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What Causes Persistent Chest Discomfort With Left Arm Pain?

Posted on Thu, 7 May 2015

Question: One year before, I had some discomfort in my chest alongwith pain in left arm...Visited cardiologist, he checked me physically through stethoscope..I didn't understood but he had written two things CVS and other one as NAD. My B.P was 140/90. He had my ECG, ECG showed probable LVH, normal sinus rythm. He thereafter went for a 2D echo & M Mode with Doppler & Color flow study...It came out normal..no LVH or other abnormalities..I used to smoke earlier, but i have left smoking since that time...He prescribed me concor AM 5..Since then I m on same medicine..Now on few days before, i had again chest discomfort with left arm pain..went to the same doctor, he again had ECG and it showed borderline ECG with LVH by voltage criteria..during ECG I normally feel anxious....This time he didn't go for echo...As i was a smoker earlier, i am having doubt whether i have Coronoray Heart Disease, or artery blockage/ heart blockage...I am not able to understand why my doctor is not going for further tests viz stress echo, TMT cardiac catherisation etc to get fully sure...I also sometime feels left arm pain during playing....I am very anxious and want to have a expert guidance for my further medical management...I also want to know that is a normal 2D echo with doppler flow study rules out the possibility of CHD or artery blockage, Further, is resting ECG also shows evidence of artery blockage... Plse Guide..whether I should go for further tests of my own? for my satisfication or not required...looking for kind guidance of an expert with anticipation..Plse asl soon...Regards

Answered by Dr. Anantharamakrishnan (8 hours later)

Brief Answer:
Right / get investigated

Detailed Answer:
Hi friend
Welcome to Health Care Magic

CVS is an abbreviation for Cardio Vascular System
NAD means Nil Abnormal Detected
The changes observed are from the blood pressure

As you rightly point out, it is wiser to be investigated for Coronary Artery Disease.,,
Especially so with age (it is not mentioned), family history, other risk factors (like cholesterol) associated morbidity (like Diabetes)

History, examination, routine ECG and ECHO – do have limitations…
     Go for TMT (Treadmill Exercise ECG)
     If TMT suggests ischemia, it is an indication for further work up – because at times, there may be false positive or false negatives. The next step is TMT with thallium isotope. It is the ideal non-invasive way to evaluate ischemia / to assess the PHYSIOLOGY (function) – to see whether the blood arriving at the heart muscle.
     If there is a suggestion, the next step is to see the ANATOMY (structure) – CT angio is non-invasive study for the anatomy.
If positive, you will need catheterisation and coronary angiography with a view for possible intervention. It is the only way to directly ‘see’ the block, if any – and its location, extent, severity and so on. Coronary arteriography is INVASIVE but it is the gold standard for this.

The aim of any investigation is to modify the treatment, based on the result… and exclusion and reassurance is itself a part of treatment!

Continue the beta-blocker (concor)
Take maintenance dose of aspirin until the tests are completed

It is wiser to look rather than guess
Seek a second opinion / preferably a cardiologist from a Tertiary Care Hospital…

Good luck
God bless you

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Anantharamakrishnan (1 hour later)

I had visited MGM New Bombay Hospital....A cardiologist having 22 years of experience, he told me that no further tests are required....I am 28 years old has normal lipid profile, total chol 146, ldl 98, hdl 34, lp(a) 42.70, apo(a), apo (b) normal, homocystenine mildly elevated 19.6, the doctor suggested me xray spine, it showed mild spondylosis...having on prescribed medicines by ortho from same hospital....should i go for further for tests...the cardio has also prescribed me homocheck tablet...Regards plse guide...

Answered by Dr. Anantharamakrishnan (1 hour later)

Brief Answer:
All well / have TMT for your reassurance

Detailed Answer:
Hi

Young age and no risk actors - make the possibility of Coronary Artery Disease really remote
It is practically, not theoretically non-existent
Prognosis is generally excellent in such situations
Still, it is better to go for a TMT – to exclude, not entertain / it is non-invasive and will be reassuring

For your neck, get some additional advice from a Physiotherapist

Regards

Above answer was peer-reviewed by : Dr. Pradeep Vitta

Follow up: Dr. Anantharamakrishnan (4 hours later)

Is 2D echo M Mode, with colour flow doppler study and ecg do not give any evidence of CHD.? LVEF of my heart is 70%... I ran 6 Km cross country two months before, no complains, usually i feel pounding of my heart during excercise sometimes only not always alongwith left arm pain...i also feels stiffness in my arms, neck, shoulder during long standing....never had sharp chest pain, however shifting pain in chest, have acidity / gastric problem also,What you think is it due to heart related problem...I recently had blood tests, no sugar, CBC normal, lipid profile as told before to you....Plse guide...

Answered by Dr. Anantharamakrishnan (6 hours later)

Brief Answer:
Suggestions detailed

Detailed Answer:
Hi

Routine ECG and ECHO/Doppler will only reveal gross/advanced insult – that is why, Stress ECHO or Stress ECG is done to unmask the discrepancy in supply with increased demand

Your effort tolerance is excellent and rules out coronary Artery Disease

Stiffness is from muscle spasm / due to nerve irritation / not related to heart

Gastric problems could contribute to chest symptoms – that can easily be resolved by endoscopy

In summary, you don’t seem to have heart disease / only anxiety and fear from heart problem. Learn to ignore and enjoy life

Regards

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Anantharamakrishnan (3 hours later)

Thanks, I ll try my best to ignore my anxiety.....plse tell me whether i should go for one more echo?

Answered by Dr. Anantharamakrishnan (8 hours later)

Brief Answer:
No need

Detailed Answer:
Hi

No need for another ECHO
Anxiety can be helped by diversion - take up a hobby / sport / going out to park, beach / spending time with friend and family - psychiatric assessment and assistance is the last resort

Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Anantharamakrishnan (2 days later)

I have fixed an appointment for TMT in a tertiary hospital tomorrow. I m on concor am 5.... what preparations i hv to do for TMT, should i stop the medication....plse guide..
i had TMT today, comments are resting ECG WNL. with stress no fresh ECG changes. Blunted Chronotropic response due to betablocker. No angina or arrhythmia. Normal haemodynamic response. Stress Test negative for reversible inducible ischemia...Plse interpret....

Answered by Dr. Anantharamakrishnan (2 days later)

Brief Answer:
NORMAL

Detailed Answer:
Hi

Perfectly Normal TMT
NO Coronary Artery Disease
Congratulations

Regards

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Anantharamakrishnan (24 minutes later)

During TMT, I hv following parameters XXXXXXX HR 152 bpm, 79% of XXXXXXX predicted 192 bpm, total exercise time: 11:38 XXXXXXX B.P: 200/90 Maximum workload: 13.4 METS....Doctor stopped the TMT before my predicted XXXXXXX heart rate...I was feeling okay that time, little fatigue...Is this test correct / conclusive...should I feel relieved? plse guide..

Answered by Dr. Anantharamakrishnan (2 hours later)

Brief Answer:
Yes - conclusive

Detailed Answer:
Excellent effort tolerance - exercised well
No problems
All well

Above answer was peer-reviewed by : Dr. Neel Kudchadkar

Follow up: Dr. Anantharamakrishnan (2 days later)

Thanks for ur advice and assurance, i wanna to know one thing i hv shoulder pain...neck pain...and arm pain also, is it not due to heart...Plse guide...should i go for investigations other than related to heart...or should i be assured now that i hv no heart disease...I must tell u one thing i got 2d echo from different cardiologists / sonologists,,,,once it was mild concentric lvh...other instance LA dilated with LA dimension 3.9cm, and subsequently by a cardiologist...normal report...what i should believe...why echo is different everytime...plse guide...is it may be different in each investigation should i go for another echo....echo from cardiologist was from a tertiary hospital...cardiologist was having 22 years of experience...who should i believe...they hv made me more anxious...Plse guide me a way ahead... Regards..

Answered by Dr. Anantharamakrishnan (6 hours later)

Brief Answer:
No need for another ECHO

Detailed Answer:
Hi
There is no problem with the heart. You do not need any further investigation for the heart. If there are symptoms, you need to consult an Orthopaedician – for assessment and assistance for the musculoskeletal pain.
ECG is machine dependent, whereas ECHO is operator dependent. There are beat to beat variations in the measurements. Also variations from the direction and position of the beam. Still, the values are no cause for concern…The minor changes are from blood pressure and may regress with time and treatment. You do not need another ECHO in the near future.

Regards

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Anantharamakrishnan (1 hour later)

i bought an arm cuff home b.p monitor from citizen company...i usually measure my b.p at home it comes normal..but when doctor measures it is always higher....from the last three months or so i m measuring the b.p at home,,,diastolic reading low usually below 60 with pulse rate also low below 70 sometimes below 50...i play basketball in the evening...could the low reading due to beta blocker alongwith workout...?

Answered by Dr. Anantharamakrishnan (1 hour later)

Brief Answer:
Yes

Detailed Answer:
Pressure is normal at home / high when seen by doctor – is due to anxiety. It is called White Coat Hypertension. Needs no active interference; only reassurance

Playing basketball means good effort tolerance and is against any significant heart ailment! Long and strenuous training does reduce the rate in the log run.

The range for the upper figure (Systolic) is 90 to 140 mm Hg.
The range for the lower figure (Diastolic) is 60 to 90 mm Hg.
Your values are in range / a bit below the range in pressure and rate is due to the Beta-Blocker and is an anticipated effect. No cause for concern

Note: For further queries related to coronary artery disease and prevention, click here.

Above answer was peer-reviewed by : Dr. Neel Kudchadkar