Oesophageal spasm and angina: diagnostic value of ergometrine (ergonovine) provocation

How often does the gut cause anginal pain?

Gastrointestinal disease imitates angina quite commonly and the oesophagus is usually responsible, both in patients presenting as emergencies and also in those who have been extensively investigated for apparent angina. A questionnaire study of 22 patients with oesophageal spasm and 15 patients with coronary artery disease failed to show any feature that discriminates reliably between these groups.

Prinzmetal's variant angina)(PVA). Circadian variation in response to hyperventilation

The study reports on the outcome of hyperventilation tests in a 57-year-old male with Prinzmetal's variant angina, formerly often complicated by ventricular fibrillation. It was found that hyperventilation for a period of 6 min after a delay of 4 to 6 min was followed by the development of ST-elevation and pain, but only when the test was performed in the morning, whereas the outcome of tests performed later in the day were negative. Pretreatment with calcium blockers, nifedipine or verapamil proved effective in preventing the anginal response to the test, also when it was performed in the morning. It is concluded that hyperventilation performed in the early morning, but not later in the day, may prove to be an effective and safe procedure for provoking Prinzmetal's variant angina, and that hyperventilation may be useful in the evaluation of the efficacy of drug therapy.

Diagnosis and prognosis of chest pain with normal coronary arteriograms

Ninety-eight patients previously investigated for suspected angina but shown to have normal coronary arteriograms were reviewed. The prognosis for like expectancy was excellent but 76% were still symptomatic after average follow up of three years. 41% of those re-evaluated were still thought to be describing cardiac-like pain. Full re-investigation showed coronary artery spasm or other causes of myocardial ischemia to be rare whereas oesophageal spasm was a common cause of the pain.

Ergonovine testing in patients with exertional angina

Injection of ergonovine has been suggested as a diagnostic test in patients with suspicion of a vasospastic component in the pathophysiology of angina pectoris. However, a thorough case history has been considered by others to give the same information regarding the anginal mechanism. Therefore a bedside ergonovine test (0.075-0.675 mg i.v.) was performed in 21 consecutive patients with effort angina in order to study the relation between the outcome of the test and the case history concerning angina at rest. A coronary angiography was performed in all cases and showed significant stenoses in 17 patients and normal coronary arteries in 4. Eight patients had angina only during effort, 11 had angina both during effort and at rest and 2 patients had atypical chest pain. Ten of the 11 patients with concomitant rest angina developed chest pain at the ergonovine test and 9 coexisting ECG changes. However, these effects were about as common among the 8 patients without angina at rest: 7 developed chest pain and 4 also ECG changes. The two patients with atypical chest pain had normal coronary angiograms and in these patients ergonovine provoked the same atypical chest pain but no ECG changes. Thus, a concomitant angina at rest is a common finding among patients with severe effort angina. However, the response to ergonovine was as common in the group with only effort angina as in the group with concomitant rest angina, indicating the limited value of this test in patients with severe angina.

Syndrome X--angina and normal coronary angiography

It is clear that angina pectoris with normal coronary arteries is a heterogeneous and ill-defined syndrome that encompasses different pathogenic entities. Differences in patient selection and in definition of 'syndrome X' has made comparison between different study groups rather difficult. Two decades of investigations have not revealed a specific cause of this syndrome. There is now a general belief that syndrome X probably encompasses several pathophysiological disease entities and the mechanisms involved in syndrome X remain to be fully elucidated.

Southwestern Internal Medicine Conference: the syndrome of angina pectoris: role of visceral pain perception

Angina pectoris is a pain syndrome caused by coronary arteriosclerosis but also by a number of other disorders, including microvascular angina, gastroesophageal reflux (GER), and esophageal dysmotility. The relationship between abnormal physiology and pain in these conditions is complex. Simultaneous ambulatory monitoring of esophageal pH and motility has demonstrated that patients may have identical episodes of chest pain with acid reflux, dysmotility, both types of events, or neither. Patients may have anginal chest pain with inflation of an esophageal balloon, and patients with microvascular angina may have pain with catheter manipulation in the right atrium. Recent evidence suggests that disorders of visceral pain perception may play a role in both chest pain of esophageal origin and microvascular angina. The physiology of visceral pain is reviewed, including concepts of convergence of somatic and visceral afferent input, descending modulation of pain perception, and sensitization of visceral pain afferents. An approach to evaluation and treatment of chest pain in patients with angiographically normal coronary arteries is outlined.

Absence of myocardial dysfunction during stress in patients with syndrome X

Stress two-dimensional echocardiographic studies were performed in 18 patients with angina, a positive exercise test and normal findings on coronary angiography (syndrome X). Rest and immediate posttreadmill exercise two-dimensional echocardiograms were performed with a digitized cine loop and side by side visual analysis in all patients. In 16 of these patients, right atrial pacing up to 160 beats/min was also performed and percent systolic wall thickening was calculated at five equally spaced segments around the left ventricle, each corresponding to an anterior, lateral and inferior wall and the posterior and the anterior ventricular septum. Measurements of percent systolic wall thickening were established in 10 age- and gender-matched normal persons for comparison. ST segment depression occurred in all patients during exercise and persisted for 42.1 s (range 18 to 75) into the recovery period. Immediate postexercise echocardiography was started within 20.1 +/- 5.4 s and completed in 54.1 +/- 11.3 s. No patient had regional wall motion abnormalities seen on two-dimensional imaging of any myocardial segment. Thirteen patients (72%) reported reproduction of their usual chest pain, which led to termination of the test. During rapid right atrial pacing, nine patients (56%) developed ST segment depression that was associated with angina in seven. In all 16 patients, percent systolic wall thickening increased over values at rest in each myocardial segment. Percent systolic wall thickening averaged 47.1 +/- 6.1% at rest and increased to 74 +/- 8% during right atrial pacing (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective study on prevalence of esophageal chest pain in patients referred on an elective basis to a cardiac unit for suspected myocardial ischemia

The prevalence of esophageal chest pain was studied prospectively in patients referred on an elective basis to a cardiac unit for suspected myocardial ischemia. A group of 248 consecutive patients without previously documented heart disease was admitted for elective diagnostic coronary angiography. The clinical history classified 185 patients as having anginal pain and the coronary angiogram was normal in 48 of them. In 37 of these 48 patients full esophageal testing was performed including 24-hr intraesophageal pH and pressure recordings with indication of chest pain episodes as well as a number of esophageal provocation tests, ie, acid perfusion, edrophonium stimulation, balloon distension, and ergonovine stimulation, all performed under continuous esophageal manometric and electrocardiographic monitoring. In 19 of these 37 patients, the familiar chest pain could be reproduced by esophageal provocative testing without ischemic ST-T segment alterations; six of these 19 patients had also a positive 24-hr pH and pressure recording. These data strongly suggest an esophageal origin of chest pain in half the patients with typical angina and a normal coronary angiogram.

Oesophageal manometry during eating in the investigation of patients with chest pain or dysphagia

Dysphagia is a frequent cause of referral for oesophageal manometry although the motor response to eating is not routinely studied. We examined symptoms and oesophageal motor patterns in response to eating bread in 30 patients with either gastro-oesophageal reflux (n = 20), or normal oesophageal function tests (n = 10). No patient experienced symptoms while swallowing water but one complained of heartburn and one developed symptomatic oesophageal 'spasm' during eating. In eight further patients, pain or dysphagia which occurred with swallowing bread was associated with aperistalsis. Comparing asymptomatic and symptomatic periods, there was a slight increase in mean swallow frequency from 7.5 (0.79) (SEM) to 9.0 (1.17) swallows per minute (NS; n = 10). The mean number of aperistalsis swallows increased from 4.5 (0.96) per minute to 6.2 (1.30) (p less than 0.01; n = 10). Aperistalsis during symptoms was mainly caused by non-conducted swallows rather than synchronous contractions (mean 5.8 (1.45) per minute compared with 1.2 (0.44]. Aperistalsis can be produced by rapid swallowing in the normal oesophagus through 'deglutitive inhibition'. These results suggest that some patients experience dysphagia associated with aperistalsis perhaps as a response to increased frequency of swallowing. Functional abnormalities of this nature will not be detected by conventional oesophageal manometry.

Continuous recording of coronary sinus oxygen saturation during atrial pacing in patients with coronary artery disease or with syndrome X

Coronary sinus oxygen saturation was measured continuously during incremental atrial pacing in 34 patients undergoing cardiac catheterisation. In eleven patients with normal coronary arteriograms, negative exercise tests, and no ST segment depression on the electrocardiogram, an increase in the rate of atrial pacing transiently decreased coronary sinus oxygen saturation but within 20 s oxygen saturation returned to the control value. In six patients with coronary artery disease ST segment depression developed during atrial pacing. The coronary sinus oxygen saturation fell and remained reduced until pacing was discontinued. The size of the fall of coronary sinus oxygen saturation increased with increasing heart rate. In seven patients with coronary artery disease the ST segments were unaltered during atrial pacing and coronary sinus oxygen saturation did not fall. Ten patients with syndrome X were studied. In six ST segment depression developed on atrial pacing. In five, three of whom developed ST segment depression, the changes in coronary sinus oxygen saturation during atrial pacing were similar to those observed in patients without any evidence of coronary artery disease. In three, all of whom developed ST segment depression, coronary sinus oxygen saturation gradually increased throughout the period of atrial pacing. In two patients coronary sinus oxygen saturation fell in a manner similar to that observed in patients with obstructive coronary artery disease who developed ST segment depression on pacing. Thus regulation of coronary blood flow in normal persons in response to an increase of heart rate is rapid. Oxygen extraction across the coronary bed can increase by up to 30% and a persistent increase in oxygen extraction is an indicator of myocardial ischaemia. The term "syndrome X" does not describe a homogeneous group of patients but in the majority coronary sinus oxygen saturation does not fall despite symptoms and changes on the electrocardiogram, indicating that inadequate coronary blood flow is not the dominant mechanism.

Angina-like chest pain of oesophageal origin

Angina-like chest pain of non-cardiac origin is a major diagnostic and therapeutic problem. The oesophagus is frequently suspected to be the cause of the chest pain in these patients. However, a positive statement for the oesophageal origin of the pain can only be made when during manometry or pH-monitoring the familiar pain attack appears to be accompanied by reflux, severe motor disorders or a combination of both. Due to the intermittent nature of the pain this is only rarely the case during short-listing conventional examinations. Provocation tests have been used to induce the familiar chest pain. The Bernstein acid perfusion test and the edrophonium test yield the best results. Prolonged (24-hour) ambulatory recording of intra-oesophageal pressure and pH to increase the chances of recording chest pain concomitantly with an episode of reflux and/or motor disorders appears to be the most sensitive and also the most physiological test. It is the only test that provides reliable information on the underlying mechanism of the pain, especially in patients with the syndrome of irritable oesophagus, thus contributing in establishing the appropriate therapy for these patients.

[Esophageal angina: detection by esophageal manometry with the methylergometrin maleate test]

The purpose of this study was to assess the value of methylergonovine maleate administration as challenge test for abnormal oesophageal contractions. Manometric exploration of the oesophagus was performed before and after administration of methylergonovine maleate 0.4 mg in 28 patients suffering from retrosternal pain of proven extracardiac origin. Six patients had unexplainably suffered when receiving the drug during coronary arteriography (group A), while 22 had experienced no pain (group B). A group of 7 control subjects were explored at the same time and with the same procedure (group C). Methylergonovine maleate produced painful oesophageal abnormal contractions in 5 of the 6 patients in group A. The 6th patient in this group and 2 patients in group B had abnormal contractions without pain. Another group B patient developed coronary arterial spasm reversed by sublingual nitroglycerin. In the 2 group A patients who received nitroglycerin, the drug rapidly relieved the retrosternal pain and the abnormal contractions induced by methylergonovine maleate. This study demonstrates the value of oesophageal manometry with methylergonovine maleate test in patients with anginal pain but normal coronary arteriography. It also highlights the need for continuous ECG monitoring during the test, even when the patients had responded negatively to methylergonovine maleate during coronary arteriography.

24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain

Sixty patients with anginalike chest pain of noncardiac origin were studied to determine the diagnostic value of 24-h ambulatory esophageal pH and pressure monitoring. The results of these 24-h studies were compared with those obtained by established methods, including x-rays, endoscopy with biopsy, conventional esophageal manometry, and acid perfusion test. Esophageal origin of the chest pain was considered to be likely if the familiar pain sensation was reproduced by the acid perfusion test, or if the pain occurred during an episode of gastroesophageal reflux, severe motor disorders, or both. When the results of established methods were combined and interpreted according to predetermined criteria, esophageal origin of the pain was shown to be likely in 27% of the patients. The 24-h recordings, alone, showed the esophagus to be the likely cause of the pain in 35% of the patients. Combination of all conventional examinations and of 24-h recordings made esophageal origin of the pain likely in 48% of the patients.

Ergonovine-induced esophageal spasm in patients with chest pain resembling angina pectoris

We studied the effect of ergonovine maleate (EM) on esophageal motor activity in 18 consecutive patients with angina-like chest pain. Significant coronary artery disease was excluded in each patient by cardiac catheterization studies. Baseline esophageal motility was abnormal in 12 patients (66%). After injection of EM, ten patients developed their typical chest pain at the onset of repetitive contractions. Thus, chest pain and esophageal dysfunction were clearly linked. Compared with saline injection, only the repetitive contractions were significantly increased after AM in these patients (P less than 0.01). Amplitude and duration of contractions were increased after EM, but not significantly. Due to potentially serious adverse effects, however, EM cannot be recommended for routine use as a provocative agent.

Diagnosis of oesophageal spasm by ergometrine provocation

Oesophageal spasm may mimic the pain of myocardial ischaemia. Forty-two patients who were thought to have angina until investigations failed to show any cardiovascular abnormality, were examined for oesophageal disease. Ergometrine provocation during oesophageal manometry caused significant deterioration in oesophageal motility, associated with familiar pain, in 24 patients. Ten age-matched controls were examined in a similar way and ergometrine produced motility changes in four and pain in two. Six volunteers with coronary artery stenosis and exercise-induced angina did not develop oesophageal motility changes during the pain. Ergometrine provocation is useful in establishing the diagnosis of oesophageal spasm in patients with recurrent angina-like pain but no cardiac abnormality.

Coronary and peripheral arterial responses to ergometrine in patients susceptible to coronary and oesophageal spasm

Vascular responses to ergometrine were compared in groups of patients subject to coronary artery spasm, or oesophageal spasm, or neither. We measured the degree of diffuse narrowing at different coronary artery sites (not in spasm), and the rise in blood pressure. The data provide no evidence for a generalised sensitivity to alpha-adrenergic stimulation underlying either of these two clinical entities. The left main stem was narrowed significantly less than the three main branches of the coronary artery tree. The degree of diffuse coronary artery narrowing was not influenced by the presence or absence of minor (less than or equal to 50%) fixed stenotic lesions, nor by the initial calibre of the arteries. Ergometrine did not alter arterial lactate concentration or lactate extraction in the absence of coronary spasm.