Esophageal motility disorders and their coexistence with pathologic acid reflux in patients with noncardiac chest pain

BACKGROUND

The aim of this study was to determine which motility data of patients with noncardiac chest pain (NCCP) differ from those of controls on the basis of long-term manometry and to evaluate the coexistence of motility disorders and pathologic acid reflux. Further, motility disorders were tested as to whether they were secondary to acid reflux.

METHODS

Combined long-term pH/manometry was performed in 95 patients with NCCP, using one pH-electrode and two pressure transducers. The motility data were compared with those of healthy controls (n = 40). In addition, an intraindividual patient-oriented motility analysis was performed. Evaluated were the amplitude, the duration in the distal and proximal esophagus, and the type of propagation, propulsive and simultaneous, of esophageal contractions. Ten patients with pathologic acid reflux and hypermotility disorders received 20 mg omeprazole twice daily and were investigated again 4 weeks after therapy began.

RESULTS

The median distal pressure amplitude (39.4 versus 28.9 mmHg, p < 0.0001) and the median percentage of simultaneous contractions (18.5% versus 10%; p < 0.0001) were significantly higher in patients with NCCP than in controls. In addition, patients whose symptoms correlated with abnormal motility (n = 18) had a significantly higher median duration of contractions (3.8 sec versus 3.2 sec; p < 0.03) than controls Patients with pathologic acid reflux showed a higher median distal pressure amplitude (38.3 mmHg versus 28.9 mmHg; p < 0.0001) and median percentage of simultaneous contractions (18% versus 10%; p < 0.0001) than controls. Furthermore, a high rate of coexistence with hypermotility disorders was observed (64%). These disorders persisted after acid suppression therapy.

CONCLUSIONS

Patients with NCCP differ from controls in their esophageal motility. Simultaneous contractions of increased amplitude and duration are pathologic. The intraindividual patient-oriented motility analysis is an appropriate evaluation method. Hypermotility disorders occur often in patients with pathologic acid reflux, but apparently they are not dependent on it.

[Syncope and chest pain. Demonstration of the mechanism by the hyperventilation test]

Two patients admitted to hospital because syncope and chest pain are presented. In both patients, hyperventilation test caused severe myocardial ischaemia (ST segment elevation) and sudden development of presyncopal sustained ventricular tachycardia which immediately responded to intravenous nitroglycerin. The relationship between coronary vasospasm and sudden death secondary to polymorphic ventricular tachycardia is discussed. Also, the usefulness of the hyperventilation test to detect this problem and to monitor its therapeutic response is addressed.

Extramedullary plasmacytomas presenting as mediastinal masses: clinicopathologic study of two cases preceding the onset of multiple myeloma

We present two cases of extramedullary plasmacytoma presenting as a mediastinal mass and preceding the onset of full-blown multiple myeloma. The patients are a 62-year-old woman who presented with progressive dyspnea and left-sided chest pain and a 59-year-old asymptomatic man. In both patients, radiographic studies revealed a posterior and anterior mediastinal mass, respectively. Surgical resection of the tumor was performed in the two cases. The tumors were characterized by a well-circumscribed proliferation of plasma cells surrounded by residual lymph nodal tissue. Immunohistochemical studies on paraffin sections demonstrated lambda light chain restriction. Follow-up in our patients revealed that both of them developed multiple myeloma after 6 months and 2 years, respectively. One patient received treatment with melphalan and prednisone and is currently alive and well without evidence of disease, 2 years after diagnosis. The second patient died 4 years after resection of his tumor with evidence of disease in lumbar spine, skull, and lungs. Extramedullary plasmacytoma presenting as a mediastinal mass may precede the onset of full-blown multiple myeloma; therefore, institution of early systemic therapy in these patients may be of value in preventing further progression of the disease.

[Chest pain similar to angina. Identification of patients at risk of developing acute coronary failure]

In order to improve the diagnostic procedure for patients with chest pain suspected of having acute ischemic heart disease we elaborated a mathematical model to predict ischemic risk and then compared its predictive capacity with that of the physician. From September 1989 to December 1992, 564 patients with a chief symptom of chest pain were seen at our Emergency Room (ER). Sixty-two percent of them were male, mean age was 58 +/- 13 years, and none had acute myocardial infarction or unstable angina. Clinical and historical data, serial sampling of enzymes and ECG patterns were collected for 4 hours after admission to the ER. At that point a decision was made to hospitalize or discharge that patient. Follow-up was completed within 2 months. At the end of follow-up, we observed that the physician's assessment resulted in 35% true positive, 55% true negative, 4.7% false positive, and 5.3% false negative judgments for acute ischemic heart disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of information as an intervention to modify clinical management. A time-series trial in patients with acute chest pain

OBJECTIVE

To test whether a low-intensity, nonintrusive intervention improved the efficiency of management of patients with acute chest pain.

DESIGN

Time-series trial with six 14-week cycles, each including a 5-week intervention period and a 5-week control period separated by 2-week "washout" periods.

SETTING

Urban teaching hospital.

PATIENTS

1921 patients aged 30 years or older with acute chest pain unexplained by local trauma or chest radiograph.

INTERVENTION

Risk estimates and triage recommendations were made available to physicians at the time of emergency department evaluation and, for hospitalized patients, on a daily basis before morning rounds. Flowsheets and stickers, but no direct human contact, were used to transmit this information.

MEASUREMENTS

Rates of admission to the hospital and coronary care unit, inpatient costs, and lengths of stay.

RESULTS

Rates of admission during intervention and control periods were similar in both the hospital (52% and 51%, respectively) and the coronary care unit (10% and 10%, respectively). Total lengths of stay in the hospital were similar (4.9 +/- 5.9 days and 4.9 +/- 5.7 days, respectively), as were average total costs ($7822 +/- $13,217 and $7955 +/- $13,400, respectively). No differences in management were detected for the subgroup of patients with low clinical risk for acute myocardial infarction.

CONCLUSIONS

The use of information alone--without direct human contact--did not affect management of patients with acute chest pain at this hospital. Although this low-intensity intervention might be more effective for other conditions and in other settings, our data support the use of other strategies to affect physician decision making.

When time is precious--time lags as indicators of quality of care in acute myocardial infarction

Intravenous thrombolytic therapy is known to reduce mortality in acute myocardial infarction. The effect is highly time dependent and is uncertain 12 hours or more after onset of major symptoms. In order to assess aspects of quality of care for the initial treatment of acute myocardial infarction, pre- and in-hospital time lags were recorded in four Norwegian hospitals for patients admitted to the intensive care unit with acute myocardial infarction and for patients who received thrombolytic therapy for acute ischemic coronary heart disease. Four hundred and forty-six patients were included, of whom 45% (199) received thrombolytic medication, 159 after the initial assessment and 40 after observation and reassessment. All patients receiving thrombolytic therapy had a history of pain, and 94% (187) had significant ECG-changes. Median pre-hospital time was 240 (1. and 3. quartil 120, 519) min for the total sample and 155 (91, 280) min for those who received thrombolytic medication after the primary assessment. Median in-hospital time before thrombolysis was 55 (35, 75) min for the latter group, and 177 (111, 335) for those who were observed and reassessed. We conclude that there is considerable potential for reducing the time lag for initiation of thrombolytic medication in acute myocardial infarction. Audits, written guidelines and standards are necessary to reduce in-hospital time.

Temporal relationships between episodes of non-cardiac chest pain and abnormal oesophageal function

Analysis of the association between symptoms and abnormal oesophageal function is a central part of 24 hour oesophageal pressure and pH recording in patients with non-cardiac chest pain. Such studies have used different time windows including a period after the onset of pain. Since stress and pain can induce oesophageal motor abnormalities and transient lower oesophageal sphincter relaxations, a proportion of the motor abnormalities and the reflux episodes observed after the onset of pain may be a consequence rather than the cause of that pain. This study aimed to assess this possibility in patients with chest pain that was presumed to be of oesophageal origin by comparing the results of analysis using time windows before and after the onset of pain. Forty eight patients experienced a total of 166 spontaneous chest pain episodes during 24 hour ambulatory monitoring. A time window beginning two minutes before and ending at the onset of pain (-2/0) was compared with a window beginning at the onset of pain and ending two minutes afterwards (0/+2). The percentage of episodes related to reflux, abnormal oesophageal motility, or neither were 22.9%, 24.7%, and 52.4% in the -2/0 time window and 9.0%, 22.3%, and 68.7% in the 0/+2 time window, respectively. However, 11 of the 37 episodes associated with abnormal motility in the 0/+2 time window were preceded by a reflux episode, and 19 of these 37 episodes had abnormal motility in the -2/0 time window. Consequently, in only seven of the 166 chest pain episodes (4.2%) in two patients were the findings consistent with secondary oesophageal motor disorders provoked by pain. Likewise, only six of the 166 chest pain episodes (3.6%) were consistent with reflux provoked by pain. These findings indicate that in patients with non-cardiac chest pain, gastro-oesophageal reflux and oesophageal motor abnormalities are rarely a consequence of the pain.

Excellent prognosis of Japanese patients with chest pain and normal or nearly normal coronary arteries--2- to 13-year follow-up of 274 patients after coronary cineangiography

Although the prognosis of patients with chest pain and normal coronary arteries is reportedly good in the Western literature, it is unclear in Japan. The purpose of this study was to examine the natural history of 274 consecutive patients with chest pain and normal or nearly normal coronary arteries, and to determine whether the possibility of minor coronary artery disease has clinical implications as a prodromal factor of other heart diseases. Six of the patients died during the mean observation period of 6 years (74.5 +/- 35.4 months): 2 cancer, 3 cerebro-vascular accident, and 1 renal failure death. Three additional patients suffered from nonfatal cerebro-vascular accidents. Eleven patients were readmitted for evaluation of chest pain, and 4 of these were diagnosed as having vasospastic angina. Progression of significant coronary artery disease was not detected in these 11 patients with repeated coronary angiography. None of the patients in this study developed fatal or nonfatal myocardial infarction. A small number of patients (36/240, 15.0%) continued to suffer from chest pain. None of the patients developed cardiomyopathies or valvular heart diseases. Our observations indicate that the prognosis of chest pain with normal or nearly normal coronary arteries is better than that presented in the Western reports.

Functional gastrointestinal disorders in unselected patients with non-cardiac chest pain

Patients with non-cardiac chest pain (NCCP) (n = 387) and cardiac chest pain (CCP) (n = 93) were compared with community controls (n = 81), using a symptom questionnaire that assessed the presence of irritable bowel syndrome (IBS), functional dyspepsia, and oesophageal dysfunction and chest pain characteristics. A significantly (p < 0.05) increased prevalence of symptoms compatible with IBS occurred in NCCP patients when compared with those with CCP and with controls. Dysphagia was more frequent in both those with non-cardiac and cardiac chest pain than in controls; this was not apparent, however, when patients with concomitant IBS were excluded. The presence of oesophageal or gastrointestinal symptoms did not enable discrimination with regard to the chest pain characteristics. We conclude that unselected referred patients with documented NCCP are more likely to have IBS and that the presence of oesophageal symptoms such as dysphagia may merely reflect the spectrum of the 'irritable gut'.

The covariation of common psychosomatic symptoms among children from socio-economically differing residential areas. An epidemiological study

Psychosomatic symptoms among children are believed to be commonplace. In this investigation by questionnaire, 47% of 1333 schoolchildren reported one or several symptoms, such as recurrent abdominal pain, headache, chest pains, loss of appetite and disturbances in bowel function. Coexistence of such symptoms was considerable and if a child had one of these, the probability that it would have one or more other symptoms was significantly increased. This correlation may strengthen both the suspicion that these symptoms are often psychosomatic and the idea that they have common CNS origin. There were appreciable differences in the frequency of the symptoms, between children at the more socially stable schools and schools with social problems. In the latter, the frequencies of symptoms differed between Swedish and immigrant children, which was not the case in the more socially stable schools.

A population survey of ischaemic heart disease and minor psychiatric disorder in men

Associations between ischaemic heart disease and psychiatric morbidity in hospital recruited samples may be confounded by differential referral of patients with co-morbidity. Associations of angina, past history of myocardial infarction, blood pressure, and electrocardiographic evidence of ischaemia with psychiatric disorder can best be examined in community samples as reported here in 2204 middle-aged men from the Caerphilly Collaborative Study. There was a strong association between past history of myocardial infarction, non-specific chest pain, Angina Grade II and psychiatric disorder measured by the 30-item General Health Questionnaire. Electrocardiographic evidence of ischaemia alone was not significantly associated with psychiatric disorder. It is suggested that non-specific chest pain is a symptom of psychiatric disorder; conversely in severe angina psychiatric disorder is secondary to the pain, restricted activity and threat to life which angina implies.

Increased prevalence of migraine and chest pain in patients with primary Raynaud disease

OBJECTIVE

To investigate the prevalence of headaches and recurrent chest pain in patients with primary Raynaud disease.

DESIGN

Postal survey.

SETTING

Raynaud disease clinic at the Lahey Clinic Medical Center, a tertiary care hospital.

PARTICIPANTS

A consecutive series of 120 patients with primary Raynaud disease who had been observed for at least 2 years, 97 of whom received and 93 of whom completed the questionnaire, and a control group of 93 age- and sex-matched hospital employees without Raynaud phenomenon.

RESULTS

Migraine was diagnosed in 57 (61%) patients with primary Raynaud disease and in 21 (23%) of the control group (odds ratio, 5.4; 95% CI, 2.8 to 10.3). Migraine with aura and migraine without aura were more common in patients with Raynaud disease than in the control subjects (27% compared with 5%; P less than 0.001 and 34% compared with 17%; P = 0.008, respectively). Nonmigrainous headaches were more common in the control group (51% compared with 25%; P = 0.003). Chest pains were reported by 44 (47%) of the patients with Raynaud disease and by 15 (16%) of the control group (odds ratio, 4.4; CI, 2.4 to 9.3). Chest pains were more frequently reported by patients with Raynaud disease who had migraine (34 of 57, 60%) than by patients without migraine (10 of 36, 28%; P = 0.003).

CONCLUSIONS

An increased prevalence of migraine was found in patients with primary Raynaud disease. Chest pain, often diagnosed as musculoskeletal or nonspecific, was common in patients with primary Raynaud phenomenon, especially in patients who had coexisting migraine.

Interdisciplinary treatment of morbidity in benign chest pain

This study tested the hypothesis that functional morbidity in benign chest pain can be modified independently of symptoms through interdisciplinary medical and cognitive-behavioral intervention. Analyses used data collected in a sixteen-week trial of interdisciplinary treatment for disability in benign chest pain. One hundred four chest pain patients having normal coronary arteriograms (NCA) (n = 14) or mitral valve prolapse (MVP) with no other known cardiac or arterial disease (n = 90) were assigned to individual treatment, group treatment, self-monitoring attention control, or a wait-list control group. Results indicate that interdisciplinary intervention, in group or individualized format, was successful for improving short-term and long-term (follow-up range = six to sixteen months) functional status, in both MVP and NCA patients. Correlation analysis indicated that functional improvements were not dependent on reductions in the frequency of symptoms. In fact, significant reductions in disability were obtained in those treated patients (13 of 43) who reported no reduction, or an actual increase, in the frequency of chest symptoms. These data indicate that disability in benign chest pain may be modified independently of symptoms by an integration of medical and cognitive-behavioral strategies.

Access to early cardiac care: chest pain as a risk factor for heart attacks, and the emergence of early cardiac care centers

The tremendous advances in cardiac patient care are not being delivered to the majority of patients because the patients are entering the system too late and are not taking advantage of prodromal symptoms. Chest discomfort must be promoted as a risk factor and emergency room programs developed whereby patients can be checked out and treated early.

Chest pain in generalized anxiety disorder

OBJECTIVES

The objectives of the current study were to evaluate the prevalence of chest pain and related medical utilization in patients with generalized anxiety disorder and to investigate the possible relationship between the occurrence of chest pain in these patients and the episodes of excessive worry which characterize this disorder.

METHOD

The presence of a history of chest pain in patients with generalized anxiety disorder was investigated in an outpatient psychiatric sample using a structured interview which also assessed related medical utilization and the relationship of chest pain to panic attacks and episodes of excessive worry.

RESULTS

Of fifty sequentially evaluated patients meeting DSM-III R criteria for G.A.D., twenty-four (48%) reported a history of chest pain. Seven of these patients also had a history of panic attacks, however, four of the seven reported that their pain occurred independently of their panic attacks. Sixteen patients with G.A.D. reported that their chest pain episodes were associated with episodes of excess worry. Eleven had sought medical evaluation for their pain. Patients with chest pain and normal coronary arteries are frequently found to have panic disorder. The pattern of utilization of medical care was comparable in this sample of patients with G.A.D. and a group of patients with panic disorder recruited in a similar manner.

CONCLUSIONS

These results suggest that in addition to panic disorder, G.A.D. may also be a common diagnosis in chest pain patients with no demonstrable coronary disease. Future studies of coronary artery disease negative patients with chest pain should include assessments for the presence of G.A.D. Our results also suggest that chest pain may be a common symptom in G.A.D. The possibility that chest pain should be included in the diagnostic criteria for this disorder should be the subject of further investigation.

Clinical symptoms in young adults with atypical chest pain attending the emergency department

Clinical symptoms were studied in 69 consecutive patients below the age of 40 years who were attending the emergency unit because of unexplained chest pain. In a structured interview a few weeks after the emergency visit, only one-third of the patients reported that they believed in the doctor's diagnosis; they believed in a psychological or cardiac origin of the pain more often than the doctors. The chest pain was most often described as oppressive and/or stabbing. In 95% of cases it was central or left-sided. Associated symptoms were commonly reported, breathlessness being most commonly reported by two-thirds of the patients, followed by dizziness, palpitation and numbness/tingling. Mental symptoms such as tiredness, anxiety and tension were frequently reported. On the basis of the background literature the aetiology is discussed. We conclude that immediate symptom analysis, including psychosomatic symptoms, particularly breathing problems, is of central importance.

Prehospital prophylactic lidocaine does not favorably affect outcome in patients with chest pain

STUDY OBJECTIVES

The purpose of our study was to determine the morbidity and mortality in initially stable patients presenting to paramedics with chest pain; to examine possible beneficial effects of its use, including reduction of sudden death syndrome in the prehospital and emergency department setting; and to determine if prophylactic lidocaine is associated with adverse effects in this patient population.

DESIGN AND SETTING

This was a randomized, prospective study using prophylactic lidocaine in patients complaining of chest pain who presented to our paramedic system between January 1984 and January 1988.

TYPE OF PARTICIPANTS

All patients aged 18 years or older with chest pain of suspected cardiac origin who presented to paramedics during the study period were included. Excluded were patients presenting with warning arrhythmias, second- or third-degree heart block, bradycardias of less than 50, hypotension of less than 90 mm Hg systolic, or known allergy to lidocaine.

INTERVENTIONS

Patients were randomized into two groups, the lidocaine-treated group and the control group. An initial bolus of 1 mg/kg IV lidocaine was administered to the lidocaine-treated group. A simultaneous 2 mg/min IV drip was established. Ten minutes after the first dose of lidocaine, a second bolus of 0.5 mg/kg was administered.

MEASUREMENTS AND MAIN RESULTS

During the study period, 1,427 patients were entered; 704 received lidocaine, and 723 did not. Discharge diagnoses included acute myocardial infarction (31%), unstable angina (33%), other cardiac problems (7%), and noncardiac problems (29%); overall mortality rate was 7.4%. There was an equal distribution of deaths between the lidocaine-treated group (57) and the control group (48). Six patients had a cardiac arrest in the prehospital setting, and 15 had a cardiac arrest in the ED. Malignant ventricular arrhythmias as the precipitating arrest rhythm in patients with acute myocardial infarctions were similar for the lidocaine-treated and control groups. The incidence of adverse effects, including hypotension, bradycardias, second- or third-degree heart blocks, tinnitus, and altered mental status, was similar in both groups.

CONCLUSION

There are no benefits from the administration of prehospital prophylactic lidocaine in stable patients with chest pain; therefore, routine use in this setting appears unwarranted.

Cardiotoxicity during chemotherapy treatment with 5-fluorouracil and cisplatin

Cardiotoxicity of 5-fluorouracil and cisplatin chemotherapy for esophageal, head and neck and gastric carcinoma was studied. Before treatment all patients had a cardiac evaluation and during treatment serial electrocardiographic (ECG) recordings were performed. In the pre-treatment evaluation signs of cardiovascular disease were found in 31(38.75%) patients. During treatment cardiotoxicity was observed in 12(15%) patients. The incidence of cardiotoxicity was not higher in patients with signs of cardiovascular disease than in those without in the pre-treatment evaluation. The most common signs of cardiotoxicity were chest pain, ST-T wave changes and arrhythmia. This study suggests that patients on 5-fluorouracil and cisplatin treatment should be under close supervision and that the treatment should be discontinued if chest pain and/or arrhythmias are observed.

Sudden death in young Israeli soldiers. Analysis of 83 cases

During the years 1974-86 in the Israel Defense Force (IDF), 83 soldiers aged 17-39 years died suddenly and unexpectedly. Cardiac causes accounted for 56% of the deaths, neurological causes for 19%, other diseases for 8% and in 17% the cause of death was unknown. Causes of death varied between soldiers younger and those older than 30 years of age. Ischemic heart disease accounted for 58% of deaths in soldiers greater than 30 years old but was an infrequent cause of death in subjects less than 30 years (4%). Congenital cardiac anomalies (27%) and myocarditis (15%) accounted for most deaths in subjects less than 30 years of age. Epilepsy was a common cause of sudden death (10%), occurring mainly during sleep, and was related to poor medical control. Effort-related deaths occurred in 25 cases (30%) and were mainly associated with cardiac causes. Syncope (18%) and chest pain (18%) were common symptoms prior to death. According to our data and previous reports, sudden death continues to be an unresolved medical problem in young adults. Preventive measures should include a more thorough evaluation of symptoms such as syncope and chest pain, particularly when occurring during or after exercise. Furthermore, early coronary artery disease should not be disregarded in subjects as young as 30 years of age.

Chest pain in chronic sputum production: a neglected symptom

One hundred and fifteen patients (80 with bronchiectasis and 35 with mucus hypersecretion alone) who produced sputum on a daily basis were asked if they had suffered chest pain unassociated with an acute exacerbation of their chest symptoms during the last six months. Those with bronchiectasis complained of 28 separate pains of which 18 were considered to be of respiratory origin. Seventeen of these 18 pains were in an area associated with a bronchiectatic lobe(s). Only six chest pains (three considered to be of respiratory origin) were found among the 35 patients with mucus hypersecretion.

Factors predictive of panic disorder in cardiology patients with chest pain and no evidence of coronary artery disease: a cross-validation

Recent data indicate that a substantial number of cardiology patients with chest pain and no clinical evidence of coronary artery disease suffer from panic disorder. Discriminant function analysis reveals that a self-report anxiety measure alone, or in conjunction with minimal demographic information, can predict whether such patients have panic disorder. Predictive accuracy ranges from 69 to 76% correct classification, significantly improving upon chance predictions alone. A 'split-half' design was used in order to cross-validate predictive equations, and the total sample was also analyzed so as to provide the most stable equation. Clinical and future research implications of these findings are discussed.

Spontaneous bilateral chylothorax: uniform features of a rare condition

A 67-yr-old woman was admitted with dyspnoea, chest and neck pain and swelling of both supraclavicular fossae and the neck. Chest X-ray showed bilateral pleural effusions. Thoracocentesis yielded a milky fluid with a high triglyceride level. Four previously published cases had similar clinical manifestations. The pathophysiology is discussed.

Behavioral treatment of intractable chest pain in a patient with vigorous achalasia

Chest pain is a major symptom of patients diagnosed with esophageal motility abnormalities. Motility disorders of the esophagus are also associated with elevated scores on measures of somatic anxiety and depression. In spite of this relationship between psychological characteristics and esophageal motility disturbances, few attempts have been made to treat complaints of chest pain in patients with esophageal motility disorders using psychological methods. This report describes the successful use of a behavioral pain management program for the treatment of persistent chest pain in a patient diagnosed with vigorous achalasia who was previously treated with pneumatic dilatation and a long Heller myotomy. This is the first report on the use of psychotherapy in treating chest pain associated with vigorous achalasia, and suggests that, in the etiology and treatment of chest pain in patients with esophageal motility disturbances, psychological influences may be more important than has generally been recognized. No long-term relationship between esophageal motility disturbances and complaints of chest pain was found.

Use of gas-forming agents in esophageal food impactions

Twenty-six patients were treated with a gas-forming mixture of tartaric acid and sodium bicarbonate to relieve esophageal food impactions. A success rate of 65% was achieved, with one patient suffering a mucosal tear of the esophagus. Recommendations are made to limit the use of such gas-forming agents to impactions less than six hours old and in patients without chest pain.

Non-invasive data provide independent prognostic information in patients with chest pain without previous myocardial infarction: findings in male patients who have had cardiac catheterization

From 1978 to 1985, 470 consecutive male patients with complaints of chest pain underwent a maximal exercise test with a thallium scan and coronary angiography (CA). Patients with a history of myocardial infarction (MI) were excluded. During the follow-up (from 12 to 96 months), 32 patients died and 30 had a non-fatal MI. Survival (SR) and event-free rates (EFR) were estimated by actuarial methods; the influence of non-invasive and invasive variables were examined in univariate and multivariate models using Cox analysis. The five-year SR was 89% and EFR was 81%. Among historical data, age (less than 0.001), type of complaints (less than 0.01) and pretest likelihood of CAD (less than 0.01) were univariate predictors of EFR; by multivariate analysis, age was the only significant predictor (less than 0.001). Most of the maximal-exercise (MEX) test data were good univariate predictors; by multivariate analysis, workload (less than 0.001) and the maximal-exercise test score (less than 0.001) were the significant predictors. From history and maximal-exercise test data, multivariate analysis indicated that the prognostic information was given by age (less than 0.05) and maximal-exercise test score (less than 0.001). Among the invasive data, the number of diseased vessels (less than 0.001) and ejection fraction were the predictors. The combination of invasive and non-invasive data indicated that age, MEX score, number of diseased vessels and ejection fraction contributed significantly and independently to the estimation of prognosis. Among 242 patients with two or three diseased vessels, the prognosis was determined by the maximal workload (less than 0.01); ejection fraction (less than 0.07) was no longer significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Alprazolam in the treatment of cardiology patients with atypical chest pain and panic disorder

Ten cardiology chest pain patients without clinical evidence of coronary artery disease and with panic disorder were enrolled in an open label trial of alprazolam. Two dropped out at week 3 because of excessive side effects. The eight study completers showed significant decreases in both Hamilton Anxiety and Hamilton Depression scales by week 2 that remained significant by week 8. On the physician's global impression of change since baseline, all completers were rated at least "much improved." Seven experienced a 50% or greater reduction in panic frequency at week 8 compared to baseline. These results suggest that alprazolam is likely to be of benefit to this patient population.

Mandibular pain as the initial and sole clinical manifestation of coronary insufficiency: report of case

A case of anginal pain limited to the mandible with secondary radiation of the pain to the neck and clavicular regions is presented. Although the pain was initially diagnosed as odontogenic in origin, further historical workup suggested the suspicion of referred pain from coronary insufficiency. Immediate cardiac evaluation confirmed the nature of the pain as angina. Important aspects involved with differential diagnosis of referred anginal pain are also discussed.

[Simultaneous occurrence of left heart block and chest pain during exertion]

Two principal theories have been formulated to explain the simultaneous occurrence of a left bundle branch system block (LBBsB) and a stress-induced chest pain: initial stage of the permanent LBBsB of a primary myocardiopathy, or original clinical expression of coronary insufficiency. In the case presented here, the similarity of symptoms, the improvement observed in ergometric exercise tests under nitroglycerin and the increase of lactate concentrations in the coronary sinus were in favour of the second theory. However, the results of a radionuclide myocardial perfusion study and a radionuclide ventriculography were not sufficiently specific to support this assumption. The lack of free interval between the LBBsB and the angina-like chest pain (neurosensorial reflex) stands against an ischaemic mechanism. The initial intermittent LBBsB phase found in our patient during the exercise test might correspond to this free interval. The favourable prognosis and the uncertain effectiveness of treatment are suggestive of a very early stage in either primary cardiomyopathy or coronary disease.

Major depression in cardiology chest pain patients without coronary artery disease and with panic disorder

104 patients in a cardiology clinic with atypical or non-anginal chest pain were studied through a structured clinical interview. 43 without coronary artery disease fit diagnostic criteria for panic disorder. 19 (44%) of this group reported a lifetime prevalence of major depression, nine (21%) current and ten (23%) past only. Nine reported that their major depressive episodes had preceded the onset of their panic disorder. On many self-report questionnaire scales the group with a lifetime history of major depression (n = 19) differed significantly from the group with no lifetime history of major depression (n = 24). These differences, however, could be attributed primarily to the group with current major depression. There appears to be a subgroup of panic disorder patients who have current major depression who are more symptomatic than those with panic disorder and past major depression and panic disorder alone. These findings also suggest that the association between panic disorder and depression may remain high outside of psychiatric settings.

Chest pain, shock, and pneumomediastinum in a previously healthy 56-year-old man

It is apparent from this discussion that it may be exceedingly difficult to make the diagnosis of Boerhaave's syndrome. The failure to correctly diagnose this patient was due, in part, to the absence of vomiting in the history. Nevertheless, the presence of pneumomediastinum on the initial chest roentgenogram was a significant finding that was missed and would have suggested this diagnosis. This patient is an example of an "atypical" presentation and demonstrates that vomiting need not be a part of the presentation. Because esophageal rupture is a rare clinical entity, a high index of suspicion and careful examination of the chest roentgenogram are mandatory to establish the correct diagnosis.

Acute chest pain without obvious organic cause before age 40--personality and recent life events

Personality and life events were measured in 69 consecutive patients (36 men and 33 women) below age 40 attending the emergency care unit because of chest pain without obvious organic cause (91% participation rate). The results were compared with 32 randomly sampled healthy subjects matched with regard to age and sex (86% participation rate). The patient group had significantly higher scores for "neuroticism', 'Type A behaviour' and 'vital exhaustion'. Further more the patients had experienced significantly more life events, in particular uncontrollable ones, during the last year. We conclude that 'Type A behaviour', 'neuroticism', 'vital exhaustion' and critical recent life events are linked with emergency consultation for chest pain of non-cardiac origin. Possible explanations of the link between the psychological reaction and the chest pain are enhanced tension in the thoracic muscles producing chest pain and oesophageal disorders. This study stresses the importance of careful medical and psychosocial examination of each case of unexplained chest pain at the emergency care unit.

Smoking and cardiac symptoms as predictors of lung cancer

In 1962, a cohort of 4604 Finnish men was interviewed about their smoking habits and cardiorespiratory symptoms. The cohort was followed up for deaths and incidence of lung cancer from 1963 to 1980 in order to study the effect of smoking and cardiac symptoms on the incidence of lung cancer. When analyzed simultaneously with smoking, the symptoms of angina, possible infarction and shortness of breath were all significantly associated with increased lung cancer risk. For example, the RR of lung cancer among those with possible infarction was 2.4, when age and smoking were adjusted for, and 1.8, when additionally shortness of breath and angina-like chest pain were adjusted for. Among smokers of greater than or equal to 15 g/day, those with symptoms of angina displayed a considerable excess risk (RR 2.5). A broad range of impairments of the cardiopulmonary functions seem to be associated with the carcinogenic processes invoked by smoking.

Rate-related left bundle branch block with chest pain and normal coronary arteriograms treated by exercise training

A clinical observation of chest pain associated with the onset of rate-related left bundle branch block has been described in patients with normal coronary arteriograms. The authors used standard cardiac rehabilitation techniques for exercise training in a 47-year-old woman with these manifestations. Serial treadmill tests revealed that during the course of 3 months of exercise training, the heart rate at onset of LBBB gradually rose from 133 to 175 beats per minute, and she no longer developed symptoms during her routine daily activities or exercises. Exercise training was a successful nonpharmacologic strategy that delayed the onset of rate-related LBBB and chest pain in this patient and avoided the need for beta blocker therapy.