Looking for advice after recent chest pain.

[IamAli_R]

Hello everyone,

I hope you are all well

I am a 44-year-old ex-smoker (who quit 7 years ago), smoking twenty cigarettes daily for fifteen years. I do not consume any alcohol or use any illicit drug use now or in the past. No high caffeine intake or soft drinks. I have a BMI of 22.2 and normal blood pressure.

Bloods from October show an eGFR of greater than 90, a normal full blood count, and thyroid function was normal.

Bloods from August this year showed a cholesterol of 5, triglycerides of 1.5, HDL of 1.3, LDL of 3, and HbA1c of 37.

ECG on 28th November showed sinus rhythm with a PR interval of 140ms, QTc of 412ms and there was no ischemia.

I had a previous exercise tolerance test in 2016 which was positive. I then went on to have a normal stress echocardiogram.

I had a CT Cardiac Angiography in 2018, which due to a fast heart rate was not completed in full, however, the scan did show some mild LAD atheroma and a 6% Calcium Score.

At the time of this scan, the cardiologist said there was nothing to worry about and discharged me back to my GP.

I also had an echocardiogram done in 2020 which was normal with an ejection fraction of 65%.

A few weeks ago on a slow 5K run, I felt some chest pain and a heavy feeling in my left arm. I stopped and went home. It took about 30 mins for my heart rate to settle and the pain had gone on the 5 min walk home.

I suffer from anxiety and I am not sure if the chest pain was from the heart or due to anxiety.

I was referred to the chest pain clinic and the nurse wants to repeat the CT Angiography because of the calcium score and mild LAD atheroma finding from 2018.

My questions are:

How bad is a calcium score of 6 with mild LAD atheroma?

How much would it have progressed in 4 years?

Why wasn't the cardiologist concerned about the findings from the 2018 scan?

Thank you for reading my post.

Ali

[Chappychap]

What a sensible and well constructed question.

I'm not sure I can provide an equally sensible and well constructed answer, but I'll try my best!

First thing is that chest pain is really common. Of course it should never be dismissed, but there are so many innocuous explanations, from gastric to muscular, that an isolated episode isn't grounds for anxiety. Keep investigating, but be calm as you do so.

Second thing is that I'd be most focussed on your HbA1c score of 37. There's an astonishing lack of consistency regarding Type 2 Diabetes indicators. For many years I had an annual company medical which showed my HbA1c scores steadily rising from low 20's to mid 30's. That was never flagged as a risk. Conversely my current GP regards any increasing trend in HbA1c scores, even at relatively low level, as a flashing warning light. My GP talks about people having a "route into heart disease", he estimates that for about a third of people with heart disease/atherosclerosis, their heart disease is actually a by-product of their slow drift into Type 2 diabetes.

I've also had treatment in Canada as well as the UK. In Canada a cardiologist went further, he told me that my HbA1c score of 37 wasn't "pre-diabetes" or "insulin resistance", in his judgement they should all simply be called "T2 diabetes". He argued that American conventions, where doctors hesitate before giving a patient a verdict that might then qualify as a "pre-existing condition", has resulted in this wishy-washy terminology. The real tragedy is that for many people T2 diabetes, when caught early enough, can be reversed with simple life style changes.

I appreciate that normally means losing weight, and you have a healthy BMI. But it doesn't only mean weight loss. It also means eating differently. For example fewer carbs, zero soft drinks, zero snacking between meals, and very very few sweet treats. By implementing a few changes I've brought my HbA1c scores down from 37 to mid 20's, and what's more important is that I've kept them both low and stable for the past five years. The key thing is that I'm far from being exceptional in this respect.

Final point, your GP will evaluate your heart attack/stroke risk using a standard piece of diagnostic software, with a view to commencing medication as a precaution even if testing produces no identifiable issues. You are entitled to see the results (and I'd encourage you to ask to be walked through the process as it's extremely informative). I'm not medically qualified but from what I know of the procedure a 44 year old, slim, South Asian male, ex smoker would have a 3.7% chance of a heart attack or stroke in the next ten years. In other words, a very low risk, incidentally if he had never smoked his risk would have been still lower at 2.8%. But that same man with a T2 diabetes diagnosis would see his risk more than double to 8.1%.

That's why making life style changes to reverse your HbA1c scores is so important.

Good luck!

[IamAli_R in reply to Chappychap]

Hello Chappy Chap

Thank you for taking the time to reply. Your answer is both sensible and enlightening.

I had no idea that an HbA1c score of 37 is high. I thought I was doing well at keeping T2 diabetes at bay.

The information you have provided is a real eye-opener. My score has been creeping up for about 10 years now. With regards to your diet advice the only thing that I might need to change is to cut down on my carbs.

I will speak to my GP about my risk score for HA or stroke.

I will begin trying to lower my HbA1c score right away.

I have been suffering from health anxiety and cardiophobia for 6 years. It was under control until this incident in October. This incident has triggered my anxiety again and I have been having chest pain daily and even ended up in A&E last week. They did all the tests and it wasn't Cardiac related.

Now the wait for CT Angiography is going to be difficult because my anxious mind is convinced I'm going to have a Cardiac event at any moment.

Your answer has been very reassuring and you seem very knowledgeable so that means I have more questions.

What are your thoughts about my calcium score and mild LAD atheroma findings from 2018 and how much that might have progressed in 4 years?

[Chappychap in reply to IamAli_R]

I've no medical qualifications Ali, you need to get your hard information from your GP rather than some bloke on the internet.

But if it helps put your mind at rest there's nothing in either your calcium scores or atheroma levels that would keep me awake at nights. A calcium score of 6 is really low. Seriously, it could go up tenfold and still not be too alarming!

Furthermore calcium scores are always a bit ambiguous. Yes, in the ideal world you want them low, but actually calcium is stable plaque, and if you're going to have plaque then far better to have the stable, calcified variety than the "hot" liquid variety. Calcified plaque may eventually grow (and I mean over decades) and cause angina, but it's the hot uncalcified plaque that can rupture causing heart attacks. I'm not saying calcium is a good thing, I'm just saying calcium scores aren't as simple as we might think. Which is why we need a cardiologist to help us interpret them, and why even far higher calcium scores than yours aren't automatically reasons to believe the end is nigh!

And "mild atheroma" is pretty much inevitable with modern lifestyles and highly processed foods. There was a study based on post mortems of people killed in accidents while still in their 20's. Nearly all the men already had at least some evidence of plaque in their arteries.

I'm not preaching complacency, far from it, I strongly advocate a pretty rigorous approach towards healthier life style choices. But let's be realistic, by quitting smoking and maintaining a healthy BMI you've already shown that you've got with the programme. And to do that in your 40's is exemplary. I left many of the tough choices until I really was drinking in the last chance saloon, you on the other hand are well ahead of the curve.

Switch to a smarter diet, look at tidying up some other peripheral life style issues like stress and sleep management, and be meticulous in taking any medication that your doctors prescribe. Do these things and you're set for another forty plus years of healthy, active life.

One last thing. You mentioned anxiety. Anxiety is a first cousin to depression, and depression is actually a major risk factor for heart disease. That hypothetical guy I mentioned previously, the one with a 3.7% chance of a stroke or heart attack in the next ten years, well if we layer a diagnosis of even mild depression on him then his risk goes up by nearly a third from 3.7% to 4.8%. Okay, no where near the same risk increase as excess weight or smoking, but still not something you'd want to get out of hand.

Good luck!

[Milkfairy Heart Star in reply to Chappychap]

About 5% to 15% of heart attacks are thought to occur without blocked coronary arteries .Myocardial Infarction non obstructive coronary arteries MINOCA.

icrjournal.com/articles/wha...

All chest pain should be taken seriously and all causes either obstructive or non obstructive causes should be ruled out.

Non obstructive coronary arteries do not necessarily mean no heart disease is present.

[IamAli_R in reply to Milkfairy]

I am waiting for a appointment for a CT Angiogram. Hopefully, that will clear things up

[IamAli_R in reply to Chappychap]

I am not looking for medical advice but I know from experience that advice from someone who has been through similar experiences is priceless. I really am grateful for the information and advice you've provided. I feel a lot more optimistic having read your answers.

I have had anxiety issues for a long time. I have had professional help and I studied anxiety disorder in my spare time too. I have a good understanding of my anxiety condition. Thankfully, I've not suffered from depression up until now.

[LindyMc in reply to Chappychap]

My goodness a gp that doesn't behave like a rabbit in the headlights when presented with Hb1Ac 37 to 42! Despite fasting bloods of 6.0 + and Hb1Ac of 39, there was no possible action that they were permitted to give according to the protocol.

[Karabiner in reply to Chappychap]

Chappychap, I'd be interested in your response to this article given your comments on a score HbA1c of 37 being high..... mine's been in at 35-40 for the last 10 years, and even before that my glucose (old measures) were always close to the upper end of normal since I was in my 20s.... 37 is definitely within the normal range, even if at the upper end of it. Anyway, take a look at this.... bmcendocrdisord.biomedcentr...

[Chappychap in reply to Karabiner]

Interesting article, thanks for linking. I'm familiar with the limitations of the HbA1c tests. I have treatment in Canada as well as the UK. I'm not saying the Canadian health system is superior, they both have their issues, but I was struck that a wider battery of tests are deployed earlier for T2 diabetes in Canada than here.

Still, many if not most people on this forum will have an HbA1c test as part of the blood work within their GP's annual cardio check-up. That's why I reference HbA1c rather than other tests that people may not be familiar with.

[Milkfairy Heart Star]

Another thought.

It is also possible to have angina without blocked coronary arteries.

Non obstructive coronary artery disease NOCAD.

Microvascular or vasospastic angina.

These types of angina are due to either the small or large blood vessels not working properly, causing a lack of blood supply to the heart.

These types of angina are often overlooked and undiagnosed.

Here's some information from Diabetes UK about how prediabetes and diabetes is diagnosed.

Whilst we can through life style changes help to reduce our risks some we cannot.

I have a raising HbA1c.

I have these risk factors that I cannot control.

I am getting older

My father was a diabetic

I had gestational diabetes.

diabetes.org.uk/

[IamAli_R in reply to Milkfairy]

Hello Milk Fairy,

Thank you for taking the time to reply, and sharing such useful information and your experiences.

My mother and father both have T2 diabetes as well as do my uncles and aunties so I may be fighting a losing battler to keep it at bay.

I will look at the website you've shared.

I will discuss NOCAD and Microvascular or vasospastic angina with my cardiac nurse when I speak to her in the new year.

Thank you

[IamAli_R]

Hello Thatwasunexpected,

Thank you for taking the time to reply.

Yes, I agree that was a brilliant answer by ChappyChap and I am grateful for all the information he has shared.

I've had slightly raised cholesterol since my mid-'20s. My cardiologist has prescribed a statin while I wait for a CT Angiogram. Hopefully, that will bring down the bad cholesterol.

The stress test in 2016 was positive for ECG changes I think. It was stopped after 13 mins, reaching over 110% of my max heart rate (I have a naturally high max heart rate. The 220 - age formula doesn't work for me).

This was followed by a dopamine-induced stress echocardiogram which was clear. I was the echocardiogram is a more reliable test and I was in the clear.

The calcium score was CT done in 2018 just to reassure me and because I was suffering from anxiety. I had another stress test in 2019 I think and that was negative.

My dad has CVD but he is diagnosed in his mid 60's and it is not too serious.

I'm trying not to worry but it's proving difficult. However, I feel a little more optimistic after reading all the replies to my question.

I do appreciate the support from all of you guys.

[Milkfairy Heart Star]

During a stress echo chest pain can occur when the small vessels are unable to dilate or stay dilated in response to the extra demands of exercise.The usual cause microvascular dysfunction

This is along with vasospastic angina are functional disorders of the blood vessels, non-obstructive coronary artery disease.

Often patients with vasospastic angina find their coronary arteries will go into transient contrictions, vasospasms after exercise.

I ended up in A&E after an stress echo which I passed with flying colours. I had coronary vasospasms leading to ST elevations and depressions as a result of exercising afterwards.

Everyone keeps forgetting it's not just about blockages 😊

[IamAli_R in reply to Milkfairy]

Hello Milkfairy,

Thank you for the information on on-obstructive coronary artery disease. I have been running 5k three times a week for the past two years without many issues apart from the chest pain on 3rd October which I am being investigated for now. I will mention on-obstructive coronary artery disease at my follow up after the CT Angiogram.

[IamAli_R]

Thank you for the information Thatwasunexpected. I have also had 2 years of running 5k three times a week until the latest incident in October. I was running at a decent pace for my age with a personal best of 25 mins over 5K. Having read all the replies to my question I am beginning to suspect that the chest pain in October might have been anxiety (at least I hope it was).

I am also beginning to feel optimistic that even if I do get 'bad news, and there evidence of CVD then it will not been the end of the world.

[IamAli_R]

25 mins 5K are rare but I can manage them on a good day. Usually I'm 28-30 mins 5k on an average day guy.

Yes, you are right if there is bad news then its been caught in time and I should feel lucky either way.

Your advice and encouragement along with the others who were kind enough to reply has been priceless since yesterday. I have felt a lot better today and my anxiety and worry about the future has lifted somewhat. I can't thank you all enough.