I Have Congestive Heart Failure, Had 7 Surgeries For Aneurysms, Has Diabetes, High Cholesterol, And Shortness Of Breath From Physical Activity. What Do You Suggest I Do

Posted on Wed, 5 Sep 2018

Medically reviewed by Ask A Doctor - 24x7 Medical Review Team

Wed, 5 Sep 2018 Answered on

Wed, 4 Oct 2023 Last reviewed on

Question : I’ve been having chest pain for the past month on and off everyday. The pain is mostly in the middle of my chest and has been getting worse and more frequent over the past 2 weeks. It comes after physical activity or emotional distress. The pain has been traveling from the middle of my chest to the right side of my chest and down my arm and to my shoulder and upper back. Sometimes I get jaw pain, nausea, and abdominal pain. I went to the ER twice. They said the EKG and Troponin was normal. When I went to the ER yesterday at 1 am, I requested an Echocardiogram and a Stress Test because I’ve been taking meds for Type 2 Diabetes (A1C 8.1) and High Cholesterol for many years and because I’ve been struggling to breath when doing any type of physical activity... for years... and it’s been getting worse... I’m out of breath even walking up the stairs or going to the bathroom. My PCP intervened and only allowed the Echocardiogram. The hospital Cardiologist said my Echocardiogram was normal and told me to do outpatient Stress Test. But when I looked at the results of the Echocardiogram I saw abnormalities. I need to know if I should press for a full cardiac workup at this point. I’m 36 years old, weigh 248 lbs, don’t smoke, or drink. I have arthritis, consistently high platelet count, Epstein Barr. In 2014 and 2016, my sedementation rate and C-Protein were very high. My legs hurt when I stand up from a seated or reclined position. I overheat quickly and sweat too much. My father is 84, weighs 290 lbs, has congestive heart failure, has had 7 surgeries for aneurysms, has diabetes, high cholesterol, and shortness of breath from physical activity. What do you suggest I do?

Answered by Dr. Ilir Sharka (57 minutes later)

Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello,
I passed carefully through your recent medical history and would explain that your clinical symptomatology ( exertional chest pain) raised some suspicions about coronary artery disease.

In addition, I agree with you that an echocardiogram is not sufficient to discriminate a possible cardiac ischemia.

More specific cardiac tests such a coronary angio CT scan of a provocative cardiac stress test such as stress cardiac echo or a nuclear perfusion cardiac stress test would be helpful to rule in/ out a coronary artery disorder.

You should discuss with your doctor about the above tests!

In addition, regarding your problems with breathing, I would recommend performing pulmonary function tests in order to investigate for possible causes of overweight/obesity hypoventilation syndrome.

Hope you will find this answer helpful!

I remain at your disposal for any further questions whenever you need!

Kind regards,

Dr.Iliri

Above answer was peer-reviewed by : Dr. Arnab Banerjee

Follow up: Dr. Ilir Sharka (2 days later)

Thanks! My mom just told me that my father had Coronary Artery Disease earlier this year and had stents put in. I scheduled an appointment with a new cardiologist this Monday. I have a few questions I%E2%80%99d like to ask you so I can prepare for my appointment. Would Troponin levels and an Echo be normal if I was having Angina due to Coronary Artery Disease or because of an Incomplete Bundle Branch Block? When you have Coronary Artery Disease, can you experience symptoms of Angina without having Angina or a heart attack? Could heart complications be causing my ankles to swell, which is recent... and my arms and lega to hurt when I lay or kneel down like my circulation is being cut off (been feeling this for probably 15 years)? What can you tell me about these results in my ECG and Echocardiogram?

Echo Test....
Left Atrium (2D) result 4.10 cm...
IVSd (2D) result 1.10 cm...
LA Vol MOD-BP result 38.0 mL.

ECG 12 Lead Test....
IMPRESSION %E2%80%9CAbnormal ECG%E2%80%9D...
REPORT %E2%80%9CSinus Rhythm%E2%80%9D...
REPORT %E2%80%9CIncomplete Right Bundle Branch Block%E2%80%9D...
QRSD Interval result %E2%80%9C110 ms%E2%80%9D...
Heart Rate %E2%80%9C87 BP

Answered by Dr. Ilir Sharka (3 hours later)

Brief Answer:
My opinion as follows:

Detailed Answer:
Hello again, dear Raquel!

I reviewed your cardiac echo and resting ECG information and would explain that, besides an incomplete right bundle branch block (which is also seen in apparently normal individuals); there is no specific data to confirm coronary artery disease.

In fact, the provided data seems incomplete (echo results refer only to inter-ventricular septum and left atrium dimensions not mentioning to the other echo parameters), I would like instead to review a copy of the echo report and a photo of the ECG recordings if it is possible.

Could you upload them here for a second professional opinion?

Regarding your photos demonstrating lower limb swelling, I would explain the a differential diagnosis between limbs venous system insufficiency and heart failure should be primarily done.

That's why it is important a careful physical exam, cardiac ultrasound and natriuretic peptides dosing. A Doppler ultrasound of the lower limb veins would help to exclude/confirm possible veins insufficiency.

Now, returning to your questions, I would say that:

- a normal Troponin test and cardiac ultrasound do not exclude coronary artery disease (CAD), as those tests result abnormal only in the case of an obvious myocardial damage or dysfunction, which is not the case in every CAD patient.

- In other words, you may experience chest pain or other cardiac ischemia equivalent symptomatology without having a heart attack (myocardial infarction).

- Not rarely (especially in diabetic patients) we encounter silent myocardial ischemia, which is detected only on ECG testing without chest pain; other times only a breathing difficulty is present.

- considering ankle edema, as I explained you above, it is necessary a careful differential diagnosis (including heart failure, lower limbs vein insufficiency, kidney dysfunction, certain metabolic or endocrine disorders, etc.) You should know that even excessive overweight may cause similar signs and symptoms.

I believe that a comprehensive discussion on the above mentioned topics will help in clarifying your issues of concern.

Please, let me know if you have any further questions!

Wishing you are having a pleasant weekend!

Regards,

Dr. Iliri

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

Follow up: Dr. Ilir Sharka (7 hours later)

Thanks! Pics of Echo, ECG, and Blood Work (from 8/28/18

Answered by Dr. Ilir Sharka (16 hours later)

Brief Answer:
I would explain:

Detailed Answer:
Hello dear Raquel!

I reviewed your uploaded medical tests and would explain that the most important issues to be concerned about seems to be your glucose level and hence your diabetes control.

An elevated glycosylated hemoglobin level (that tells us to what degree the glucose level control has been achieved in the recent three months) of 8.1% is an evidence that the strategy for diabetes management (diet and therapy) has not been appropriate.

You should know that an uncontrolled diabetes will certainly introduce the diabetic individual to a very high risk level for future cardiovascular events.

Coming to this point, it is necessary to undergo urgent measures regarding your diet and actual anti-diabetic therapy.

In addition, it is necessary to start an antilipemic treatment, such as a statin (Atorvastatin, Rosuvastatin, etc.) for a better control of you blood lipid level.

Regarding your ECG and cardiac echo reports, they seem to be in general without any concerning abnormal evidence (echo parameters look OK, and incomplete right bundle branch block on ECG doesn't reflect any serious health disorder).

Hope to have been helpful to you!

In case of any further questions, feel free to ask me again!

Best regards,

Dr. Iliri

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

Follow up: Dr. Ilir Sharka (2 hours later)

Thank you for reviewing. Yes I%E2%80%99ve been diabetic and have had high cholesterol for many many years. I had been taking pills until I got pregnant last year and was put on insulin injections. After I gave birth late last year I lost insurance coverage... a lot of changes in my life... So I wasnt staying on top of my health. But I have insurance now and am back on Lipitor, Metformin, Januvia, and Lisinopril. My greatest concern is all this chest pain I%E2%80%99ve been having for the past 5 weeks.

Were you able to view the EKG and 2 Echocardiogram reports? What can you tell me about the abnormalities in the Echo values, the %E2%80%9CAbnormal EKG%E2%80%9D Impression, and the Incomplete Bundle Branch Block? What about the Trace/Mild Regurgitation? Do the results alert you to any immediate cardiac or coronary issues or are these reports not very telling?

Thanks so much for your help and guidance!

Answered by Dr. Ilir Sharka (18 hours later)

Brief Answer:
I would explain as follows :

Detailed Answer:
Hello again, dear Raquel!

Once again I would like to assure you that after reviewing your ECG and cardiac ultrasound report, I didn't find any serious abnormalities.

Incomplete right bundle branch block doesn't seem any issue of great concern as it is present in many apparently healthy individuals.

In addition, your echo report lookz OK; and when indexed for your body size all the echo parameters are within normal ranges.

I would like to encourage you to keep following a healthy lifestyle and diet; and at the meantime to always adjust your therapy by conxulting periodically your attending doctor.

You should aim a lower glycosylated hemoglobin HbA1c (less than 6.5%) in order to effectively prevent future cardiovascular events.

Wishing you good health!

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Prasad