come down with analgesics. Also, in the presence of mild discomfort, it is not necessary to have any other associated symptoms or signs that you have mentioned, and it would not be wise to rule out any of these causes for the reasons that you have mentioned. Also, it is well known that cold temperatures worsen a musculo-skeletal pain.
Thus, you could do a repeat ECG during ongoing chest pain, do blood tests for cardiac troponin/CK MB 6 hours after the onset of pain, elective stress test and echo of the heart. If all the above are normal, you can safely disregard cardiac causes.
I have not discussed the possibility of psycho-somatic pain syndromes since it is necessary to consider all organic causes of pain first. The pain, however, is real pain though the cause may be stress/anxiety, etc.
I hope this answers your query.
With regards,
Dr RS Varma
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you very much for the detailed response.
The following is my response to the causes listed by you for
1) I do not smoke or consume alchohol.
2) I do not have any symptoms of diabetes though I have never had a blood test to check it.
3) My BP is found 70/130 most of the times.
4) I do not know about my cholesterol levels.
5) My BMI is approximately 28 - height 180 Cms, weight 89 Kgs.
6) I do not have symptoms of Thrombophilia.
7) I have never consumed any drugs (cocaine) etc.
8) My father died young due to an accident so no information available about whether he had any coronary artery problems but my grandmother had some issues and had an angiography done in 1993. Her heart pumping was 25-30%. My grandfather had a 100% block detected in 1996 but as another artery had taken over, the doctors said it was a natural by-pass and no action was necessary then. He had another angiography done in February 2012 and found a 80% block in one artery but doctors suggested to control it with medication. His father also had some heart problem but her mother is not known to have any cardiac problem. My mother is 42 and has had no cardiac problems so far. Her parents also dont have any significant cardiac problems. So this is the family history.
As I had mentioned in my original message, the pain is often unnoticeable if I am busy with some work and very mild. It seems difficult to do an ECG while feeling the discomfort because by the time I go to the doctor and it is done the pain may have disappeared.
I am not keen on doing any tests if you believe that my symptoms will not lead to any life-threatening problem. I do not need to take any Pain-Killers as the pain is not troubling me at all but the only worry is it should not be a warning to a serious problem.
Thank you.
The following is my response to the causes listed by you for
1) I do not smoke or consume alchohol.
2) I do not have any symptoms of diabetes though I have never had a blood test to check it.
3) My BP is found 70/130 most of the times.
4) I do not know about my cholesterol levels.
5) My BMI is approximately 28 - height 180 Cms, weight 89 Kgs.
6) I do not have symptoms of Thrombophilia.
7) I have never consumed any drugs (cocaine) etc.
8) My father died young due to an accident so no information available about whether he had any coronary artery problems but my grandmother had some issues and had an angiography done in 1993. Her heart pumping was 25-30%. My grandfather had a 100% block detected in 1996 but as another artery had taken over, the doctors said it was a natural by-pass and no action was necessary then. He had another angiography done in February 2012 and found a 80% block in one artery but doctors suggested to control it with medication. His father also had some heart problem but her mother is not known to have any cardiac problem. My mother is 42 and has had no cardiac problems so far. Her parents also dont have any significant cardiac problems. So this is the family history.
As I had mentioned in my original message, the pain is often unnoticeable if I am busy with some work and very mild. It seems difficult to do an ECG while feeling the discomfort because by the time I go to the doctor and it is done the pain may have disappeared.
I am not keen on doing any tests if you believe that my symptoms will not lead to any life-threatening problem. I do not need to take any Pain-Killers as the pain is not troubling me at all but the only worry is it should not be a warning to a serious problem.
Thank you.
Hello,
Thank you for the reply.
You need to do a complete fasting lipid profile and a fasting blood sugar (even if you dont have any symptoms). This is essential for risk stratification.
Your BMI is high. Try reducing it to around 24 at least, with diet and exercise.
Family history is considered as a significant risk factor only if your first degree relatives/parents have had "premature" CAD (men less than 55years and women less than 65years). So, it is probably not very significant in your case. Above a particular age, anybody can develop heart disease.
A solution to your problem of taking an ECG during pain is to do a 24 hour Holter monitoring (using atleast a 3 channel recorder) to document the ECG changes, if any, during the pain. There is a continuous 24 hour record of the ECG and you can XXXXXXX the time when you felt the discomfort.
If you could an echo also done, this would be enough to reasonably exclude any serious problems.
I hope this answers your query.
Wishing you all the best,
With regards,
Dr RS Varma
Thank you for the reply.
You need to do a complete fasting lipid profile and a fasting blood sugar (even if you dont have any symptoms). This is essential for risk stratification.
Your BMI is high. Try reducing it to around 24 at least, with diet and exercise.
Family history is considered as a significant risk factor only if your first degree relatives/parents have had "premature" CAD (men less than 55years and women less than 65years). So, it is probably not very significant in your case. Above a particular age, anybody can develop heart disease.
A solution to your problem of taking an ECG during pain is to do a 24 hour Holter monitoring (using atleast a 3 channel recorder) to document the ECG changes, if any, during the pain. There is a continuous 24 hour record of the ECG and you can XXXXXXX the time when you felt the discomfort.
If you could an echo also done, this would be enough to reasonably exclude any serious problems.
I hope this answers your query.
Wishing you all the best,
With regards,
Dr RS Varma
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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