I’ve been getting severe chest pains, mainly on the right-hand side, but sometimes they feel like they’re down my arm, too. I went to A&E and they ruled out a heart attack. It seems to flare up when I’m stressed. Now I’m waiting for a referral for cardiology. I am 34 and otherwise healthy. – Connie Murray, Bicester, Oxfordshire
Dr Scurr replies: It is reassuring that serious causes, including a heart attack, have been ruled out. I imagine that this involved having an electrocardiogram (ECG), which checks the heart’s electrical activity and rhythm, and a blood test for troponins (a protein released from damaged heart muscle).
But I think more testing is needed as what you’ve described sounds like angina – heart pain that occurs when there’s insufficient blood supply to the muscle, such as when exercising or stressed. As angina doesn’t directly damage the heart, it won’t show up in these tests.
Although angina is more common in older age, as fatty plaques build up in the blood vessels, it can occur in younger people – even at just 34.
It’s diagnosed with a CT angiogram, which checks how the blood is flowing, or a stress ECG, in which your heart is monitored under ‘stress’ on a treadmill.
If there is any restriction of the blood supply to your heart muscle, there are good and effective options such as medication including a statin, or – if there is serious restriction of blood flow – the insertion of a stent.
If angina is ruled out, the pain could be due to oesophageal spasms – painful contractions of the muscle in the gullet that can be stress-related.
If there is any restriction of the blood supply to your heart muscle, there are good and effective options such as medication including a statin, writes Dr Scurr
Gallstones can also cause chest pain and radiate up to the right shoulder (this is diagnosed with an abdominal ultrasound).
It may also be pain referred from the spine (although this would be unlikely to cause the tightness in your chest that you describe in your longer letter).
I suggest you speak to your GP and raise the possibility of the pain being angina – mention any of these risk factors, if these apply to you: being overweight, smoking, high blood pressure or a family history.
Whatever the case, you should ask your GP to push your referral to the cardiology department as a matter of urgency.
Over the past year I have experienced extreme fatigue and tiredness – and this has got worse; I am now tired from the time I wake until the time I go to bed. I have severe sleep apnoea and for the past six months have slept with a face mask. I am 83 and at my wits’ end. – Name and address supplied
Dr Scurr replies: Obstructive sleep apnoea (OSA) is a common condition in which your breathing is constantly interrupted during sleep.
It’s often related to obesity, as the excess fat around the neck presses down on airways while you sleep, causing them to collapse. Symptoms include constant daytime fatigue, as well as poor concentration, headaches and low mood. The standard treatment is with a CPAP (continuous positive airway pressure) machine – the face mask you describe. This delivers constant air to keep the airway open, and I would have expected you to improve within weeks of starting with it.
You should first check that the CPAP equipment is functioning correctly – this includes the mask fitting well to prevent air leaking out. Contact the experts at the sleep department where you were diagnosed to ensure the device is working.
There may be other factors that need to be considered.
Potentially, your symptoms could be the result of interaction between the medications you are taking.
Another possibility is that it is depression – I would suggest that you discuss both of these possibilities with your GP.
