I am in hospital ER and have to stay overnight. They want to do a chemical stress test with imaging but it makes no sense. I just had stress test a month back and passed fine. Also before I had echo which was fine.
im trying to fight for a ct scan of heart to validate no blocks which is unlikely but issue is I have had almost non stop angina since Sunday with brief relief of nitro but comes right back. I was taking nitro 4-5 times daily which is not normal.
so not sure what to do. I am getting morphine and nitro (not iv though ) …… Anyone have input /advice as to chemical stress test. My angina is always at rest and never exertion. I fear that this test could cause horrendous spasm as it chemically constricting the vessels. I mean having worse spasms that I already do is insane. Please help with anyone that has experience with this test and vasospasms.
Also have to mention there all blood troponin, chest X-ray, and ct pe scan were normal. So all the usual protocol. Also ekg was fine. They always are for me but I don’t know what else to do as pain won’t go away….
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Andy5S
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They gave me a ct pe scan but that not same thing. It only looked for pulmonary embolism and things like dissection. This is good to catch the life/death things but not the heart or possible blocks.
Hi Andy, I'm sorry to hear that you are going through this, I wish I could offer something other than my empathy but hope that someone who can comes along soon Milkfairy is very knowledgeable in this field and I hope she picks up your question soon
A CT angiogram is useful to look for permanent blockages of the coronary arteries, it cannot diagnose microvascular or vasospastic angina.
Are you being offered a non invasive assessment using adenosine?
Adenosine is a chemical that speeds up the heart. This type of testing can look for issues such as microvascular dysfunction, but not vasospastic angina.
This can be a stress echo or cardiac MRI.
An invasive functional angiogram uses adenosine and guidewires to measure how the blood flows through the smallest blood vessels of the heart. This can detect microvascular dysfunction.
Then another chemical acetylcholine is injected into the coronary arteries.
Normal functioning coronary arteries should dilate in response to acetylcholine. If the coronary arteries almost completely constrict in a spasm, there are ECG changes accompanied by chest pain, then vasospastic angina is confirmed.
A functional angiogram is done in a very controlled environment. When I had mine done, I had spontaneous and acetylcholine induced coronary vasospasms.
I was given morphine and GTN was injected directly into my coronary arteries.
When I have a high heart rate this can trigger my coronary vasospasms too.
I had coronary vasospasms after my stress echo and cardiac MRI.
When my coronary vasospasms are unrelenting, I am admitted to hospital and have an infusion of IV GTN and IV morphine via a patient controlled analgesia system.
The tests were not pleasant for me, however I have a confirmed diagnosis which helps me to psychologically manage better and guides my Cardiologist how to treat me.
Ask the Cardiologist to explain the procedure to you.
I always consider the following when making a decision about my care.
What is the benefit ?
What are the risks, are these risks acceptable to me?
They wanted to do a nuclear test with something called lexiscan. However the cardiologist came into to chat with me after reviewing all my history and discussing with my care team. He said that this test would not make sense and I don’t have microvascular disease. He is basing that on fact that I have never had angina on exercise and work out regularly with cardio and weights. I had just done boxing workout the day before with but already had very mild angina. It just ramped up all week and would not release with 4-5 times a day nitro spray or pills.
He said I have all symptoms of vasospasm but one. Here is where we disagreed as I know he is wrong. He said most people will show changes in ekg during spasm and after it’s gone another ekg with show arythmia. This is incorrect , although true for some in severe episode, not true for most. I have heard many here talk about this. I myself never have ekg changes and fit first time I was actively having pain while in ER and having tests.
I ended up getting an entire battery of ct scans pe, and angiogram, echo, blood tests for all kinds of cardiac related things besides just troponin. (Heart failure, elevated inflammation, pericarditis, viral, and others I can’t recall) essentially got first time everything short of heart cath.
All tests were normal and only findings were slight calcium build with score of 1.6 which is not considered clinically significant here and slight elevated cholesterol. No other findings at all.
Here is what seemed to finally calm things down. A nitro paste that is put over skin on chest (nitro-bid topical) . It’s a 6 hour release of 1gram and it calmed the spasm in about a hour. The morphine helped but not as much although I did need. I got a script for this paste to use at home. They put me on crestor 40mg which is very high and claimed this may help with nitrogen production but my cholesterol is barely over limit and side effects of this can be horrible so not sure I will take. They also said I could try a drug called nebivolol which he assured me I’d not a beta blocker that can exacerbate spasms like the others . I did not get a script but can later if need be.
I’m not sure why they won’t do the acetylcholine test here but I think they don’t want to do invasive unless other tests failed. I had every test available and all showed no issue which is always challenge. I don’t have the other heart issues that many have and can complicate further but is still frustrating. I am now really understanding what you have said before where we must learn to accept some things with this condition and try to cope. I’m hoping this paste will keep me from going to ER every couple months and get me past bad spells. Since I have now ruled anything else out , the ER has nothing for me unless I am really bad and even paste does not work. I wish we had something like what you mention with care plan but that’s not how US works. You must go through hell at hospital and days of things. However one good thing is they have no problem giving you medications here even when they are skeptical of your diagnosis. I suspect it’s because if they make a mistake our court system will hang an entire hospital for millions of dollars so lots to lose.
So on I trudge through this difficult journey. It’s not all bad but when it is man it’s really bad!
Question. Are you aware of vitamin D3 with k2 causing any kind of flare ups with vasospasm? It does increase calcium uptake even thigh k2 is supposed to carry it to bones and teeth more versus heart. I’m curious as I notice when I take it , it seems to cause agitation and angina. Sometimes does get hard to isolate root causes but just wandering if you heard of or knew about anything like that?
So you have not experienced the horrible muscle aches and other side effects from crestor (rosuvastatin)? They gave me 40mg which is very high. I mean I am big guy 6’6 290 but I doubt dosage has anything to do with your height weight lol :). I was leery about side effects that I see so many complain about.
I recently went private because I was getting nowhere with the NHS. They gave me a CT first and determined all bypass grafts were patent. They then gave me a Perfusion MRI with Adenosine which induces angina, but they took me out of the scanner to do that and then put me back in when the pain had mostly subsided. I'm glad I was outside the scanner during the adenosine administration because it was very painful. From that they determined that I had 5 out of 20 regions of the heart that are suffering ischaemia and hence this is where the angina is. I am not suffering vasospasms though. This MRI also showed that my native coronary vessels were blocking again. Sometimes above and sometimes below the point of the bypass graft. They then did an angiogram to see if there was an opportunity to put a stent in my LAD, but there wasn't. They concluded that the only thing they could do is insert a coronary sinus reducer (CSR) which I had done last Monday. There is no guarantee that this will work but it is my last hope for a plumbing intervention so I went ahead with it. Glad to say I had the latter done on the NHS because the CSR device itself costs 13k and the NHS are withdrawing funding for it at the end of their financial year which is in about 16 days time. It is hoped they will reintroduce a funding for the device but they want to have a discussion about it and these things move at a glacial pace.
I could be wrong, but I suspect the stress test you are talking about having is the same as the Perfusion MRI scan with Adenosine that I had. I wish I could tell you that it will be pain free, but it wasn't for me and the pain seemed to last considerably longer than the couple of minutes they stated before the scan. The good news is that within 5 minutes, I am sure the pain will be over if you are having one of these scans. You have a binary choice here to either have the scan or not and if you don't have it, you are asking your cardiologist to work in the dark with regard to the cause of your spasms and hence limiting what they can do for you. My advice would be to have it and just accept that it is going to be uncomfortable for up to 5 minutes. Just think about the discomfort you are having now which isn't going away without some sort of intervention. Best of luck with it whatever you choose.
The problem for those of us living with transient constrictions of the coronary arteries, coronary vasospasms our blood vessels can be very trigger happy.
A cardiac perfusion MRI can diagnose, microvascular dysfunction rather than coronary vasospasms.
I ended up in A&E after my perfusion MRI with adenosine.
I had ST elevations and ST depressions as the increase in my heartrate triggered coronary vasospasms. Thankfully my coronary vasospasms settled after a dose of morphine and extra GTN patches.
If my coronary vasospasms don't settle it means I need to be admitted to hospital for about 10 days.
It makes the decision to have any testing more challenging.
I would be interested to know how you get on with your coronary sinus reducer.
Unfortunately there are very few large scale studies into it's use, which is perhaps why funding is being withdrawn.
Not sure if you know Milkfairy, but it takes a while for the endotheliol cells lining the inside of the coronary sinus to grow over the wireframe of the reducer to make it become effective. I've been told up to 6 months. I certainly intend to review it at some point in the future. I have so far done a couple of 1 mile walks and if anything, I seem to be worse than I was before, but it is way to early to draw any conclusions. According to my cardiologist, he thinks the funding withdrawal is just a cost saving measure by the bean counters, but cardiologists are up in arms about it because on average, patients experience 1 class of angina improvement with the device and there are 4 classes. The extreme ends of the class are someone who experiences angina only if they run a half marathon and experiencing angina at rest. But there are definitely winners and losers with the device. The most extreme winner he told me about was someone who was getting angina after walking 100 yards, who is now sea kayaking around Anglesey.
I also was considering this device and participated , or attempted to participate, in it here in Boston. Mass general hospital is a top east coast hospital for this device and heart intervention in general. However I was ruled out for 2 reasons. 1) diagnosed with vasospasm regardless of not having the acetylcholine test. 2) I will not fail a stress test and can pass that with above average performance.
This helps folks with microvascular disease that have problems with exertion. I was also told that it can take 6 months to see the full benefit post implant. However results are really varied and some can improve greatly and others marginally. It’s only approved for research here in US and fda is not ready to allow yet. I would have tried if I fit criteria but when they said it can make vasospasm worse, well let’s just say I treated it like a grenade and ran!!!
I hope you have success and it helps as many people have had great success with it in terms of being more active and less angina.
Yes, if it can make vasospasms work, you were dead right to avoid.
The research study you are talking about will also be taking place in the UK shortly because they had trouble getting enough numbers in the USA and Canada. The reason for that, is it has to be double blinded with a sham device to rule out the placebo effect, but it is a very invasive procedure to go through and find out 6 months later that you never had a CSR implanted after all. The sweetener if you can call it that, is that anyone who received the sham device will be notified after 6 months and will be offered a real CSR implant free of charge, but that means going through the procedure twice and you only have a 50% chance of getting the real device first time around. No wonder they had trouble getting the numbers they needed.
I can't help wondering if the withdrawal of UK funding has something to do with trying to get more UK participants on the study, because nobody will take part in it if they can get the real device free of charge on the NHS anyway.
Yes that is exactly right. They told me about the sham and that really turned me off. So you go in and possibly got nothing but a bunch of analysis. This is absurd and I can understand why many don’t want due to that. What’s intersting is, before they knew I had vasospasm , they told me “you may not have to be randomized”. They said because my angina was not as bad as what they usually see. I asked what is the norm they see and it was people they had to take nitro 5-6 times daily so the very extremes of cases.
I could not find any US patient stories either which was not super helpful as to others experience. I found more stories in EU and Israel where this device came from. There was a National Geographic article on it some time back and a story of a male in Israel with great success.
Hi Wingnutty, Prior to my issue with Vasospastic Angina, I could walk long distances without pain or reduced stamina. I suffer angina at rest and during exertion. I will be very interested to see how well the Coronary Sinus Reducer works for you . Please keep us updated. Best of luck.
I am going to have a meeting with my cardiologist in about 3 months time, so I will wait until then when I have had a chance to ask a lot of questions and I will give another update in about 6 months. Of course, if there is anything wonderful or drastic to report, I will do so sooner.
One other thing to add which always frustrates. The drs will always ask about responding to nitro and how it works for me. I always tell them it will dull the horrible pain quickly but does not fully work until 10-15 mins. They always act like if it does not work instantly then maybe it’s not heart. Well it does work but not instantly and takes the 10-15 to fully work for me. There must be this manual they all read from or see symptoms in typical people and just assume it applies to all. I know more is known on the condition now but seems like long way to go yet!
Hi Andy, I understand what you are saying. I have bad episodes when my Nitro works quickly e.g. within 5 mins, but other times I have not felt well for about 15 mins.
After a couple of days non-stop angina pain, I was advised at a visit to A&E last year that I only needed to be admitted if I had raised troponin levels. I haven't so far had any raised troponin or vasospasms that showed up on ECGs. I have had many extreme episodes over this last year and not visited hospital when I felt I should have done.
I waited 5 days to go to ER because I hate going and have been so much last year. Our ER’s around here are a bit like combining circus, a mental ward, and episodes of the show COPS as you will experience folks from each area with colorful sites, sounds, and smells! In short one does not wish to visit unless it’s a must. I’m sure UK can be fun as well. Oh and of course the obligatory 6-8 hours wait time on good day but usually more like 12. Not pleasant…….
I suspect it’s chaos all over world though and US is not unique in that regard today.
I absolutely hate going too. The trouble is how can I distinguish between a severe angina attack and a heart attack? If we call the GP surgery with chest pain you are advised to go to hospital. I've resigned myself to the fact that probably the only way I'm going to get improvement is finding the right combination of meds for this condition that work for me.
Hi Andy 5S, Sorry to hear you are currently having a rough time with your vasospasms. I was not on any medication, I was well and leading a completely normal life before my issues with Vasospastic Angina began.
I have undergone a stress echo which was normal and a CT Angiogram which was also normal - no obstructions of the large arteries or calcification. I'm being treated with medication for Vasospastic Angina. However, I continue to suffer unpredictable episodes. I respond well to Nitro and carry it with me at all times. I would say on my worst days, I have needed Nitro three times a day but on better days during summer I could go days on end without reaching for it.
I can completely understand your desire for answers. This condition has impacted dramatically on every aspect of my life from my career to participating in holidays, and recreational activities etc.
I've identified that mainly cold, temperature changes/humidity/air pressure impact hugely as does mental stress and lack of sleep. Please let us know how you get on. Best wishes.
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