Chest Pain but Normal Test Results: What’s Next?
Find out what you should do if you have chest pain but “all the tests” are normal.
Many people have chest pain but the cardiac tests come back normal. Chest pain is the No. 1 reason for emergency room visits.
Most of these patients are told that their chest pain is not related to their heart.
“The etiology for chest pain is not always the heart, but it is so important to be sure it is not the heart!” says Dawn Kershner, DO, a cardiologist at MedStar Union Memorial Hospital, Baltimore, MD.
Dr. Kershner continues, “Chest pain can be caused by numerous GI problems, musculoskeletal — like a pulled or inflamed muscle/joint — pulmonary embolus,” which is a blood clot in the lung that can kill within minutes.
“As a cardiologist, I make sure the chest pain is not cardiac and then start looking for the non-cardiac cause.”
Do not delay; if you are having chest pain, you do have a choice: Sit or lie there wondering if it’s your heart preparing for an attack, or — you can head to the emergency room to get it checked out.
If the incident passes and you’re still alive, do not assume it’s nothing to worry about.
Make an appointment with a cardiologist and get tests done.
Now what if all the tests are normal?
This includes blood tests, EKG, echocardiogram, Holter monitor and “stress test.” A stress test can be via exercise or chemical.
After these normal test results, if you continue having chest pain, and also have other symptoms (e.g., sweating, nausea, jaw pain, back pain, labored breathing) that are well-known as being part of many heart attacks or signs of severe coronary blockage, then you need to:
- Ask your doctor about a CT angiogram.
A CT angiogram is non-invasive and will show if you have blockages in your coronary arteries.
Board certified in internal medicine/cardiovascular disease, Dr. Kershner treats abnormal EKG and abnormal stress test among many other cardiac conditions.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Freepik.com
Why Some Athletes Have Higher Resting Heart Rate
Find out why it’s a myth that all athletes or gym rats have a low resting heart rate.
Do you work out hard at the gym and even do high intensity interval training, yet are mystified over your relatively high resting pulse?
A normal resting heart rate for the general population is between 60 and 100.
A muscle-building enthusiast who also does high intensity interval training, and even some miscellaneous cardio jaunts such as lengthy hikes, may still find he or she has a resting heart rate in the 70s or even low 80s – which seems high for an athlete.
What’s the reason some athletes have a higher resting heart rate?
“Most ‘athletes’ are weekend warriors or those who run daily or work out; but they are not necessarily career athletes,” says Dr. Sameer Sayeed, a cardiologist at ColumbiaDoctors of Somers, NY.
“Their level of exercise is greater than the general population who doesn’t exercise or just does light walking.
“But their exercise is not enough to cause the very low resting heart rates associated with more career athletes like Olympians or marathon runners who train every day, all year-round, and are so well-conditioned that their hearts develop the features of an athlete’s heart, with a stronger, thicker muscle and larger chamber for higher blood flow and the low resting heart rate from such severe endurance.”
Tennis great Bjorn Borg was reported to have had a resting pulse of 38, though that’s been refuted, and it was likely more like 50-60.
Many marathon runners, who are not professional caliber, report a resting heart rate in the 40s and 50s.
I asked Dr. Sayeed if the really low resting heart rate is associated usually with elite endurance athletes, and he said it is. “They do severe training daily for months to years,” he adds.
What about hardcore gym athletes who strain and severely tax their bodies with heavy weight workouts?
Though a powerlifter or bodybuilder will strain through sets that leave their heart pounding at the end, this type of training simply cannot be compared to running for two hours straight.
“They are not doing severe training like a marathoner or Olympian,” says Dr. Sayeed.
The “severity” in this case refers to how much the cardiac muscle is taxed, not how much weight the bones and skeletal muscles can move.
Serious marathoners may run 10-15 miles every day, and at a painful, nonstop pace.
Whereas the powerlifter or bodybuilder is painfully active only for a fraction of that time, even though a gym workout may last two hours. Most of that training time is spent resting.
High intensity interval training will help lower resting heart rate and has several advantages over long-distance running, for those whose goals are related to fitness and fat loss rather than completing marathons.
An athlete or hardcore gym enthusiast may have a relatively fast resting pulse due to factors that raise resting heart rate, such as ongoing stress and anxiety, caffeine, medications and smoking (yes, some gym enthusiasts actually smoke).
Finally, overtraining can elevate the resting pulse.
Signs of overtraining also include moodiness or irritability, ongoing fatigue, trouble with sleep, failure to progress, or even regression with performance.
Dr. Sayeed performs echocardiograms and stress tests at the Midtown Manhattan and Westchester offices at Columbia Doctors. He is also trained in cardiac CT imaging.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: ©Lorra Garrick
Source: runnersworld.com/community/forums/training/marathon-race-training/low-heart-rate
Knee Replacement Revision without General Anesthesia?
An orthopedic surgeon discusses anesthesia options for knee revision surgery.
Are you wondering if general anesthesia is absolutely necessary for knee revision surgery?
After all, this is quite unnerving, being that a tube is stuck down your throat (intubation) and a mechanical device breathes for you.
Good News
“Knee revision can be done under regional (spinal, epidural, femoral/sciatic block) with sedation, depending on the efficiency of the surgeon and the skills of the anesthesiologist,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.
“There is some controversy whether the DVT/PE rates are lower with regional some studies show), but it is a commonly held belief,” adds. Dr. Boucher.
Reasons why a patient should have general anesthesia for knee revision surgery (or primary replacement).
Dr. Boucher explains, “Contraindications (to regional anesthesia) include elevated risk of bleeding (use of anticoagulants); certain cardiac conditions (severe aortic stenosis) where a drop in blood pressure due to proximal migration of the spinal would be very risky; some patients with extensive spinal surgery.”
Why would some surgeons prefer general anesthesia for knee replacement or revision surgery in a patient without any contraindications?
Dr. Boucher explains, “Some surgeons are reluctant to agree to regional because of 1) the time it takes to place and 2) time to achieve proper anesthesia.
“The flip side is that it can save time at the end of the case since there is no lengthy wakeup.
“Sometimes the spinal does not take—which then requires general—or requires extra time to set up even in the best of hands.
“Some anesthesia providers feel the same way and may be more comfortable with general.
“Efficiency and willingness to do regional is certainly related to the skill of the anesthesia provider.”
This has me thinking that the surgeon and anesthesiologist don’t consider what’s best for the patient in terms of blood clot risk, which includes the DVT becoming a life-threatening pulmonary embolus.
Dr. Boucher says, “Regarding DVT/PE, there is research that both supports and refutes lower rates in regional anesthesia.
“It is true that DVT/PE are major medical complications after knee replacement, but in my opinion the more pertinent risk factors are the patient’s comorbidities and post-op immobility rather than type of anesthesia.”
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Freepik.com
Non-Surgical Treatment of Failed Total Knee Replacement
Could there be any nonsurgical alternatives to knee revision surgery for a failed TKR?
After all, revision surgery involves just as much recovery time as the original operation.
Furthermore, knee revision surgery is more complicated than the original procedure, because the defective parts must be removed.
And there’s no guarantee that the revision won’t eventually become loosened or failed either.
Loosened Knee Replacements Can’t Repair Themselves on Their Own
“A loosened implant requires surgery to correct,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.
There is just no way around this. The alternative is to live with pain, and the pain from a failed knee replacement will get worse. Your only recourse, unfortunately, is the revision surgery.
However, isn’t there anything that a person can do to take the edge off the pain if they decide not to have the knee revision surgery?
“For patients not willing or able to undergo surgery, a hinged brace and assistive device — cane, crutch, walker — can can help with comfort,” says Dr. Boucher.
Don’t confuse this with pain relief. The pain of a failed total knee replacement can be so significant that walking with these assistive devices will still be painful.
And even prescription painkillers will not be enough to make life bearable for some patients unless they decide to live their life out of a scooter or wheelchair.
In short, there are no non-surgical treatment alternatives for a failed or loosened knee replacement.
Warning Signs that Your Knee Replacement Implants Are Loosened
• Soreness, and especially a severe degree of pain, long after normal postop pain should have disappeared.
• Signs of an infected knee joint: fever, muscle aches, chills.
• Stiffness in the joint or a limited range of motion.
• Swelling or puffiness due to excess fluid in the joint.
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
Does a Marcaine Gel Exist for Failed TKR Pain?
Marcaine injections can do wonders to suppress the pain of a failed or loosened knee replacement.
This begs the question of if a gel form of this drug can also be effective.
Very Fast Pain Relief
If Marcaine is injected into the knee of a person with loosened implants from a failed total knee replacement procedure, the pain will be subdued nearly instantly.
For some patients, this quick result will be enough to enable them to walk surprisingly comfortably — when normally, due to the failed TKR, they’d have difficulty walking due to the pain.
But So Temporary
Unfortunately, the anesthetic effect of Marcaine against the pain of a loosened knee replacement lasts for only several hours.
Obviously, the patient can’t keep getting injections every several hours.
Source of the Pain
A doctor will inject Marcaine into the joint to see if the pain in the knee is originating from there, rather than from elsewhere in the body such as a compressed nerve higher up.
Thus, if it’s suspected that the patient’s TKR has failed or loosened, and is therefore causing aggravation in the joint, the physician may elect to administer an injection of Marcaine to help guide in a diagnosis.
This begs the question:
Why can’t a gel form of marcaine be developed to be applied as needed to manage pain from a loosened TKR?
Is there even a such thing as a gel form of this drug?
“Not that I know of, but there are Lidoderm patches that can be applied 12 hours daily which can give some topical relief,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.
What about a permanent fix to failed TKR pain? Well, unfortunately, the only permanent fix is a knee revision surgery, which takes longer than the original one.
And this is not a guarantee that the problem will be fixed. The revision surgery can also be a fail.
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Freepik.com
Gold Standard for Diagnosing Failed Knee Replacement
There is a gold standard for the identification and diagnosis of a failed or loosened knee replacement.
The hardware can fail due to unknown factors in some cases. In other words, when a failure occurs with a total knee replacement, it’s not necessarily surgeon error at play.
And when the hardware begins loosening up, the patient starts to experience pain in the knee. The pain could be pretty bad, too.
Gold Standard for Diagnosing a Failed Knee Replacement
“The gold standard is serial X-rays and follow-up exam,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.
He continues, “These diagnose the vast majority of loose implants.”
Serial X-rays are valuable for diagnosing a failed knee replacement because they allow doctors to monitor changes over time.
By comparing images taken at different stages, physicians can detect loosening of components, implant shifts, bone loss or signs of infection.
These progressive changes may not be visible in a single image — but become evident with repeated imaging, helping a doctor identify complications early and guide appropriate treatment or surgical revision if needed.
What about a Marcaine injection to diagnose a failed knee replacement surgery?
Marcaine is an anesthetic, and an orthopedic surgeon may inject the bothersome joint for an evaluation.
“The injection is best to determine if the knee is the actual cause of pain,” says Dr. Boucher.
Pain in the joint may actually originate from elsewhere in the body.
The Marcaine injection can rule out referred pain from another location, “but it does not give the exact diagnosis,” says Dr. Boucher.
An arthogram can look for any loosening or instability in the knee joint.
A bone scan may also be used to look for tell-tale signs of a failed knee replacement, but Dr. Boucher adds that a bone scan is not always reliable, and is open to conflicting interpretation by doctors.
While one surgeon sees no problem with the hardware as viewed on the bone scan image…another surgeon may identify a loosening.
Causes of Loosened Knee Replacements
• Friction caused by the joint surfaces wearing away the implant surface.
• Bacterial infection on the metal or plastic pieces.
• The soft tissue that surrounds the knee is not strong enough to support walking or even standing.
• The implants have been incorrectly placed.
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image credit: Rama
Failed Knee Replacement: Can Marcaine INJECTION Diagnose?
Find out how effective a Marcaine injection might be for detecting a loosened knee replacement (failed TKR).
If your doctor suspects that you have a failed total knee replacement (TKR), he might give you an injection of an anesthetic called Marcaine (bupivacaine).
He may even term the procedure as a “Marcaine diagnosis.”
Effectiveness of Marcaine Injection
It sounds too good to be true, that all a doctor need do is inject your knee, wait a bit, and then voila, he can tell if you have a loosened knee implant.
“The gold standard is serial X-rays and follow-up exam,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.
“These diagnose the vast majority of loose implants. The injection is best to determine if the knee is the actual cause of pain (rather than a referred or external source), but it does not give the exact diagnosis.”
In other words, the Marcaine injection will alert the physician that the source of pain originates in the knee, rather than the lower back or hip.
However, just what’s going on in the knee (e.g., failed implants) cannot be determined by the Marcaine injection.
Symptoms of a Failed Knee Replacement
An implant may loosen or fail soon after the operation or years after. The following are suspicious symptoms.
Pain during rest or while simply bending the knee a bit while changing position in a chair.
The pain may be a feeling of soreness or severe, and is suggestive of excess fluid in the knee.
Abnormal gait (walking) pattern. However, a normal gait does not rule out a failed or loosened knee replacement.
The surgical knee feels “hot.”
The knee is swollen, reddish or has a rash.
Stiffness and reduced range of motion (more so than what a knee replacement in and of itself would normally cause).
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Shutterstock/Africa Studio
Elderly Patient’s Knee Revision Surgery’s Biggest Risk?
Find out just how much advanced age plays a role in determining if you’re a poor candidate for knee revision surgery.
Can you be too old for knee revision surgery due to failed implants? Is old age, in and of itself, a contraindication to knee revision surgery?
“Age by itself is not a contraindication,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD. “Risk increases with the number and severity of comorbitities.”
Age Is not the Only Factor in Risk Assessment for an Elderly Patient’s Knee Replacement Surgery
Examples of comorbidities are diabetes and congestive heart failure. These may prove a lot greater in the risk-benefit assessment for the operation for an elderly man or woman.
A 65-year-old with these issues would be a less suitable candidate for knee revision surgery, or even a first-time joint replacement, than a 90-year-old who does not have any other diagnosed health problems.
Another comorbidity that would really get the surgeon’s attention is pre-existing kidney disease.
“Patients need to be evaluated by their primary MD and/or cardiologist for risk assessment,” adds Dr. Boucher. “Elderly patients are often candidates for revision surgery.”
Other comorbidities of greater concern than how old the patient is would be obesity, emphysema and uncontrolled high blood pressure.
If an orthopedic surgeon has reservations about performing a knee revision procedure due to how old you are, it’s probably because he is not knowledgeable of your general health.
Be sure to make sure that the surgeon has every bit of information about your health so that your advanced age isn’t the only thing that the surgeon bases an opinion on.
A patient of very elderly age who still has decent heart pumping function, healthy kidneys, normal blood pressure, no diabetes and no other serious issues would be a suitable candidate for a knee revision surgery.
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
Treating Failed Knee Replacement Surgery: Latest Techniques
Exciting new techniques are available for treating failed or loosened total knee replacements, which can cause pain and mobility issues, reducing quality of life.
A typical TKR surgery takes three hours.
Knee revision surgery is a bit more complicated because the parts must be removed.
It’s not as simple as it may sound, and if you’re in need of knee revision surgery, it’s understandable that you may want to know what the latest advancements are.
Options for Failed Knee Replacements
“Best new advances are special metal augments which allow for bone ingrowth fixation to the implant even in cases with significant bone loss,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.
“Most revision knee systems rely on stems (cemented/uncemented) and surface augments to reconstruct the knee.”
I asked if there was a such thing as resurfacing to repair a failed TKR. Dr. Boucher responds, “No such thing as resurfacing in a revision knee.”
What about partial revisions for failed TKR?
Dr. Boucher explains, “Partial revisions are possible depending on identification of the existing implant and the skills of the surgeon. Some studies show worse outcomes from partial revision, but it is still a viable and effective option depending on the situation.”
How to Tell if Your Knee Replacement Has Loosened
A bone scan is one way to tell, though two doctors viewing the same scan may disagree on whether or not the implant has loosened.
But if you’re having the following symptoms, you should suspect a loosened or failed knee replacement:
• Soreness, and especially severe pain, long after normal postop pain should have gone away.
• Signs of infection: fever, muscle aches, chills.
• Stiffness in the joint or limited range of motion.
• Swelling due to excess fluid in the joint.
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
Top image: Freepik.com
Bone Scans Difference of Opinion Re: Loosened TKR
Unfortunately, there is no one, single test that can definitively detect a failed total knee replacement. Individual doctor interpretation is much involved.
Have you seen your surgeon about the possibility that your total knee replacement has failed, and he said something like, “It might be loose?”
You get a second opinion from another orthopedic surgeon who says they look okay.
BONE SCAN. You get a bone scan. Your surgeon says the bone scan looks normal. The second opinion is that the bone scan shows “there may be some loosening.”
A third doctor feels the knee, asks questions, then says it’s probably old age or possibly compressed nerves in the lower spine radiating pain to the knee.
Adding to the mess is that the X-rays of your knee replacement have gotten differing interpretations.
“Bone scans are not always helpful tests and can be tricky to interpret,” says Henry Boucher, MD, clinical instructor of Adult Reconstruction, Medstar Union Memorial Orthopaedics, Baltimore, MD.
“There is a high false positive rate if the patient is within two years of the surgery.
“The bone scan needs to be correlated with the X-rays and physical exam. The test should be reviewed by the surgeon and not rely solely on the radiologist report.
“Patients who have two differing opinions unfortunately need a tie-breaker, and if all opinions are different they should rely on reputation and gut feel.”
Medicine is not absolute; much of it is, indeed, based on common sense and gut instinct.
Deciding whether or not you have a failed knee replacement can also be aided by ruling out other possible causes (with tests such as an EMG for spinal nerve compression) of your knee pain and other symptoms associated with loosened implants: swelling and warmth about the knee.
Dr. Boucher’s specialties are hip and knee surgery, replacement and revision, and sports medicine surgery. He has been the recipient of the Golden Apple Award for teaching excellence multiple times.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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