Hubby getting chest pains

[KIMMY60]

We had the ambulance Friday night stabbing chest pains, went into hospital all the tests ecg, blood tests no heart attack. They think angina sent home with aspirin and throat spray. He's had four episodes in two days having to use the 4 aspirins and Nitrolingual spray under the tongue. Last night had to do it twice nearly off too hospital again as thought it wasn't going to stop. The pain is coming on while relaxed watching TV, or when he wakes up in the night which is strange for angina any ideas what else it could be ,have got him to GPS this morning and referral sent as we think he needs further investigation angiogram and scan

[Lezzers]

Hi Kimmy

If your husband is getting angina pains at rest/sleep than that would suggest unstable angina & does need immediate medical attention particularly as it's continuing. My husband used to suffer from unstable angina after his heart attack & he was always immediately admitted to hospital for intravenous heparin.

My advice would be to phone nhs111 for advice rather than wait until it happens again. He can be given medication to help with this,Isosorbide mononitrate is very effective. I'm surprised the GP didn't suggest this or said go to A&E, my husband's GP sent him straight to the hospital.

Good luck, I hope it's sorted quickly for you

[momander in reply to Lezzers]

Hi,I've had 3 heart attacks and was never given heparin? Maybe it depends on the hospital you are in? I was, however given blood thinning injections in my tummy daily. Isosorbide mononitrate was a nightmare for me I'm afraid. It made me very unwell and so I was taken off it. I am sure it is very effective, but like all medicines, it doesn't suit everyone. Im Glad it worked for you.

[Lezzers in reply to momander]

Hi, it's my husband who has the heart condition not myself.

I think heparin & the stomach injections probably work in different ways. Maybe heparin is used for different situations, but he was given it for unstable angina not because he was having a heart attack. His unstable angina had reached a crescendo so having it intravenously meant it was faster acting.

You're quite right that not all meds are suitable for everyone, idosorbide mononitrate certainly didn't suit my husband at all until he was switched to the slow release tablets & that did work for him with no side effects, thankfully.

[momander in reply to Lezzers]

Hi,

so sorry, I knew it was your husband!!! just my clumsy use of language!!! Im glad the slow release tablets work for him. With me they just me so unwell.Strange isnt it? I think the name of my injections was fondaparinux. I hope your husband gets all the medical attention he needs

[Lezzers in reply to momander]

Thank you, this was some years ago now unfortunately his health is quite complicated now. 3 heart attacks is a lot!! I hope you're keeping well now

[momander in reply to Lezzers]

Hi Lezzers,I am really well thank you. One year post op!! We are all different and the surgeon decided a bypass was the best option for me!? I went with the flow!! The artery they had stented twice had collapsed and they were concerned that if ot was left like that then another heart attack was likely. I'm very lucky all things considered!! All 3 heart attacks were mild!! They certainly didn't feel mild!!

[Lezzers in reply to momander]

That's good to hear you're doing so well. We were told that by having a bypass your pretty much as good as new, unfortunately that wasn't an option for my husband.I don't doubt those heart attacks didn't feel mild! Incredibly painful and scary is more like it! Hopefully now you have the bypass the fear of another heart attack has eased a bit?

[Tos92]

Hi Kimmy60,

I’m sorry to hear your husband is poorly at the moment.

In addition to what Lezzers has suggested, I have a less common type of angina called Vasospastic angina. This is when my arteries go into spasm and limit blood flow to my heart muscle that usually come on at rest, so during the night and early hours of the morning. When my angina is unstable, I can experience them on exertion and during normal day to day chores/activities.

bhf.org.uk/informationsuppo....

inocainternational.com/what...

A functional angiogram using acetylcholine is considered the gold standard of diagnosing vasospastic angina.

Usually, a specialist is needed if you want to get a definite confirmation or diagnosis of vasosapstic angina due to the limited knowledge of this type of angina amongst cardiologists and doctors, albeit, slowly improving.

I feel my angina in my chest, upper back, between my shoulder blades and in my arms. I have triggers such as stress, the cold and different types of emotion that can exacerbate my symptoms. To keep it interesting, my angina never feels the same. Sometimes it’s a squeezing sensation, stabbing, deep pressure or ache.

It would be a good idea if your husband or you could keep a diary of his symptoms and if there seem to be any triggers.

Calcium channel blockers are usually the first line of treatment for spasms, followed by nitrates as the second line of treatment. Though a combination of both are used normally. Some have an addition of a beta blocker but can make spasms worse in some patients, and a statin.

There is a patient support group Facebook page for Microvascular Angina and Vasospastic Angina which you may find helpful.

facebook.com/groups/2879606...

I suggest printing off some of this information above and taking it to your GP or husband’s cardiologist.

There are others with angina at rest so I hope they also share their experiences.

I hope your husband improves soon.

Tos

[theonethatgotaway1 in reply to Tos92]

Hi Tos. Do you know what has caused this? How often do the pains come on ? Come and go?

Just curious if this is something I may have after my HA and heart failure diagnosis. Having pains for years now. All sorts. Sharp and dull. Center chest. Left chest. All random and no known cause. Suppose the cold and heat can increase it but now its daily.

[Tos92 in reply to theonethatgotaway1]

The vasospastic angina is thought to be related to a congenital heart defect that I have in the form of a myocardial bridge. A myocardial bridge is an incidental finding and only affects a minority of people. My spasm was seen at the site of the bridge, so it is thought that this maybe causing it.

However, vasospasms can be present in both obstructed and non-obstructed arteries. They are difficult to catch on ECGs. I don’t believe any of mine have ever been caught on an ECG.

Vasospasms are felt more often on rest, as opposed to exertion. I do have daily unstable episodes now where I have the spasms on minimal exertion and during rest. Have you noticed a pattern for when your chest pain starts? This may help give you an indication.

My pain happens on a daily basis. I couldn’t really give you a definitive answer on how often, but they are present consistently without a break.

Before considering vasospasms as a cause, I would suggest seeing your cardiologist or your chest clinic first. Ask your GP to refer you to them. It could be that you have developed some form of angina since your HA and heart failure diagnosis.

Do you have a GTN spray?

[theonethatgotaway1 in reply to Tos92]

Yes I do have a spray but have been put off from using it since the last time I used it was right before my heart attack. The pains are present at rest for me and occur at random times and are usually short lived. Except for today where I have been getting them quite a lot.

We drove to AnE but could not gey parked up at all. Tried for an hour to get parked and whilst in that time they subsided so had left it. Got home and had a nap there. Feeling okay but they do keep creeping up. A short stab pain. No other symptoms at all.

[Tos92 in reply to theonethatgotaway1]

It’s hard to know if everything is ok until some further testing is carried out. An MRI or an echo can show the extent of heart muscle damage. Have you had one of these recently? It can also show ischaemia which is indicative of angina.

Regarding vasospastic angina, a functional angiogram with acetylcholine is considered the gold standard testing to diagnose this. However, only a handful of hospitals carry this out in the U.K. I have linked some more info below.

bhf.org.uk/informationsuppo...

You will also see unstable angina in the link which can also occur at rest.

I suffer with costochondritis from time to time and I find that a stabbing or shooting pain is often associated with it. You may want to try and press down on your sternum or where it hurts during the time of the pain to see if you can replicate it via touch. If so, it may not be cardiac as the view is that cardiac pain cannot be replicated.

I hope you will contact your GP tomorrow for an appointment at least. Any worsening of your symptoms tonight would really warrant a visit back to A&E.

[theonethatgotaway1 in reply to Tos92]

Thank you so much for taking the time to reply. Great advice 👍 😃

[Fanfab1 in reply to Tos92]

Hello

Myocardial bridges (layer of heart muscle that grows over instead of under an artery when the heart developed in the womb) whilst can be an “incidental finding”, in a patient who has no other cardiac abnormalities and is symptomatic can experience exertional angina as well as other associated issues such as arrhythmias, ischemia and in some documented cases infarction, cardiac arrest or sudden death. But microvascular angina and vasospasms can co exist alongside a bridge in their own right and / or be associated with the presence of a heomodynamically significant bridge.

Whilst it is a minority, this congential condition can and does have a significant impact on quality of life (changed mine fundamentally) and I feel MUST be investigated and treated in its own right and not left as an incidental finding when there are no other reasons especially where no obstructions - the same fight microvascular and vasospasms have and continue to face but are now more advanced in understanding, Diagnosis with the appropriate testing is challenging to get as most cardiologists believe the abnormality to be benign but there are the rare few who it does affect. Me! 😊

One article I’ve recently seen is the first I have seen that does not start with the traditional words that bridges are incidental / benign findings which most doctors have been trained to believe) and puts the investigation of bridges on the same footing as that of microvascular and vasospams albeit bridges are very far behind in research terms in comparison (with diagnostic protocols yet to be fully established and widely accepted, and treatment - medication or surgery - yet to be fully researched in their effectiveness).

If a bridge is suspected to be the cause of other issues like spasms then logic would dictate that the bridge itself should be investigated and treated - through an invasive angiogram with intravascular ultrasound (IVUS) wires and dobutamine to determine the physiological nature of the bridge and FFR/dFFR. A dFFR I think less the 0.8 is deemed heomodynamically significant and therefore affecting blood flow. Alongside this, testing is necessary through use of adenosine and acetylcholine (angiogram and MRI) the gold standard testing for confirmation of microvascular angina and vasospasms respectively re the two substances mentioned above. Collectively these would achieve a more informative picture and therefore diagnosis and treatment. There is an association per research between all three.

My bridge has been fully tested with an angiogram as above with dobutamine and shown to have a confirmed bridge (2cm long and 24mm deep - a deep bridge per research) with pressure drop and a dFFR of 0.70 (diastolic pressure drop in my LAD).

I have exertional angina (with all the trimmings) whenever I move / walk / do basic tasks. I have now developed a flip flop sensation in the heart at rest and on exertion which I am hoping to have investigated, I often get a sharp peircing pain before the flip flop happens at rest.

I have been cleared of microvascular issues through adenosine on various tests including angiogram and stress MRI. I do have a small left ventricle and ventricular premature beats noted, as well as mild LVH.

I fit the profile of a symptomatic MB patient and have been tested according to the gold standard that is currently available. I have had the appropriate tests for microvascular issues and I keep an open mind on vasospasms (I found an old letter where cardiologist said a test with acetylcholine should be considered long term).

My life has been fundamentally changed as the result of my bridge becoming symptomatic. It’s non reversible and no treatments options had worked re meds, meds for microvascular including nitrates make things significantly worse. Surgery is not an option for me and their is a severe lack of research into the long term efficacy of surgery. And no BBs due to asthma. I’m not allowed GTN.

As a fellow bridge person and as there are so few of us I’m keen to learn from others and their experience as I often feel like a billy no mates but do feel a “kinship” with microvascular people but more affinity with vasospasm patients regards their journeys, struggles and the lack of cure and how they manage their condition physically and mentally.

So I’d be interested to know what tests have you had of your bridge and what tests have you had for microvascular and what test for spasms diagnosis for comparison.

sorry for the long post (I’ve added more detail for others in case there are any other members with bridges or just if anyone is interested) but I felt I needed to explain the world of Myocardial Bridges - I’ve had a paramedic google it right in front of me to find out what it is 😂

👍 (ps I used to be FishFace101 but things got “dark” during my journey of diagnosis and I left for a bit).

[Tos92 in reply to Fanfab1]

Hi Fanfab/Fishface,

It’s nice to see you back on here.

I’m not sure if you remember my heart history regarding my heart, and I think you may have responded to a post that I had done on being diagnosed with MVA (microvascular angina) and VSA (vasospastic angina) recently. I had a MINOCA (myocardial infarction in non-obstructed arteries) and a spasm was seen at the site of my bridge. As a specialist recently confirmed, the bridge is thought to be the reason for the spasms and the heart attack that took place, therefore I am well aware that bridges can trigger major cardiac events.

However, the bridge, in my case, was an incidental finding which I believe continues to be the case for most people who are considered healthy otherwise with an unremarkable medical history like myself. Even upon the discovery of my bridge, there was still not an agreed consensus among UK cardiologists that a bridge can in fact cause infarction as my heart attack happened abroad and due to the relatively small amount of literature on bridges and their impact on quality of life and role in cardiovascular disease and conditions, the easiest thing for cardiologists often is to dismiss the bridge as a cause for angina/issues with blood flow to the heart which I am sure you have experienced first hand as well.

I believe dFFR numbers vary depending on the country. Stanford in the USA, which is a leading medical institute in treating and performing unroofing surgeries on MBs has a cut off/borderline of 0.75. I assume you have had your testing in the U.K. by the MB specialist in London which have a dFFR cut off 0.80 I think.

I have had a CMR perfusion with adenosine however, the general cardiologist performing the test was not looking for MVA. I have not had the functional angiogram with acetylcholine. This was because initially, at the beginning of my journey of finding answers, the handful of cardiologists which I visited advised that I did not have it. Then having seen a specialist in INOCA/ANOCA conditions recently where I obtained my diagnoses, he too has advised that I do not need a functional angio as I clearly fit the clinical picture of someone who has vasospasms and there is strong evidence to support this diagnosis based on the medical evidence that I have. This would only be performed if I didn’t respond to treatment. He has the same opinion for the MVA diagnosis as well. The concern is also possibly having another MINOCA being triggered as I have previously had one already, and as you know, the functional angio can induce spasms. I do think my history of having the MINOCA makes cardiologists a little bit hesitant in sending me for the functional angio with the acetylcholine. I am never 100% sure why they have not been onboard with it.

I was on the waiting list to have specialised testing for my bridge however, the INOCA specialist has advised against this too. He wants to proceed with the treatment plan set out first, before any further testing is carried out. I’ve been advised against unroofing surgery by 3 cardiologists.

I am currently on Tildiem and GTN. I have a treatment plan in place which involves increasing dosages and adding another 4-5 medications to help manage my symptoms. However, due to side effects that I am having, they will be introduced slowly. I have always been skeptical about using the GTN as you may already know it is a hit and miss for people with bridges whereby some may find relief from it, whereas for others, it can make symptoms worse. I have tried to avoid nitrates however, it is the second line of treatment for VSA therefore, I am willing to give the addition of long-acting nitrates a go.

I sympathise with how you feel regarding having a bridge and its impact on your life. Its role in cardiovascular conditions is less known in comparison to vasospasms and MVA as the research in these two areas is developing more than the research into bridges, though like myself, bridges should also be considered more widely within this as it does fall under INOCA/ANOCA conditions. I am an example of this.

I’ve had paramedics, A&E doctors and cardiologists Google a myocardial bridge, MINOCA, vasospastic angina and microvascular angina.

Perhaps you can get into contact with the BHF regarding creating awareness around bridges? I have been in contact with them also and it would contribute to getting the word out if it was something you were comfortable with doing.

[Fanfab1 in reply to Tos92]

Hi

Thanks for explaining, I have been struggling to understand if the bridge was the potential cause of the spasm, how can it be incidental? And why no cardiologist has thought to investigate it. I’m getting that the cardiologists you saw were the kind that dismissed the bridge like you say is so much the experience of asymptomatic and symptomatic bridge patients, I’m also wondering how cardiologists said no to surgery when they haven’t investigated the bridge before coming to that conclusion. Apoligies if I’ve missed understood, it’s not a cut and dry condition and we’re all different - no two bridges are the same.

I’m sorry that’s been your experience and hope one day you find a cardiologist open to the possibility but recognise you have the issue of the risk of infarction.

I do hope your treatment with your current cardiologist goes well and you don’t need to be tested. Wishing you the best.

👍

[Tos92 in reply to Fanfab1]

I say that’s it’s incidental, as mentioned to me by the cardiologist who originally looked after me during my MINOCA because he couldn’t give a definite answer on whether the bridge is causing the spasms, a part from stating what he saw on the angio which was a spasm at the site of the bridge. I saw him again in April 2023, and again, he couldn’t say for definite if the bridge was causing the spasms but he did change my type of heart attack from an NSTEMI to a MINOCA. He held the belief that it was a “one off” episode for me and that I’d be asymptomatic, but that of course was not the case when I saw him the second time around and he was a little surprised that I continued being symptomatic.

Two years on from the MINOCA, the belief currently is that the bridge did cause the spasm after speaking with the specialist and there is angiographic evidence for this. I hope that makes sense. Prior to that, the bridge was considered an incidental finding as the first cardiologist could not confirm that the bridge was the cause for the vasospasms so he did not fully consider the bridge in the context of it being harmful or injurious to my health.

I have been advised against surgery because it carries a fair amount of post-op risks/complications and they just feel I’m too young to have a surgery that big. I know of a few people currently suffering quite majorly from post-op complications as a result of unroofing. Unfortunately, some are also not unroofed completely, leaving them to deal with prior symptoms, as well as post-op complications and recovery. However, partial unroofing seems to be more of an issue in the U.K. than anywhere else at the moment. This may reflect the fact that further training in carrying out unroofing procedures/surgeries need to be reviewed in the U.K.

You mention that you cannot have unroofing. Is that because your bridge is considered too deep?

I wish you well too. I hope you find a way of getting some symptomatic relief. It can be debilitating to live with chronic pain.

[Fanfab1 in reply to Tos92]

A NHS surgeon assessed and advised couldn’t be down with assurance would work, be possible to unroof or improve symptoms but acknowledged the significant impact on daily life. 👍

[Milkfairy Heart Star in reply to Tos92]

You might be interested in this article?frontiersin.org/articles/10...

[Weetabixie]

Hopefully the appointment will be pretty quick🤞. And as said above if it happens again ring 111 or 999 .

[PilgrimsProgress in reply to Weetabixie]

NHS 111 is utterly useless.... - Don't waste your time.

[Weetabixie in reply to PilgrimsProgress]

Oddly enough I've seen them being utterly useless and good. It's pot luck I think.

[PilgrimsProgress in reply to Weetabixie]

worst experience for me was waiting on hold for 4 whole hours (I kid you not ) 4 hours !!! then the usual tedious triage questions.... It's a national disgrace --- the NHS is irretrievably broken - and standards of care are not up to the standard of comparable countries... - We are about "halfway down" in all measures of outcome, compared to Europe and the US ... It's the simple truth..........

[Weetabixie in reply to PilgrimsProgress]

That's scandalous, had a friend waited 8hrs for a call back, she'd already had to be taken to A&E in an ambulance by the they received a call back. I try to stick it out for gp opening times. Have another friend she was dealt within the hour and they sent ambulance. How bad it really is just isn't out there in public knowledge, can't think of the right word I apologise, unless you've needed and are in the system you don't see how falling apart it really is. Sorry to hear what you went through, I hope you're ok now🤞 x

[Partner20 in reply to PilgrimsProgress]

Sorry you had such a bad experience of 111. We have used this service successfully in the past, most recently a few weeks ago in a suspected TIA scenario. Professional triage, prompt GP callback, and possibility of an ambulance if needed. We couldn't have asked for more.

[KIMMY60 in reply to PilgrimsProgress]

I wouldn't bother with 111, I will call an ambulance or drive my husband straight to A&E if really worried we only live ten minutes away with both if us having heart problems has been very handy

[Milkfairy Heart Star]

Hello KIMMY60

Lezzers has given you some good advice.

The BHF website has this information about angina, it describes stable and unstable angina along with vasospastic and microvascular angina.

bhf.org.uk/informationsuppo...

I have lived with vasospastic angina for nearly 12 years.

I have been in hospital since Wednesday as my vasospastic angina has become unstable again. I am being treated with IV GTN.

It can be difficult to tell unstable angina due to obstructive coronary artery disease from a unstable vasospastic angina.

Both unstable obstructive angina and unstable vasospastic angina require an immediate review from a doctor.

I suggest if your husband continues to experience chest pain at rest which is not relieved by 2 sprays of sublingual GTN 5 minutes apart that you ring 111 or 999 for further advice.

Good luck.

[Blearyeyed in reply to Milkfairy]

Oh Dear , I hope they get things managed for you soon , take care , Bee

[momander]

HiI would agree he perhaps needs seen again. If they took bloods at hospital the they would have tested for tropinin levels in the blood which is an indictator of whether someone has had a heart attack. If the levels are between 6 and 8 ( which is what I was told) then it is assumed the patient has not had a heart attack . Perhaps they may do an echo or a scan or refer him for an angiogram . I hope he finds out what is wrong soon. I know only too well how miserable angina is, and also heart attacks. Good luck