Medical Mystery: Seeking the source of a strange feeling

After a 61-year-old man had been complaining of left flank and abdominal discomfort for several weeks, he saw his family doctor. During the exam, he recalled that he had been experiencing a rushing, or pulsating, feeling going down both of his arms.

by David Becker, MD

Published Jun. 30, 2016, 6:57 p.m. ET

Each episode lasted about one minute, and a couple of these episodes seemed worse after eating. He did not feel short of breath, had no chest discomfort, and was able to walk the dog with no problems.

His exam was entirely unremarkable. His blood pressure was normal and his belly was not tender. A CAT scan was ordered because of his continuing abdominal pain. This showed no evidence of kidney stones or abdominal abnormalities, but prostate and aortic calcifications were incidentally noted.

His medical history included high blood pressure, high cholesterol, arthritis, and an ulcer. Medications included a daily blood pressure pill, Lipitor for his cholesterol, the arthritis drug meloxicam, and hydrocodone as needed for arthritis pain.

His doctor was frustrated with the lack of a diagnosis. It was time for some help, but what to do next?

His stomach discomfort, history of ulcer, and use of meloxicam could suggest the need for a gastroenterologist. The flank pain and prostate calcification might point in the direction of urology. His history of elevated blood pressure and cholesterol, along with the calcification seen in his aorta, could mean that he needed his heart checked.

What did his doctor do?

Solution:

The patient's doctor referred him to a cardiologist, because of his multiple cardiac risk factors.

His initial exam in my office was unremarkable. His EKG was abnormal, but consistent with his history of high blood pressure. His aortic calcifications, noted on the CAT scan, raised a flag because calcium in blood vessels can suggest atherosclerotic disease.

I asked him to have a nuclear stress test, which involves receiving a small amount of a radioactive material that can help detect coronary blockages. He had the same rushing feeling in his arms while walking on the treadmill, and his scan suggested that his heart was in trouble because of blockages.

A cardiac catheterization was done at Temple University Hospital, which showed a critical blockage of his right coronary artery, with several other blockages that were less severe. He had a stent put in his right coronary artery, and all of his symptoms disappeared immediately. At his last visit, he told me that he has not felt this well in years.

When it comes to heart disease, it pays to keep an open mind about what symptoms may occur. Other unusual signs of potentially missed coronary disease that I have seen include arm pain, neck discomfort, shortness of breath, intense sweating, jaw discomfort, and one patient who presented with discomfort in his ears that occurred only with activity. Extreme shortness of breath during sex can be a warning.

Women are much more likely to have unusual warning signs. Squeezing or pain in the arm, jaw, back or neck, unusual stomach discomfort, profound sweating, shortness of breath, and even intense fatigue can be the presenting complaint in some women.

Here are 10 things that you should know about an impending heart problem:

1. Angina (heart discomfort) can be an early warning sign that often occurs before an actual heart attack. It can be typical (chest pressure with activity) or atypical (such as the examples above).

2. If you are experiencing chest discomfort, unusual shortness of breath, discomfort of the arms with activity, unusual sweating, jaw discomfort, or any sudden change in how you are feeling, discuss this with your doctor as further testing might be in order to exclude a heart problem. Although these symptoms are often not heart related, they need to be checked out.

3. Know your risk. It is higher if you smoke, have high blood pressure, diabetes, high cholesterol, are overweight, or have a family history of heart problems.

4. People who have inflammatory diseases such as rheumatoid arthritis or lupus may be at increased risk of having a coronary problem.

5. Silent heart attacks can occur, more commonly in diabetics, because pain sensation can be decreased because of neuropathy.

6. Having a stress test, or a special kind of screening test called a calcium scoring CAT scan, can often exclude the heart as a source of the trouble.

7. If you have sudden shortness of breath, chest discomfort or heaviness, which occurs at rest or with low levels of activity, this may no longer be an attack of angina, but could be an actual heart attack.

8. If you think you might be having a heart attack, call 911, chew an aspirin (so it can begin working immediately), and do not wait to call your doctor the next day.

9. During the early moments of a heart attack, the heart muscle is vulnerable to possibly fatal irregular heartbeats, so it is important not to drive to the hospital, but to call for an ambulance.

10. Act quickly, as damage can be reversed if too much time has not gone by.

David Becker, M.D., is a board-certified cardiologist at Chestnut Hill Temple Cardiology, and associate director of preventive cardiology at the Temple Heart and Vascular Institute.