Twenty-four hour pH monitoring in the assessment of esophageal function

Ambulatory 24-hour esophageal pH monitoring is an important test in the management of patients with gastroesophageal reflux disease. It quantifies esophageal acid exposure while patients pursue their everyday activities without restrictions. The test is performed with a compact portable data logger, miniature pH electrode, and computerized data analysis. The pH electrode should be positioned 5 cm above the manometrically defined lower esophageal sphincter. The patient is asked to press a button on the data logger indicating the onset of the symptom in question, which allows symptoms and acid reflux correlation. Twenty-four hour pH monitoring is generally performed after a therapeutic trial of antireflux medications, preferably proton pump inhibitors.

Prospective evaluation of esophageal motor dysfunction in Down's syndrome

OBJECTIVE

The aim of this study was to determine the prevalence and way of presentation of esophageal motor dysfunction in a nonselected population of subjects with Down's syndrome.

METHODS

The study was conducted in 58 Down's syndrome patients and 38 healthy controls. A global symptom score and individual scores for dysphagia for liquids and solids, heartburn, vomiting/regurgitation, and chest pain were obtained. Esophageal function was evaluated initially by scintigraphy using liquid and semisolid bolus. Time-activity curves based on the mean condensed images were used to calculate residual activity at 100 s after swallowing. According to both scintigraphy and clinical evaluation results, participants underwent a radiological and manometric study.

RESULTS

The most frequent symptoms in Down's syndrome patients were: dysphagia for liquids (n = 9), dysphagia for solids (n = 10), vomiting/regurgitation (n = 8), and chest pain (n = 2). Liquid and semisolid retention of the tracer was significantly higher in Down's syndrome patients than in controls (p < 0.05). In 15 participants with Down's syndrome, tracer retention was higher than the 95 percentile of controls' retention. No correlation was found between the global or individual symptom score and esophageal retention quantified by scintigraphy. Hypothyroidism was unrelated to esophageal symptoms or retention. Five of the 15 esophagograms performed were abnormal, showing barium retention and/or esophageal dilation. Manometry showed achalasia in two subjects, total body aperistalsis in one, and nonspecific esophageal motor disorder in two.

CONCLUSION

Esophageal motor disorders, particularly achalasia, are frequent in individuals with Down's syndrome. Awareness of esophageal dysmotility in this population is important, even though symptoms are not evident, to avoid potential complications.

Which factors determine the long-term outcome among patients with a very small or unconfirmed AMI

AIM

To describe various factors associated with the very long-term prognosis for patients with a very small or an unconfirmed acute myocardial infarction (AMI).

METHODS

Patients below 76 years of age, hospitalized due to suspected AMI who either developed a very small AMI (enzyme elevation<twice upper normal limit and maximum serum (S) aspartate aminotransferase (S-ASAT)<1.4 ukat/l) or an unconfirmed AMI (a suspected ischemic event with no signs of myocardial necrosis) were evaluated at our out-patient clinic. The 10-year mortality was related to the clinical history, age and sex, metabolic factors, diagnosis at hospital discharge, various psychosocial factors, use of medication, current symptoms, underlying reason to the symptoms, maximal working capacity and other observations at bicycle exercise test including signs of myocardial ischemia.

RESULTS

In all, 714 patients (33% women) with a median age of 63 years were included in the analyses. The following appeared as independent risk indicators for 10-year mortality: S-gammaglutamyl transpeptidase (GT) (P<0.0001), age (P<0.0001), current smoking (P<0.0001), a history of previous AMI (P<0.0001), maximal working capacity at bicycle exercise test (P=0.002), and current treatment with digitalis (borderline significance; P=0.022).

CONCLUSION

Among patients with a suspected acute myocardial ischemic event with no or minimal myocardial necrosis, various factors reflecting their age, history of cardiac disease and smoking, liver function, working capacity and possibly use of medication affected their very long-term prognosis.

Prognostic value of dipyridamole stress echocardiography in hypertensive patients with left ventricular hypertrophy, chest pain and resting electrocardiographic repolarization abnormalities

BACKGROUND

Hypertension is a major cardiovascular risk factor in the development of coronary artery disease (CAD); therefore, evaluating the presence of CAD is a primary clinical goal. However, the noninvasive tests that are commonly used have poor diagnostic specificity, particularly in patients with left ventricular hypertrophy.

OBJECTIVES

To assess the prognostic value of dipyridamole stress echocardiography (DET) for ischemic events in a subset of patients with hypertension with left ventricular hypertrophy, chest pain and resting electrocardiographic repolarization abnormalities.

PATIENTS AND METHODS

Eighty-two patients (48 men and 34 women; average age 65+/-7.2 years with left ventricular hypertrophy documented echocardiographically (left ventricular mass index greater than 50 g/h(2.7)), and resting ST segment shift of 0.1 mV or more from baseline at 80 ms after J point in at least two contiguous leads, were submitted to DET according to high-dosage protocol and coadministered with atropine.

RESULTS

The follow-up period was 25.11+/-8.3 months. The stress test produced positive results in 30 patients (36.5%); 16 (53%) and three (5%) cardiac events occurred in positive and negative stress test groups, respectively. At multivariate analysis, only positive DET response (P=0.000002), left ventricular mass index (P=0.028) and a family history of CAD (P=0.037) were independent predictors. The two-year event-free survival rates were 95% and 47% (log-rank 21.093, P=0.00001) for negative and positive stress test results, respectively.

CONCLUSIONS

DET is a useful tool in the prognostic assessment of coronary events in this particular subgroup of patients with hypertension.

Can myocardial infarction be rapidly identified in emergency department patients who have left bundle-branch block?

STUDY OBJECTIVES

Fibrinolytic therapy is recommended for patients who have chest pain and left bundle-branch block (LBBB). However, the presence of baseline ECG abnormalities makes early accurate identification of acute myocardial infarction (AMI) difficult. The predictive ability of clinical and ECG variables for identifying patients with LBBB and AMI has not been well studied. We sought to determine the prevalence and predictors of myocardial infarction among patients presenting to the emergency department with LBBB on the initial ECG who were evaluated for myocardial infarction.

METHODS

All patients presenting to the ED were prospectively risk stratified on the basis of clinical and historical variables. ECGs from patients with LBBB were compared retrospectively with previously published criteria for identification of AMI. The ability of a new LBBB to predict AMI was also determined.

RESULTS

Twenty-four (13%) of the 182 patients with LBBB had AMI. Clinical and historical variables were similar in patients with and without AMI. A new LBBB had a sensitivity of 42% and a specificity of 65%. The presence of concordant ST-segment elevation or depression had specificities and positive predictive values of 100%; however, sensitivities were only 8% and 17%, respectively. The best diagnostic criterion was the presence of concordant ST-segment elevation or depression on the ECG or an initially elevated creatine kinase MB (sensitivity, 63%; specificity, 99%).

CONCLUSION

ECG criteria for identifying patients with AMI and LBBB identify only a small minority of patients with AMI. Treating all patients with LBBB and chest pain with fibrinolytics would result in treatment of a significant number of patients without AMI.

Eruptive xanthomas and chest pain in the absence of coronary artery disease

Because hyperlipidemia may present as xanthomas, a dermatologist may be the first to diagnose these skin lesions and associated lipid abnormalities. Xanthomas are of concern because of their association with coronary artery disease and pancreatitis. We describe the case of a 40-year-old white male with chest pain and eruptive xanthomas. Laboratory tests revealed severe hypercholesterolemia, hypertriglyceridemia, and diabetes mellitus, and the histopathology of the skin lesions was consistent with eruptive xanthomas. Surprisingly, even with overwhelming risk factors for both atherosclerosis and pancreatitis, this patient did not show evidence of either disease process. After initiating therapy for the diabetes and hyperlipidemia, the patient has had no recurrence of chest pain, and the skin lesions have gradually resolved. The most likely explanation for this patient's pattern of symptoms and laboratory results is the chylomicronemia syndrome, which can be seen in patients with type I or type V hyperlipoproteinemia.

Chest pain in asbestos-exposed individuals with benign pleural and parenchymal disease

Many asbestos-exposed individuals complain of chest pain for which there is no clear explanation. To determine whether chest pain is associated with the presence of benign pleural or parenchymal disease on chest radiograph, we studied 1,280 subjects undergoing surveillance because of prior asbestos exposure at Wittenoom, Western Australia. All subjects completed the Rose questionnaire on chest pain and this revealed 556 subjects (43%) who experienced some chest pain. A posterior-anterior chest radiograph was performed at the same clinic visit and was subsequently graded independently by two experienced readers for diffuse parenchymal disease and pleural disease. Logistic regression models adjusted for sex, age, and cumulative asbestos exposure indicated that the presence of chest pain was significantly associated with the presence of both benign pleural disease and diffuse parenchymal disease. Further analysis after stratification of chest pain into nonanginal and anginal pain showed that there was a significant association between anginal pain and the presence of pleural and parenchymal asbestos-induced radiologic abnormalities and an association of nonanginal pain with parenchymal disease. We conclude that radiographic evidence of either parenchymal or pleural disease in subjects exposed to asbestos is significantly related to the presence of chest pain, particularly anginal pain.

Treatment and outcomes of left bundle-branch block patients with myocardial infarction who present without chest pain. National Registry of Myocardial Infarction 2 Investigators

OBJECTIVES

We sought to determine the importance of chest pain on presentation as a predictor of in-hospital treatment and mortality in myocardial infarction (MI) patients with left bundle-branch block (LBBB).

BACKGROUND

Left bundle-branch block patients have a high mortality after MI but are unlikely to receive reperfusion therapy despite evidence from clinical trials demonstrating the efficacy of thrombolytic therapy. Nearly half of MI patients with LBBB present without chest pain.

METHODS

We studied the clinical features, treatment and in-hospital survival of 29,585 patients with LBBB enrolled in the National Registry of MI 2 June 1994 through March 1998). Multivariate logistic regression was used to assess the independent effect of chest pain on reperfusion decisions and in-hospital mortality.

RESULTS

Left bundle-branch block patients with chest pain were greater than five-fold more likely to receive reperfusion therapy (13.6% vs. 2.6%) than LBBB patients without chest pain; they were also more likely to receive aspirin, beta-adrenergic blocking agents, heparin and nitrates (all p < 0.0001). Unadjusted in-hospital mortality was 18% in patients with chest pain and 27% in patients without chest pain. Adjusting for patient characteristics reduced the odds ratio associated with the absence of chest pain from 1.47 (95% confidence interval: 1.41 to 1.54) to 1.21 (95% confidence interval: 1.12 to 1.30). The remainder of the mortality difference was caused by the undertreatment of patients without chest pain, particularly the low utilization of aspirin and beta-blockers.

CONCLUSIONS

Left bundle-branch block patients with MI who present without chest pain are less likely to receive optimal therapy and are at increased risk of death. Prompt recognition and treatment of this high-risk subgroup should improve survival.

[Occurrence of reflux esophagitis in patients with chest pain and a normal selective coronary angiogram]

BACKGROUND

Chest pains are related to coronary disease, and to several other disorders, among which the most commons are the oesophageal diseases. The aim of the work was the identification of the reflux oesophagitis in patients with chest pain and normal selective coronary angiogram.

METHODS AND RESULTS

In the examined group 65 patients (42 females, 23 males) of the average age 55.2 years were included. All of them underwent endoscopic investigation with biopsy from the terminal part of the oesophagus. Endoscopy picture was evaluated according Savary-Miller classification. Biopsy samples were histologically examined and evaluated according our proper classification of the reflux oesophagitis (1st degree: mild, 2nd degree: medium, 3rd degree: heavy, 4th degree: ulcerous). Endoscopical finding was normal in 59 patients (90.8%), reflux oesophagitis of the 1st degree in 2 patients (3.1%) 2nd degree in one patient (1.5%), 3rd degree in 2 patients (3.1%), 4th degree in one patient (1.5%). Histological changes which can be included into the picture of so called microscopic oesophagitis were found in 49 patients (75.4%). The rest of patients had the histology picture normal.

CONCLUSION

In 75.4% of patients with chest pain and negative selective coronary angiogram histological examination revealed structural changes corresponding with oesophagitis, mostly of the mild type.

Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes

OBJECTIVES

We prospectively evaluated the relation between cardiac troponin T (cTnT) level, the presence and severity of coronary artery disease (CAD) and long-term prognosis in patients with chest pain but no ischemic electrocardiographic (ECG) changes who had short-term observation.

BACKGROUND

Cardiac TnT is a powerful predictor of future myocardial infarction (MI) and death in patients with ECG evidence of an acute coronary syndrome. However, for patients with chest pain with normal ECGs, it has not been determined whether cTnT elevation is predictive of CAD and a poor long-term prognosis.

METHODS

In 414 consecutive patients with no ischemic ECG changes who were triaged to a chest pain unit, cTnT and creatine kinase, MB fraction (CK-MB) were evaluated > or = 10 h after symptom onset. Patients with adverse cardiac events, including death, MI, unstable angina and heart failure were followed for as long as one year.

RESULTS

A positive (>0.1 ng/ml) cTnT test was detected in 37 patients (8.9%). Coronary artery disease was found in 90% of 30 cTnT-positive patients versus 23% of 144 cTnT-negative patients who underwent angiography (p < 0.001), with multivessel disease in 63% versus 13% (p < 0.001). The cTnT-positive patients had a significantly (p < 0.05) higher percent diameter stenosis and a greater frequency of calcified, complex and occlusive lesions. Follow-up was available in 405 patients (98%). By one year, 59 patients (14.6%) had adverse cardiac events. The cumulative adverse event rate was 32.4% in cTnT-positive patients versus 12.8% in cTnT-negative patients (p = 0.001). After adjustment for baseline clinical characteristics, positive cTnT was a stronger predictor of events (chi-square = 23.56, p = 0.0003) than positive CK-MB (>5 ng/ml) (chi-square = 21.08, p = 0.0008). In a model including both biochemical markers, CK-MB added no predictive information as compared with cTnT alone (chi-square = 23.57, p = 0.0006).

CONCLUSIONS

In a group of patients with chest pain anticipated to have a low prevalence of CAD and a good prognosis, cTnT identifies a subgroup with a high prevalence of extensive and complex CAD and increased risk for long-term adverse outcomes.

[Prognosis is often poor in chest pain not interpreted as angina pectoris. Simultaneous occurrence of cardiovascular risk factors increases the risk of premature death]

BACKGROUND

Typical angina pectoris is easy to recognize, but coronary insufficiency may present with nonspecific chest discomfort.

AIMS OF STUDY

We wanted to investigate long-term prognosis in men with different types of chest pain.

METHODS

A random population sample comprising 5,773 men aged 51-57 years at baseline were followed for 16 years.

RESULTS

Mortality due to coronary heart disease was 8.0% among men without chest pain, 19.5% (total mortality 44%) among those with non-specific chest pain, 24.8% (total mortality 45%) among those with typical angina and 48.5% among those with a history of myocardial infarction at baseline.

CONCLUSION

Non-specific chest pain is associated with poor prognosis, and coronary risk factors have strong predictive value.

Smoking among emergency chest pain patients: motivation to quit, risk perception and physician intervention

The feasibility of the emergency department (ED) as a setting for smoking interventions was examined among 159 adult patients presenting with chest pain (38% were smokers). Subjects had been admitted to a 24-h observation unit (OU) to rule out myocardial infarction. We examined the frequency and extent of physician interventions for smoking using the AHCPR guidelines as a model. We also assessed patients' perceptions of risk from smoking and motivation to quit. Results indicate that ED physicians provided incomplete and inconsistent intervention. While most patients were asked if they smoked, only half were advised to quit, and few were offered assistance with quitting. Perceived risk from smoking was low among almost half of all smokers. However, over three-quarters were willing to receive smoking cessation counseling while in the ED. The ED may be an opportune setting in which to initiate smoking cessation counseling for certain high-risk populations.

Extraesophageal gastroesophageal reflux disease. Presentations and approach to treatment

Prevalence of gastroesophageal reflux disease (GERD) is common in the adult US population, but likely is underestimated as many patients present with symptoms other than heartburn or regurgitation. Ears, nose, throat, pulmonary, and cardiac symptoms also frequently are related to GERD. The diagnosis of GERD as a cause of these symptoms can be difficult and treatment strategies are much less clear than in patients presenting with heartburn or regurgitation. This article discusses the epidemiology, pathogenesis, diagnosis, and treatment of some of the manifestations of extraesophageal reflux disease.

Clinical characteristics of diabetic vs nondiabetic patients who "rule-in" for acute myocardial infarction

OBJECTIVE

To compare the clinical characteristics of diabetic vs nondiabetic patients who present to the ED with acute myocardial infarction (AMI).

METHODS

This was a prospective, observational study at a suburban, university hospital ED of patients presenting to the ED during study hours between December 1993 and October 1996 with typical and atypical symptoms consistent with cardiac ischemia. Diabetic and nondiabetic patients with AMI were compared. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Final discharge diagnosis of AMI was assigned by WHO criteria. Continuous variables were analyzed by t-tests. Clinical variables were analyzed by chi-square tests. All tests were two-tailed with alpha preset at 0.05.

RESULTS

There were 216 patients with AMI during the study period; 51 of these patients (24%) were diabetic. For diabetic vs nondiabetic patients with AMI, there was no significant difference in age (64.0 +/- 13 vs 60.0 +/- 14 years, p = 0.13), female gender (37% vs 26%, p = 0.13), and time to presentation from symptom onset (192 +/- 238 vs 251 +/- 456 minutes, p = 0.41). Hypertension was the only cardiac risk factor significantly more prevalent in diabetic vs nondiabetic patients with AMI (77% vs 50%, OR = 1.54, 95% CI = 1.24 to 1.91, p = 0.001), though elevated cholesterol (48% vs 33%, OR = 1.47, 95% CI = 1.02 to 2.12, p = 0.06) tended to be more prevalent in the diabetic group. There was no statistically significant difference between the two groups in terms of the frequency of chest pain (OR = 1.04, 95% CI = 0.95 to 1.14, p = 0.30), associated symptoms, and diagnostic ECGs (OR = 1.16, 95% CI = 0.76 to 1.79, p = 0.53).

CONCLUSION

Diabetic patients with AMI may have similar symptoms upon presentation as do nondiabetic patients with AMI. Of the cardiac risk factors, hypertension is more prevalent in diabetic vs nondiabetic patients with AMI.

Effect of diabetes mellitus on the presentation and triage of patients with acute chest pain without known coronary artery disease

PURPOSE

Patients with diabetes and acute chest pain may be admitted to hospitals more frequently than patients without diabetes because physicians suspect atypical presentations for ischemic heart disease. This study aimed to determine whether the presentation of acute myocardial infarction and risk for major cardiac complications differs among patients without known coronary artery disease who do or do not have diabetes.

PATIENTS AND METHODS

Data from an emergency department of an urban teaching hospital on the medical histories, physical examinations, and electrocardiograms of 2,694 subjects with acute chest pain and without known coronary artery disease were prospectively recorded.

RESULTS

Diabetes was present in 301 (11%) patients. Compared with patients without diabetes, patients with diabetes were more likely to be < or = 60 years old (51% versus 20%) and to have a history of hypertension (70% versus 35%) or high blood cholesterol (35% versus 19%). A discharge diagnosis of acute myocardial infarction was made in 25 diabetic (8%) and in 148 nondiabetic (6%; P = 0.16) patients. A major cardiac complication occurred in two patients with diabetes (0.7%) and in 20 patients without diabetes (0.8%; P = 1.0). Patients with and without diabetes who had atypical chest pain complaints had similar rates of myocardial infarction (3% and 4%, respectively; P = 0.6). Patients with diabetes were more likely to be hospitalized (67% versus 47%; P = 0.001) both before and after adjusting for clinical and electrocardiographic data.

CONCLUSIONS

For patients with acute chest pain without a prior history of coronary artery disease, diabetes was not associated with a higher rate of acute myocardial infarction or complications. However, diabetes was associated with a higher rate of hospitalization in this population, suggesting that physicians have a lower threshold for admission to the hospital of patients with diabetes.

Understanding articles describing clinical prediction tools. Evidence Based Medicine in Critical Care Group

OBJECTIVES

Clinical prediction rules and models are developed by applying statistical techniques to find combinations of predictors that categorize a heterogeneous group of patients into subgroups of risk. Our goal is to teach clinicians how to evaluate the validity, results, and applicability of articles describing clinical prediction tools. CLINICAL EXAMPLE: An article describing a rule to predict the need for intensive care unit care admission in patients presenting to the emergency room with chest pain.

RECOMMENDATIONS

Valid clinical prediction tools are developed by completely following up a representative group of patients, by evaluating all potential predictors and testing the independent contribution of each predictor variable, and by ensuring that the outcomes were independent of the predictors. To evaluate the results of an article describing a clinical prediction tool, clinicians need to know what the prediction tool is, how well it categorizes patients into different levels of risk, and what the confidence intervals are around the risk estimates. Valid prediction tools are not applicable in every patient population. Before patient care application, the clinician should ensure that the tool maintains its prediction power in a new sample of patients, that the patients are similar to patients used to test the tool, and that the tool has been shown to improve clinical decision-making.

CONCLUSIONS

There has been an increase in the development and validation of clinical prediction rules and models. It is important to evaluate the validity and reliability of these prediction tools before application.

Seeking help for chest pain: NIDDM and non-diabetics' responses to three hypothetical scenarios

Seeking medical assistance early during illness is important to decrease the associated morbidity and mortality. A cross sectional survey was carried out to determine how long people with non-insulin dependent diabetes (NIDDM), and a group of non-diabetics would wait before seeking medical advice for chest pain. Self-administered questionnaires were completed by 50 diabetics (22 males, 28 females) age range 42 to 81, mean 64.26 +/- 9.78 from the diabetic outpatient clinic of a major hospital, and 51 non-diabetics, (15 males, 35 females) age range 16 to 84, mean 56.28 +/- 21.6 from a suburban general practice. Both groups were most likely to seek help when experiencing severe pain (56% diabetics, 59% non-DM). Previous heart disease was not a major motivating factor in either group. Subjects with previous chest pain would be more likely to seek help early. Females would be more likely to seek help immediately than males for severe chest pain (p < 0.05). The diabetic group were more likely to seek help immediately than the non-diabetic group (p < 0.05). There was a significant difference in potential help seeking for mild chest pain in diabetic subjects between those with previous history of chest pain and those with no history of chest pain (p < 0.05). There was no significant relationship between help-seeking behaviour and diabetes treatment, duration of diabetes or age (p > 0.05). An important implication for nursing was the absence of a significant relationship between previous diabetes education and potential help-seeking behaviour.

Increased QT dispersion in patients with vasospastic angina

BACKGROUND

The risk factors for ventricular arrhythmias in patients with coronary vasospasm have not been identified. We evaluated QT dispersion in patients with vasospastic angina and its relation to susceptibility to ventricular arrhythmias during myocardial ischemia and reperfusion.

METHODS AND RESULTS

We assessed the corrected QT (QTc) dispersion before induction of coronary artery spasm by intracoronary injection of acetylcholine (baseline) and 30 minutes after administration of isosorbide dinitrate in 50 patients with vasospastic angina and 50 patients with atypical chest pain. The baseline QTc dispersion was significantly greater in patients with vasospastic angina than in patients with atypical chest pain (mean+/-SD: 69+/-24 versus 44+/-19 ms, 95% confidence interval of mean difference [CI]: 16 to 33 ms; P<0.001). QTc dispersion decreased significantly, to 48+/-15 ms (CI: 15 to 26 ms; P<0.001 versus baseline), after administration of isosorbide dinitrate in patients with vasospastic angina but did not change significantly in patients with atypical chest pain (mean+/-SD: 41+/-17 ms, CI: -3 to 9 ms). During the provocation test, 24 of 50 patients with vasospastic angina experienced ventricular arrhythmias. The baseline QTc dispersion was significantly greater in patients with than without ventricular arrhythmias (mean+/-SD: 77+/-23 versus 61+/-19 ms, CI: 4 to 26 ms; P<0.05).

CONCLUSIONS

Patients with vasospastic angina exhibited an increased baseline QTc dispersion compared with patients with atypical chest pain, which suggests that inhomogeneity of repolarization and susceptibility to ventricular arrhythmias are increased in patients with vasospastic angina, even when asymptomatic. The association between increased QTc dispersion and ventricular arrhythmias during the provocation test suggests that measurement of QT dispersion may help predict which patients with vasospastic angina are at high risk for ventricular arrhythmias during ischemia.

Effect of omeprazole in patients with chest pain and normal coronary anatomy: initial experience

Gastroesophageal reflux is frequently found in patients with chest pain despite normal coronary anatomy, but little data on the effect of specific medication exist. After performing 24 h ambulatory pH monitoring and the Bernstein test on 23 patients with normal coronary anatomy, we gave omeprazole, 40 mg nocte, for six weeks to these and to a control group of ten patients with coronary disease. Pain episodes per fortnight fell from 16.2 to 12.0 (P=0.02) in the patients with normal anatomy and from 19.6 to 17.1 (nonsignificant) in the patients with coronary disease. Improvement occurred in seven (30%) of the patients with normal coronary anatomy compared with one (10%) of those with coronary disease, while complete resolution occurred in four (17%) and none, respectively. Improvement or complete resolution were not predicted by the results of 24 h pH monitoring, although there was a trend towards the prediction of efficacy by the Bernstein test. Omeprazole shows promise as a treatment for patients with chest pain despite normal coronary anatomy and larger placebo-controlled trials should now be undertaken.

[The clinical characteristics of panic attacks in adolescents with the cardiac form of the autonomic dystonia syndrome]

Peculiarities of paroxysmal course of autonomic dystonia of cardiac type were studied in 148 juveniles aged 14-15 years. It was found that frequency of panic attacks was very high, i.e. they occurred in 67-92.4% of the cases in dependence on severity of the disease. Panic attacks had no definite clinical picture at the onset. However, as the intensity of the main clinical manifestation of the disease (chest-pain syndrome) increased they acquired clear-cut sympatho-adrenal or vago-insular direction. Short duration and incomplete nels are typical for panic attacks in these patients.

[The effect of ischemic preconditioning on early death in acute Q-wave myocardial infarction]

Ischaemic preconditioning is still a laboratory-based phenomenon, not conclusively documented in patients. In this study it was of interest whether there is any beneficial influence of ischemic preconditioning on 30-day in-hospital mortality in patients undergoing acute Q-wave myocardial infarction. All men and women admitted to our ward between December 1994 and July 1996 with their first acute Q-wave myocardial infarction were divided into two groups. I group--29 patients with prodromal angina, defined as chest pain episodes in the 24-hour period before myocardial infarction. II group--25 patients who showed no chest pain before infarction onset. Both groups did not differ statistically in view of age, sex, smoking habits and adjunctive therapy. The use of streptokinase in the I and II group was also similar--in 58.6% and 56% of patients respectively in the first and second group. In the I group there was no fatal outcome, all 5 death cases occurred in the II group. The results are statistically significant and suggest lower in-hospital mortality in Q-wave myocardial infarction patients with previous ischaemic preconditioning.

[Frequency of precordialgia in chagasic and non-chagasic women]

The aim of this study was to compare the frequency of precordialgia between chagasic and non-chagasic women. A cross-sectional study comprised 647 female aged > or = 40, chagasic (n = 362) and controls (n = 285) was done at a Brazilian university hospital. Chagasic were classified as cardiac (n = 179), megas (n = 58) or indeterminate (n = 125) clinical forms. Chest pain was ascertained by typical or atypical retrosternal pain. Age (57.0 +/- 11.3 vs 57.3 +/- 10.4 years), and percentage of white women (75.8% vs 77.1%) were similar between chagasic and controls, respectively. Chest pain was more prevalent (p < 0.01) among chagasic (14.6%) than controls (5.6%), mainly in the cardiac form (relative risk = 2.41; range: 1.38-4.23), a phenomenon possibly related to cardiac parasympathetic denervation and myocardial microvascular changes.

Dyspnea resulting from fibromyalgia

Two patients with chronic, severe, episodic dyspnea underwent prolonged, extensive, and invasive evaluations without a diagnosis being made. Both were subsequently diagnosed with fibromyalgia, and therapy directed at this condition resulted in resolution of their symptoms. Fibromyalgia is rarely included in the differential diagnosis of dyspnea, and timely diagnosis and treatment may be delayed. However, this condition must be considered because it can only be established by seeking the appropriate history and physical findings.

Improved specificity of transesophageal dobutamine stress echocardiography compared to standard tests for evaluation of coronary artery disease in women presenting with chest pain

The detection of coronary artery disease (CAD) by noninvasive methods has been hindered in women by the high rate of false-positive results. To determine the feasibility and accuracy of transesophageal dobutamine stress echocardiography for identification of CAD in women, we studied 84 patients (age 51 +/- 11 years) who underwent symptom-limited exercise treadmill testing, exercise thallium-201 scintigraphy, and coronary angiography for evaluation of anginal chest pain. Of the 84 patients, 62 had normal coronary arteries or nonsignificant coronary lesions, and 22 had significant stenosis of > or = 1 major coronary artery. During treadmill exercise, repolarization changes were observed in 16 of 21 patients with CAD and in 19 of 60 patients with normal coronary arteries. With thallium scintigraphy, a reversible defect was observed in 19 of 22 patients with CAD and in 12 of 60 patients with normal coronary arteries. Regional wall motion abnormalities during dobutamine infusion developed in 18 of 22 patients with CAD and in none of the 62 patients with normal coronary arteries. All 3 tests had similar sensitivity for detection of CAD (76% for exercise treadmill test, 86% for thallium scintigraphy, and 82% for transesophageal dobutamine stress echocardiography). However, transesophageal dobutamine stress echocardiography had significantly higher specificity than the other 2 tests (100% vs 68% for exercise treadmill test and 80% for thallium scintigraphy; p = 0.0001). Thus, transesophageal dobutamine stress echocardiography is accurate for evaluation of CAD among women presenting with chest pain; its use should be considered when more conventional tests are equivocal or technically suboptimal.

Effects and pharmacokinetics of high dose metoprolol on chest pain in patients with suspected or definite acute myocardial infarction

OBJECTIVE

Pain intensity and the plasma concentrations of metoprolol and its major metabolite alpha-hydroxymetoprolol as well as noradrenaline (NA), adrenaline (A) and neuropeptide Y (NPY) were determined in patients with pain due to definite or suspected acute myocardial infarction (AMI) after graded metoprolol infusion. Pain intensity and metoprolol kinetics were assessed over 8 h.

METHODS

Twenty-seven patients of either sex, aged 48-84 years with ongoing chest pain upon arrival to the Coronary Care Unit (CCU) were subdivided into two groups: (1) patients with ECG signs of threatening transmural myocardial damage (n = 15); and (2) patients without such ECG signs (n = 12). Pain intensity was assessed by a numerical rating scale (NRS) and venous blood was obtained for determination of plasma catecholamine and NPY concentrations. A continuous infusion of metoprolol (3 mg.min-1 i.v) was started and serial blood samples for plasma catecholamines, NPY as well as metoprolol and its major metabolite alpha-hydroxymetoprolol were obtained from the contralateral arm.

RESULTS

Initial pain intensity was 5.9 (arbitrary units) and 5.4 in the groups with and without signs of transmural myocardial damage, respectively. One third of the patients with ST changes reported full pain relief (NRS = 0) within 70 min after starting metoprolol infusion (accumulated dose, 15-180 mg). Among the patients without ST changes upon arrival, full pain relief was obtained in 70% (accumulated dose, 30-120 mg). There was a dose-dependent relation between accumulated metoprolol dose and pain relief. The diagnosis of acute myocardial infarction (AMI) was confirmed in all 15 patients with ECG signs on arrival of transmural myocardial damage. The mean metoprolol dose in this group was 91(12) mg. The mean metoprolol dose in the 12 patients without ST changes was 64(8) mg. In all, seven of these patients developed definite AMI. The terminal half-life of unchanged metoprolol ranged from 2.5 to 8.5 h in group 1 and from 2.2 to 5.2 h in group 2. In group 1, metoprolol half-life was 4.5 h and total plasma clearance (CL) 54.1 1.h-1. In group 2, the metoprolol half-life was 3.7 h and total plasma clearance 75.4 1.h-1. There was a significant difference in clearance between the groups. After the intravenous metoprolol infusion, alpha-hydroxymetoprolol concentrations increased gradually. In groups 1 and 2, maximal concentrations in plasma (Cmax) were 143 and 135 nmol.1(-1) for alpha-hydroxymetoprolol and 2830 and 1653 nmol.1(-1) for metoprolol, respectively. Plasma NA or NPY did not differ between the groups. In contrast, plasma A was significantly higher during the initial 90 min of observation in patients with ECG signs of transmural myocardial damage.

CONCLUSION

High-dose intravenous metoprolol was well tolerated in patients with suspected AMI. There was a more rapid and almost complete pain relief in patients without signs of transmural ischaemia compared with the patients with ECG signs of transmural AMI at arrival. In the later group of patients, plasma clearance of metoprolol was significantly reduced.

Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota

BACKGROUND & AIMS

Gastroesophageal reflux is considered a common condition, but detailed population-based data on reflux in the United States are lacking. The aim of this study was to determine the prevalence and clinical spectrum of gastroesophageal reflux in Olmsted County, Minnesota.

METHODS

A reliable and valid self-report questionnaire was mailed to an age- and sex-stratified random sample of 2200 Olmsted County residents aged 25-74 years.

RESULTS

The prevalence per 100 of heartburn and/or acid regurgitation experienced at least weekly was 19.8 (95% confidence interval [95% CI], 17.7-21.9). Heartburn and acid regurgitation were associated with noncardiac chest pain (odds ratio [OR], 4.2; 95% CI, 2.9-6.0), dysphagia (OR, 4.7; 95% CI, 2.9-7.4), dyspepsia (OR, 3.1; 95% CI, 1.9-5.0), and globus sensation (OR, 1.9; 95% CI, 1.0-3.6) but not with asthma, hoarseness, bronchitis, or a history of pneumonia. Among subjects with reflux symptoms, 1.0% reported an episode of hematemesis and 1.3% had a past esophageal dilatation.

CONCLUSIONS

Symptoms of reflux are common among white men and women who are 25-74 years of age. Heartburn and acid regurgitation are significantly associated with chest pain, dysphagia, dyspepsia, and globus sensation. The percentage of patients reporting complications is low, but the absolute number is probably considerable given the high prevalence of the condition in the community.

Presentations of acute myocardial infarction in men and women

OBJECTIVE

To assess the influence of gender on the likelihood of acute myocardial infarction (AMI) among emergency department (ED) patients with symptoms suggestive of acute cardiac ischemia, and to determine whether any specific presenting signs or symptoms are associated more strongly with AMI in women than in men.

DESIGN

Analysis of cohort data from a prospective clinical trial.

SETTING

Emergency departments of 10 hospitals of varying sizes and types in the United States.

PATIENTS

Patients 30 years of age or older (n = 10,525) who presented to the ED with chest pain or other symptoms suggestive of acute cardiac ischemia.

MEASUREMENTS AND MAIN RESULTS

The prevalence of AMI was determined for men and women, and a multivariable logistic regression model predicting AMI was developed to adjust for patients' demographic and clinical characteristics. AMI was almost twice as common in men as in women (10% vs 6%). Controlling for demographics, presenting signs and symptoms, electrocardiogram features, and hospital, male gender was a significant predictor of AMI (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.4, 2.0). The gender effect was eliminated, however, among patients with ST-segment elevations on electrocardiogram (OR 1.1; 95% CI 0.7, 1.7) and among patients with signs of congestive heart failure (CHF) (OR 1.1; 95% CI 0.8, 1.5). Signs of CHF were associated with AMI among women (OR 1.9; 95% CI 1.4, 2.6) but not men (OR 1.0; 95% CI 0.8, 1.3). Among patients who presented to EDs with chest pain or other symptoms suggestive of acute cardiac ischemia, AMI was more likely in men than in women. Among women with ST-segment elevation or signs of CHF, however, AMI likelihood was similar to that in men with these characteristics.

Predictors of mortality and morbidity following admission with chest pain

This study aimed to identify the predictors of outcome in 102 patients following their first admission with acute chest pain. Outcome was measured at three months by interview and at five years by questionnaire. Chest pain, change in physical activity, return to work, smoking, psychiatric disorder, and mortality were assessed. The principal predictors of chest pain and smoking were previous psychiatric disorder and a diagnosis of non-specific chest pain; a previous history of psychiatric disorder was associated with a five-fold increase in the risk of continued chest pain at five-year follow-up (95% CI = 1.1-25.0). Psychiatric disorder at five years was predicted by psychiatric disorder at admission (adjusted odds ratio (adj OR) = 3.2; 95% CI 1.0-11.0) and non-specific chest pain (adj OR = 7.5; 95% CI = 1.7-32.1). Mortality at five-year follow-up was independently associated with older age (adj OR = 1.1; 95% CI = 1.01-1.2), an elevated Norris score (adj OR = 1.41; 95% CI = 1.01-1.96) and a previous history of psychiatric disorder (adj OR = 5.06; 95% CI = 1.13-22.0). These findings suggest that prediction of outcome, irrespective of underlying diagnosis, requires careful assessment of previous or current psychiatric symptoms in patients admitted with chest pain. Early intervention with psychological treatment for patients with non-specific chest pain should be considered; this may also involve help to reduce smoking. The study provides further evidence that mortality following myocardial infarction is closely linked to psychiatric disorder, but suggests that prior psychiatric disorder may be more important than 'post-infarction' depression. A larger study is needed to confirm these results.

Incidence of cardiac arrest during self-transport for chest pain

STUDY OBJECTIVE

To assess the incidence of cardiac arrest among patients who use self-transport to seek medical care for chest pain.

METHODS

This was a retrospective cohort study of patients admitted to a CCU for suspected acute myocardial infarction (AMI) and patients experiencing out-of-hospital cardiac arrest preceded by symptoms in King County, Washington, between January 1, 1992, and July 31, 1994. Participants were identified through use of the databases compiled by the Myocardial infarction Triage and intervention Trial, which reviewed medical records in all area hospitals, and the Cardiac Arrest Surveillance System, which tracks all incidences in which CPR is performed by EMS personnel in King County. Patients whose sudden cardiac arrests were not preceded by symptoms were excluded. Hospital records were abstracted to find the means of transport for patients admitted to CCUs. For cardiac arrest patients, the medical history, presence of symptoms, means of transport, and prehospital death information were abstracted from paramedic field reports. Outcome (admission, discharge, or in-hospital death) was obtained from hospital records. An event cause (cardiac or other) was determined from death certificates, hospital records, or consultation with private physicians.

RESULTS

During the 30-month study period, 13,187 patients sought help for cardiac symptoms and were either admitted to a CCU or died before admission after calling 911. A majority, 7,393 (59%), were transported by emergency medical services, and 5,182 (41%) used private transportation to obtain medical care; the means of transport could not be determined for 612 patients. Of the EMS group, 6,978 were admitted to the hospital without experiencing prehospital cardiac arrest, and 415 (5.6%) arrested before arriving at the hospital. Of the group using private transportation, 5,164 were admitted without arresting and 18 (.35%) arrested before arrival, after which 911 was called (P < .001).

CONCLUSION

The incidence of cardiac arrest among patients who attempted to reach the hospital by private transportation was very low compared with the incidence among those who chose the EMS system for transport. This suggests that patient self-selection occurs, with the more seriously ill patients more commonly calling 911 for transport.

Gastro-oesophageal reflux in patients with coronary artery disease: how common is it and does it matter?

OBJECTIVE

To investigate the influence of spontaneous gastro-oesophageal reflux (GOR) on symptoms and cardiac ischaemia in patients with coronary artery disease.

DESIGN

Simultaneous 24-h ambulatory oesophageal pH, 7-lead electrocardiographic (ECG) monitoring and symptom diary in patients taking their usual anti-anginal medication.

SETTING

Regional cardiothoracic unit and gastroenterology unit of a teaching hospital.

SUBJECTS

Twenty-four patients (20 males, 4 females, mean age 59 years) with post-myocardial infarction angina and angiographically proven coronary artery disease.

MAIN OUTCOME MEASURES

Quantitation of acid gastro-oesophageal reflux (% total time pH < 4, number of reflux episodes, duration of reflux episodes), identification of ST segment elevation or depression of 1 mm or more on 24-h ECG recording and occurrence of chest pain ("heartburn' or "angina') within 5 min of GOR or ischaemic ST segment shift.

RESULTS

There were 568 episodes of GOR, 28 of which were symptomatic. Abnormal GOR (% total time pH < 4 greater than 7%) occurred in 9 (38%) of the patients; all reflux parameters were increased in nitrate users compared to non-users (P < 0.05). Ischaemic ST-segment shift was seen on 113 occasions. Of a total of 41 chest pain episodes, 20 were related to GOR ("angina' with 8, "heartburn' with 12), while 8 coincided with both GOR and ST depression together ("angina' in 5, "heartburn' in 3). In addition to these eight episodes, coincidence of ST depression with GOR occurred on another nine occasions (all asymptomatic).

CONCLUSION

GOR is common in patients with coronary artery disease and may be increased by drug therapy; GOR may occasionally be associated with myocardial ischaemia, but this is uncommonly symptomatic; GOR-induced pain is sometimes mistaken for angina. These effects were uncommon overall, but frequent in a few individuals and should be considered in the evaluation of patients with persistent chest pain despite seemingly adequate antianginal treatment.

[Echocardiography with dobutamine in hypertensive patients with chest pain]

INTRODUCTION

The exercise stress test shows limited diagnostic accuracy for the detection of coronary artery disease in hypertensive patients. Echocardiography with dobutamine is a useful tool in the assessment of coronary artery disease.

PURPOSE

Our purpose has been to compare dobutamine stress echocardiography and exercise stress test for diagnosing coronary disease in hypertensive patients.

MATERIAL AND METHODS

Dobutamine stress echocardiography (administered up to 40 micrograms/kg/min, and atropine when necessary), exercise stress test and coronary arteriography were performed on 74 hypertensive patients with chest pain and no previous history of coronary artery disease.

RESULTS

Forty-eight (65%) patients underwent a diagnostic exercise stress test and 66 (89%) a diagnostic dobutamine stress echocardiography. Coronary artery disease (> or = 70% stenosis in, at least, one major vessel) was demonstrated in 28 (58%) patients who underwent a diagnostic exercise stress test, and in 39 (59%) patients who completed a dobutamine stress echocardiography. Sensitivity for exercise stress test was 82%, and 79% for dobutamine stress echocardiography (p = NS). Specificity was higher for dobutamine stress echocardiography (100% vs 60%; p < 0.005).

CONCLUSIONS

Dobutamine stress echocardiography has high sensitivity and specificity for the detection of coronary artery disease in hypertensive patients. Dobutamine stress echocardiography has higher feasibility and specificity than exercise stress test in this group of patients.

Chest pain during daily life in patients with hypertrophic cardiomyopathy: an ambulatory electrocardiographic study

Patients with hypertrophic cardiomyopathy frequently complain of chest pain during daily activities. ST-segment depression is described in association with sudden death and pacing, but its prevalence during ambulatory electrocardiographic monitoring is unknown. The aim of this study was to determine the relation of ambulatory ST-segment depression to clinical characteristics, risk factors for sudden death and thallium-201 perfusion in patients with hypertrophic cardiomyopathy. Continuous 48 h ambulatory electrocardiographic monitoring was performed in 113 patients (age 38 +/- 14 years) with hypertrophic cardiomyopathy. Ninety-four (83%) recordings were suitable for ST-segment analysis. A total of 109 episodes of ST-segment depression (> or = 1 mm from baseline) were recorded in 25 (27%) patients (mean 4 +/- 5). In patients < or = 30 years of age (but not > 30) there was an association between ST-segment depression and a history of exertional chest pain (seven of 12 vs one of 20; P = 0.001), and dyspnoea NYHA class II/III (seven of 15 vs one of 17; P = 0.008). There was no association between ST-segment depression and risk markers for sudden death, i.e. family history of sudden death, syncope and non-sustained ventricular tachycardia, in any group. Reversible thallium-201 defects occurred in 27 (29%) of the 94 patients with analysed recordings but were not associated with symptoms, risk factors for sudden death or ambulatory ST-segment depression. In young patients with hypertrophic cardiomyopathy, ischaemia-like ST-segment depression is common and is associated with a history of typical angina and dyspnoea. Reversible thallium-201 perfusion defects are associated with neither symptomatic status nor ambulatory ST-segment depression.

Frequency of pulmonary embolism in patients admitted with chest pain and suspicion of acute myocardial infarction but in whom this diagnosis is ruled out

The purpose of this study was to determine the frequency of pulmonary embolism in patients admitted with acute chest pain but without myocardial infarction (non-AMI patients). We examined 175 consecutive non-AMI patients without unstable angina pectoris within the first 48 h of admission. The patients were first examined by perfusion pulmonary scintigraphy. If the scintigraphy was abnormal, it was combined with a 81mKr ventilation scintigraphy. Perfusion scintigraphy was abnormal in 21 patients, and the subsequent combined perfusion/ventilation scintigraphy was used to identify 5 patients (2.5%) who had a high probability for pulmonary embolism, which was not clinically suspected at the time of admission. Three of these 5 patients had a decreased arterial oxygen tension upon admission, and 3 had abnormalities in their electrocardiogram. Pulmonary embolism only occurred in 2.5% of the non-AMI patients. The prognosis of untreated patients, however, it markedly worse as compared with treated patients. We, therefore, suggest that pulmonary scintigraphy be performed in non-AMI patients who have uncharacteristic electrocardiographic changes and/or a low arterial partial oxygen tension when no other abnormality has been found within 24 h of admission.

Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain

BACKGROUND

Patients who come to the emergency department with chest pain are a heterogeneous group. Some have ischemic heart disease that may lead to serious complications, whereas others have minor disorders. We performed a study to identify clinical factors that predict which patients will have complications requiring intensive care.

METHODS

We first studied 10,682 patients with acute chest pain at seven hospitals between 1984 and 1986 (derivation set) to identify potential clinical predictors of the development of major complications. We then validated these predictors in a separate set of 4676 patients at one hospital between 1990 and 1994 (validation set).

RESULTS

In the derivation set of patients, we identified the following set of clinical features, which, if present in the emergency department, were associated with an increased risk of complications: ST-segment elevation or Q waves on the electrocardiogram thought to indicate acute myocardial infarction, other electrocardiographic changes indicating myocardial ischemia, low systolic blood pressure, pulmonary rales above the bases, or an exacerbation of known ischemic heart disease. On the basis of these criteria, the patients in the validation set were stratified into four groups, with the risk of major complications in the first 12 hours ranging from 0.15 to 8 percent. After 12 hours, the probability of a major complication could be updated on the basis of whether the patient had already had a complication of major severity, a complication of intermediate severity, or a myocardial infarction (independent relative risks, 18.9, 7.7 and 4.0, respectively, as compared with patients without prior complications or myocardial infarction).

CONCLUSIONS

The risk of major complications in patients with acute chest pain can be estimated on the basis of the clinical presentation and new clinical observations made during the hospital course. These estimates of risk help in making rational decisions about the appropriate level of medical care for patients with acute chest pain.

[Clinical diagnostic problems of the female coronary heart disease evaluated by coronary artery angiography]

The clinical data of 100 female cases with suspected coronary heart disease (CHD) undergoing coronary artery angiography (CAA) were analysed. CHD was defined as an estimated diameter stenosis of 75% and more in the main coronary arteries or coronary stenosis of 50%-75% with evidence of cardiac ischemia. Forty-eight case were confirmed as having CHD by CAA. The remaining 52 cases were confirmed as non-CHD and served as the control group, including 49 cases with normal coronary arteries and 3 cases with stenosis of less than 50% in the right coronary artery or left anterior descending artery. The risk factors of CHD and clinical characteristics of chest pain were compared for the two groups. The data demonstrated that menopause was a special risk factor for females and the incidence of CHD was increasing with aging after menopause. However, the clinical characteristics of chest pain in female CHD were usually atypical. When chest pain, whether clinically typical or atypical, were present after menopause and accompanied by evident risk factors, the probability of CHD would be high. If there was only chest pain without any risk factor after menopause, the diagnosis of CHD would be less likely.

Variance cardiography for emergency department evaluation of chest pain patients

OBJECTIVE

To determine the test performance of 24-lead variance cardiography (VC), an ECG technique that measures QRS morphologic variability, for ED evaluation of chest pain associated with coronary artery disease (CAD).

METHODS

A prospective, single-blind study of VC was performed in a community teaching hospital ED. All chest pain patients (> 30 years of age) who, after initial emergency physician evaluation, were believed to have pain of potential cardiac etiology and were admitted to the hospital were eligible. Exclusion criteria included obvious noncardiac etiology for discomfort, bundle-branch block, atrial fibrillation, and incomplete subsequent cardiac evaluation. After initial evaluation and stabilization, VC was obtained. The numerical output of VC was a CAD index (CADI). Serum myoglobin and creatine kinase (CK)-MB levels were obtained at the time of presentation and after one, two, and six hours. Hospital records were reviewed to determine final diagnosis and in-hospital evaluation results.

RESULTS

Fifty-two of 75 eligible patients had complete data. Final diagnoses were as follows: 27/52 (52%), noncardiac; 13/52 (25%), acute myocardial infarction (AMI); and 12/52 (23%), unstable angina due to CAD. Twenty-three percent (12/52) of the patients had CADIs < 75. Eleven of these were found to have noncardiac origins for their chest pain. The twelfth patient had a 12-lead ECG revealing AMI and had been given thrombolytic therapy with subsequent reperfusion prior to VC. Using a CADI < 75 as the cutoff for a negative study, VC alone had a negative predictive value of 92%, a sensitivity of 96%, a positive predictive value of 60%, and a specificity of 41%.

CONCLUSION

A CADI < 75, in addition to clinical impression and initial ECG, may identify chest pain patients who do not have significant CAD. Further prospective assessment of VC is warranted.

Distress correlates with the degree of chest pain: a description of patients awaiting revascularisation

AIM

To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain.

DESIGN

All patients were sent a postal questionnaire for symptom evaluation.

SUBJECTS

All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904).

RESULTS

88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P < 0.001), as were sleep disturbances (P < 0.001), and dyspnoea and various psychosomatic symptoms (P < 0.001). Nevertheless only 44% of the patients reported chest pain as the major disruptive symptom, whereas the remaining 56% reported uncertainty about the future, fear, or unspecified symptoms as being the most disturbing.

CONCLUSIONS

In a consecutive series of patients on the waiting list for possible coronary revascularisation, half the participants reported that uncertainty and fear were more disturbing than chest pain.

Serial electrocardiograms for chest pain patients with initial nondiagnostic electrocardiograms: implications for thrombolytic therapy

OBJECTIVES

To determine the proportion of acute myocardial infarction (AMI) patients without ST-segment elevation who subsequently develop ST-segment elevation during their hospital courses; and to compare demographics and presenting features of AMI patient subgroups: those with initial ST-segment elevation, those with in-hospital ST-segment elevation, and those with no ST-segment elevation.

METHODS

A retrospective cohort analysis of admitted chest pain patients who had a hospital discharge diagnosis of AMI was performed. Each chart was examined for initial ECG interpretation, serial ECG analysis, patient age, gender, cardiac risk factors, in-hospital survival, time between sequential ECGs, and number of ECGs performed within the first 48 hours of hospital admission.

RESULTS

Of the 114 charts reviewed, 20 patients had ECGs meeting thrombolytic criteria on arrival. Of the 94 AMI patients who had nondiagnostic ECGs on arrival, 19 (20%) subsequently developed ECG changes meeting thrombolytic criteria. Seven patients developed these changes within eight hours of the initial ECG, four from eight to 12 hours after, two from 12 to 24 hours after, and six more than 24 hours after. Most patients who had documented AMIs did not develop ECG criteria for thrombolytic therapy during their hospitalizations. Male gender and smoking history were more commonly associated with late ST-segment elevation for those presenting with nondiagnostic ECGs. All the patients who had late diagnostic ECG changes survived to hospital discharge. Serial ECGs were performed more frequently in the group who had initially diagnostic ECGs and least frequently in the group who did not develop ST-segment elevation during their hospitalizations.

CONCLUSIONS

Most patients with AMI do not meet ECG criteria for the administration of thrombolytic therapy. A significant minority (20%) of the admitted chest pain patients with subsequently confirmed AMIs developed ECG criteria for thrombolytics during their hospitalizations. Further attention to such patients who have delayed ST-segment elevation is warranted. A standardized in-hospital serial ECG protocol should be considered to identify admitted patients who develop criteria for thrombolytic or other coronary revascularization therapy.

Hemodialysis immediately after acute myocardial infarction

Acute myocardial infarction (AMI) is common in patients who have end-stage renal disease. However, the prudent interval after AMI until resuming hemodialysis is unknown. Also incidence and severity of intradialytic morbid events during the initial dialysis treatment after AMI have not been determined. We conducted a retrospective analysis of the course of hemodialyses performed immediately after AMI in 13 maintenance hemodialysis patients (group 1) hospitalized with AMI over the 5-year period 1988-1992. For comparison, the incidence of intradialytic morbid events (hypotension--systolic blood pressure < 90 or diastolic blood pressure < 60 mm Hg or a fall in systolic or diastolic blood pressure of > 30 mm Hg--with and without symptoms, arrhythmias, and unplanned termination of hemodialysis was extracted from the charts of 9 maintenance hemodialysis patients (group 2) admitted during the same period with angina but no AMI, and in 13 stable ambulatory hemodialysis patients (group 3) dialyzed during the same period who had no evidence of heart disease. Patients in groups 1 and 2 were sorted by time interval from onset of chest pain to initiation of hemodialysis (< 12, 12-24, and > 24 h). In group 1, we examined the relationship of anatomic location of AMI, number of antihypertensive medications, predialysis left ventricular systolic ejection fraction, and various other clinical and laboratory parameters to the incidence intradialytic morbid events. The mean (+/- SD) age of the study subjects was 67 +/- 7.5 years in group 1, 57 +/- 3.7 in group 2, and 60 +/- 11 years in group 3 (p = 0.6). Arrhythmias and early termination of dialysis did not occur in any patient. Intradialytic hypotension (IDH) was recorded in 5 (38%) of 13 patients in group 1, in 3 (33%) of 9 in group 2, and in 2 (15%) of 13 patients in group 3 (p = 0.47). 4 (80%) of 5 patients in group 1 had multiple episodes of IDH. There were 0.92 +/- 1.4 episodes of IDH per patient in group 1 as compared with a rate of 0.44 +/- 0.68 per patient in group 2, and of 0.15 +/- 0.36 per patient in group 3 (p = 0.2). IDH responded to 0.9% normal saline replacement in all cases. Group 1 patients who had IDH (n = 5) were older (68 +/- 3 vs. 58 +/- 7 years, p = 0.01), had a lower diastolic blood pressure at the start of hemodialysis (59 +/- 13 vs. 83 +/- 13 mm Hg; p = 0.01), had a lower post-AMI left ventricular systolic ejection fraction (42 +/- 19 vs. 62 +/- 10%; p = 0.04), and also had a lower predialysis serum albumin level (3.6 +/- 0.4 vs. 4.1 +/- 0.4 g/dl; p = 0.09) than those who did not have IDH (n = 8). All 5 group 1 patients who had IDH (100%) had had prior AMI as compared with 2 (25%) of 8 of those who did not have IDH (p = 0.02). AMI involved the inferior myocardial wall in more (4 of 5; 80%) of the group 1 patients who had IDH as compared with those who did not have IDH (2 of 8; 25%; odds ratio = 9.5; p = 0.08; 95% confidence interval = 0.7-341.0). In group 1 patients, the time from onset of chest pain to hemodialysis did not affect the risk of IDH (p = 0.4). We conclude that a low diastolic blood pressure at onset of hemodialysis prior myocardial infarction, inferior myocardial wall involvement, advanced age, and a low predialysis serum albumin level are risk factors for the development of hypotension during the first hemodialysis session after AMI.

Relationship of migraine headaches to experience of chest pain and subsequent risk for myocardial infarction

This study examined the relationship between migraine, chest pain, and risk of myocardial infarction (MI) in a retrospective cohort of 79,588 enrollees in the northern California Kaiser Permanente Medical Care Program who underwent comprehensive, multiphasic preventive medicine examinations in 1971 to 1973. Migraine was ascertained by questionnaire as either symptom-based or self-report of physician diagnosis. Chest pain was ascertained by two questions regarding feelings of pain, pressure, or tightness in the chest that either hurt in the middle under the breastbone or forced the respondent to stop walking. Follow-up began at the time of each participant's medical examination and continued until the earliest occurrence of hospitalization for MI, death, termination of enrollment, or December 1987. There was a strong relationship between migraine and chest pain, but, in general, no significant association was found between migraine and risk of MI except among women with a family history of MI in whom a self-reported physician diagnosis of migraine was related to a greater than two-fold increase in risk.