Non-cardiac, non-oesophageal chest pain: the relevance of psychological factors

Clinico-Epidemiological Profile of Patients Presenting With Acute Chest Discomfort in Emergency Medicine Department of a Tertiary Care Hospital in Uttarakhand, India: A Prospective Observational Study

Background Acute chest discomfort is a common presenting complaint in the emergency department. There is a paucity of studies related to clinico-epidemiological profile of patients with acute chest discomfort in the emergency department (ED). Hence, we intended to conduct the study to address the dearth of research in this field. Aims and objectives The primary objective of this study was to study the clinico-epidemiological profile of patients with acute chest discomfort presenting to the ED. The secondary objectives were to assess the prevalence of premature acute coronary syndrome (ACS), to study the ED disposition and final hospital discharge diagnosis, and to assess the predictors of 24-hour mortality in such patients. Methods A prospective observational study of patients presenting with acute chest discomfort was conducted in the emergency medicine department of a tertiary care hospital. We included adults above the age of 18 years from December 2021 to December 2022 and excluded trauma patients. A standardized form was used to document patient demographic patterns, comorbidities, chest discomfort description, physical findings, investigations, consultations, ED management, and disposition. Variables having p-value ≤ 0.05 were considered to be significant. Results A total of 200 patients were included. The most common cause of chest discomfort in the ED was cardiac, accounting for 48.5% (n = 97) of patients. The most common cardiac cause of acute chest discomfort was ST-elevation myocardial infarction (STEMI) ~ 21% (n = 42). Cardiac diagnosis was associated with the maximum number of admissions (≈80%; n = 78). The prevalence of premature ACS was 13.9% (n = 10). A 24-hour mortality was significantly associated with male gender, ambulance transport, history of coronary artery disease, and hypoxia and hypotension at the initial presentation. Conclusions ACS followed by respiratory causes are the predominant etiologies of acute chest discomfort in the ED. Knowledge of the differential diagnosis of acute chest discomfort in the ED can aid in prompt diagnosis and delivery of lifesaving treatment to these patients.

Can short-term heart rate variability predict coronary artery disease in patients undergoing elective coronary angiography due to typical chest pain?

BACKGROUND

Presence of typical chest pain and normal coronary angiography suggests the possibility of microvascular ischemia of the myocardium as well as other non-cardiac causes that are also likely to decrease heart rate variability (HRV). This raises a question of whether poor HRV can predict abnormal elective coronary angiography (ECA).

AIM

The aim of this study was to compare HRV in patients with typical chest pain when they are classified according to ECA outcomes.

METHODS

The study enrolled 150 patients planned for ECA in the cardiac center of AlShaab Teaching Hospital, Khartoum, Sudan, due to typical chest pain. Following assessment of medical history and clinical examination, the Bluetooth electrocardiography (ECG) transmitter and receiver were used for ECG recording and evaluation of time and frequency domains HRV. ECA confirmed the diagnosis of coronary artery disease (CAD) in 108 patients, who were considered as the test group. The other 42 subjects were considered as a control group after the exclusion of CAD.

RESULTS

The Mean±SD of Ln(pNN10), Ln(pNN20), LnLF, and LnHF was significantly higher in subjects with normal angiography compared with CAD patients. However, these statistically significant differences disappeared when the comparison was adjusted for age, gender, BMI, and HR of the studied groups.

CONCLUSION

HRV is comparable in patients with typical chest pain regardless of ECA outcomes.

RELEVANCE FOR PATIENTS

The HRV differences between patients with normal and abnormal ECA are likely to be biased by CAD risk factors such as old age, male gender, and tachycardia that are known to disturb HRV. The possibility of microvascular ischemia in patients with normal ECA may have attenuated HRV in this group and make it comparable to those suffering from macrovascular ischemia due to CAD.

Anxiety Level and Cardiac Autonomic Modulations in Coronary Artery Disease and Cardiac Syndrome X Patients

BACKGROUND

Anxiety and cardiac autonomic modulations (CAM) were thoroughly investigated in coronary artery disease (CAD) and cardiac syndrome X (CSX) patients worldwide, but not among Sudanese with similar pathology.

AIMS

To compare levels of anxiety and CAM between Sudanese patients with CSX and CAD.

MATERIALS AND METHODS

Anxiety was evaluated in 51 CAD and 26 CSX patients using Taylor Manifest anxiety score (TMAS) questionnaire while heart rate variability derived indices were used to assess CAM, namely natural logarithm of low frequency (LnLF), high frequency (LnHF) and LF/HF ratio (LnLF/HF).

RESULTS

Low anxiety levels were achieved by 6 (23.1%) and 9 (17.6%) patients with CSX and CAD respectively. High anxiety level was achieved by only one (3.8%) patient, who was suffering from CSX. TMAS was significantly higher in CSX (31.27 (21.97)) compared to CAD (21.86 (12.97), P = 0.021). However, abnormally increased anxiety was not associated with higher risk of CSX. LnLF, LnHF and LnLF/HF were comparable in CAD and CSX patients.

CONCLUSION

CSX and CAD patients showed comparable CAM. Although anxiety levels were higher in CSX compared to CAD, TMAS ≥ 35 failed to show significant association with CSX.

Characteristics and Outcomes of Women Veterans Undergoing Cardiac Catheterization in the Veterans Affairs Healthcare System

Background—

The number of women veterans is increasing, yet little is known about their cardiovascular risk factors, coronary anatomy, cardiac treatments, and outcomes after cardiac catheterization. Prior studies have shown that nonveteran women have more risk factors, receive less aggressive treatment, and have worse outcomes, despite having less obstructive coronary artery disease than men. Whether these differences exist among women veterans in the veterans affairs healthcare system is unknown.

Methods and Results—

Data on 85 936 veterans (3181 women) undergoing initial cardiac catheterization between October 1, 2007, and September 30, 2012, were examined using the national veterans affairs Clinical Assessment Reporting and Tracking (CART) Program. Sex differences in demographics, indications, coronary anatomy, cardiac treatments, and outcomes were analyzed. Women veterans were younger (56.9 versus 63.0 years, P <0.0001) with fewer traditional cardiovascular risk factors, but with more obesity, depression, and posttraumatic stress disorder than men. Women had lower rates of obstructive coronary artery disease than men (22.6% versus 53.3%). Rates of procedural complications were similar in both genders. Adjusted outcomes at 1 year showed women had lower mortality (hazard ratio, 0.74; confidence interval, 0.60–0.92) and less all-cause rehospitalization (hazard ratio, 0.87; confidence interval, 0.82–0.93), but no difference in rates of unplanned percutaneous coronary intervention.

Conclusions—

Women veterans undergoing catheterization are younger, have more obesity, depression, and posttraumatic stress disorder, less obstructive coronary artery disease, and similar long-term outcomes, compared with men. These findings suggest a significant portion of women veterans may have chest pain not attributable to obstructive coronary artery disease. Further research into possible causes, such as endothelial dysfunction or concurrent psychological comorbidities, is needed.

Mental symptoms in patients with cardiac symptoms and normal coronary arteries

Objectives

Patients with chest pain and normal coronary arteries often suffer from physical and psychological symptoms. Therefore, this study aimed to examine the incidence of mental symptoms in patients with angiographic exclusion of a coronary heart disease.

Design

In 253 patients with angiographic exclusion of a coronary heart disease the type and intensity of their symptoms were evaluated before and after coronary angiography. In addition, the incidence of psychopathological symptoms was quantified by standardised questionnaires such as general anxiety and depression (HADS), heart-focused anxiety (CAQ), hypochondria (Whiteley Index) and somatoform disorder (SOMS) and quality of life (SF-12). Finally, the incidence of psychological symptoms in these patients was compared to the incidence in the normal population.

Results

Despite the absence of a coronary artery disease, 70% of patients continue to suffer from cardiac symptoms. The incidence of general anxiety was increased by 37% in women and by 22% in men in comparison to the normal population. Heart-focused anxiety was raised by 27%. Somatoform disorder appeared 120% more often in patients after cardiac catheterisation in comparison to the normal population. In addition, the incidence of hypochondria was elevated by 68% in patients after coronary angiography compared to normal population. This increased appearance of psychological symptoms was reflected in a significantly lower quality of life (SF-12) in patients with inconspicuous coronary angiography.

Conclusions

Patients with cardiac symptoms and normal coronary arteries more often suffer from mental symptoms in comparison to the healthy population.

Symptomatic diffuse esophageal spasm as a major ictal manifestation of post-traumatic epilepsy: a case report

Post-traumatic epilepsy (PTE) can create diagnostic confusion when typical epileptic seizures are not manifest. Abdominal symptoms as a manifestation of PTE are rare in this setting. We present a 43-year-old female with paroxysmal chest and abdominal pain, nausea, salivation, and intermittent dysphagia. Esophageal testing demonstrated diffuse esophageal spasm, but smooth muscle relaxants provided no relief. Finally, after history revealed that a motor vehicle accident temporally preceded symptom onset, video electroencephalography confirmed PTE. Therapy with anti-epileptic drug completely resolved symptoms, and the esophageal motor pattern normalized. We speculate that abnormal epileptiform discharges from the seizure focus altered cerebral input to intrinsic esophageal innervation, resulting in inhibitory dysfunction and a picture resembling diffuse esophageal spasm. This is the first report of symptomatic esophageal spasm as a major ictal manifestation of PTE.

Cognitive-perceptual factors in noncardiac chest pain and cardiac chest pain

OBJECTIVE

Noncardiac chest pain (NCCP) is a common condition associated with considerable patient distress and substantial healthcare costs. Our aim was to investigate associations between illness perceptions, anxiety sensitivity, somatic amplification, and experience of chest pain, and to assess whether a multifactorial model including these factors can distinguish patients with NCCP from patients with cardiac chest pain (CCP).

METHODS

A total of 240 patients with chest pain answered questionnaires concerning anxiety sensitivity (Anxiety Sensitivity Index-3), somatic amplification (Somatosensory Amplification Scale), illness perceptions (Illness Perception Questionnaire-Brief, health concerns, and heart disease conviction), and pain characteristics (intensity, disability, and frequency) before the evaluation of chest pain causation. They were classified as having NCCP or CCP by cardiac angiography. Partial correlation analyses and binary logistic regression analyses were performed.

RESULTS

Seventy percent of patients with chest pain were classified as having NCCP. A range of cognitive-perceptual factors were associated with the experience of chest pain. On multivariate analyses, the only psychological factor found to differentiate NCCP from CCP was elevated somatic amplification (relative risk = 1.06, 95% confidence interval = 1.00-1.13).

CONCLUSIONS

The current DSM-5 proposal with regard to somatic symptom disorder recommends using psychological factors as diagnostic criteria for medically unexplained symptoms while placing less emphasis on the criterion of lack of somatic causation. In this study, an association between pain characteristics and cognitive-perceptual factors was found both for patients with NCCP and for patients with CCP. We found no evidence for a specific profile of psychological characteristics distinguishing patients with NCCP from patients with CCP, except for somatic amplification.

Panic disorder subtypes: deceptive somatic impersonators

Traditional panic attacks are characterized by multiple somatic symptoms involving the cardiac, respiratory, gastrointestinal, and vestibular systems. However, on occasion, panic disorder symptoms may congeal into one predominant system. These atypical presentations, in which symptoms manifest in a single system, are described as panic disorder subtypes. Four subtypes are commonly reported: 1) cardiac, 2) respiratory, 3) gastrointestinal, and 4) vestibular. In this edition of The Interface, we discuss how these subtypes may mimic organic diseases, leading to under-recognition, under-treatment, and over-utilization of healthcare resources.

Negative mood affects brain processing of visceral sensation

BACKGROUND & AIMS

A link between negative emotional state and abnormal visceral sensation has been frequently reported. However, the influence of negative emotion on brain processing of painful visceral sensations has not been investigated. We used functional magnetic resonance imaging (fMRI) and negative emotional stimuli to investigate the effects of negative emotion on brain processing of esophageal sensation.

METHODS

Twelve healthy male volunteers (age range, 21-32 years) participated in the study. Negative emotion was induced using emotionally valent music. fMRI images were acquired during 2 experimental runs; throughout these, volunteers received randomized nonpainful and painful distentions to the esophagus during neutral and negative emotion. Subjective perception of each stimulus was acquired, as were mood ratings.

RESULTS

Sadness ratings increased significantly following negative mood induction (P < .01). There was no significant effect of emotion on subjective perception of painful and nonpainful stimulation (P > .05). Following painful stimulation, brain activity increased in the right hemisphere during negative emotion and was localized to the anterior cingulate cortex (ACC; BA24/32), anterior insula, and inferior frontal gyrus. Following nonpainful stimulation during negative emotion, brain activity increased in the right anterior insula and ACC (BA24 and 32).

CONCLUSIONS

This study provides new information about the influence of negative affect on central processing of visceral pain. Evidence of right hemispheric dominance during negative emotion indicates this hemisphere is predominately associated with sympathetic activity (arousal, negative affect) and that the right insula and right ACC are integral to subjective awareness of emotion through interoception.

Evaluation and management of patients with noncardiac chest pain

Up to a third of patients undergoing coronary angiography for angina-like chest pain are found to have normal coronary arteries and a substantial proportion of these individuals continue to consult and even attend emergency departments. Initially, these patients are usually seen by cardiologists but with accumulating evidence that the pain might have a gastrointestinal origin, it may be more appropriate for them to be cared for by the gastroenterologist once a cardiological cause has been excluded. This review covers the assessment and management of this challenging condition, which includes a combination of education, reassurance, and pharmacotherapy. For the more refractory cases, behavioral treatments, such as cognitive behavioral therapy or hypnotherapy, may have to be considered.

Chest pain and its importance in patients with panic disorder: an updated literature review

CONTEXT

Chest pain is a common symptom in primary care settings, associated with considerable morbidity and health care utilization. Failure to recognize panic disorder as the source of chest pain leads to increased health care costs and inappropriate management.

OBJECTIVE

To identify characteristics of the chest pain associated with the presence of panic disorder, review the consequences and possible mechanisms of chest pain in panic disorder, and discuss the recognition of panic disorder in patients presenting with chest pain.

DATA SOURCES

Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking.

STUDY SELECTION

The diagnosis of panic disorder in eligible studies was based on DSM criteria, and studies must have used objective criteria for coronary artery disease and risk factors. Only case control and cohort studies were included.

DATA SYNTHESIS

Although numerous chest pain characteristics (believed to be both associated and not associated with coronary artery disease) have been reportedly linked to panic disorder, only nonanginal chest pain is consistently associated with panic disorder (relative risk = 2.03, 95% CI = 1.41 to 2.92).

CONCLUSION

Chest pain during panic attacks is associated with increased health care utilization, poor quality of life, and phobic avoidance. Because the chest pain during panic attacks may be due to ischemia, the presence of panic attacks may go unrecognized. Ultimately, the diagnosis of panic disorder must be based on DSM criteria. However, once panic disorder is recognized, clinicians must remain open to the possibility of co-occurring coronary artery disease.

Elderly Women Diagnosed with Nonspecific Chest Pain May Be at Increased Cardiovascular Risk

BACKGROUND

Women are more likely than men to have nonspecific chest pain (NSCP) symptoms. The long-term outcomes in women discharged with a diagnosis of NSCP are unknown.

METHODS

The Women's Health Initiative Observational Study enrolled postmenopausal women aged 50-79 years. After excluding those with prior cardiovascular disease (CVD), 83,622 women were studied. NSCP cases were defined as having an initial primary hospital discharge diagnosis of NSCP (ICD-9 codes 786.50, 786.51, 786.59) without a prior diagnosis of coronary heart disease (CHD). Risks of subsequent CHD events were estimated from Cox proportional hazard ratio (HR) models stratified by clinic and adjusted for baseline age, cardiovascular risk factors, and hormone use.

RESULTS

Over an average of 8 years of follow-up, 11% (230 of 2,092) of women with NSCP experienced a cardiovascular event compared with 9.5% (7,724 of 81,530) who did not. Compared with women without a hospitalization for NSCP during follow-up, those with NSCP had a greater than 2-fold higher risk of a subsequent hospitalization for clinically diagnosed angina (HR 2.18, 95% CI 1.66-2.86) and at least a 1.5-fold higher risk of nonfatal myocardial infarction (MI) (HR 1.59, 1.10-2.31), revascularization (HR 1.67, 1.28-2.20), and congestive heart failure (HR 1.75, 1.27-2.41). Women with NSCP who subsequently experienced a CHD event were more likely to be over age 65 or to have cardiovascular risk factors.

CONCLUSIONS

Older women discharged with a diagnosis of NSCP may be at increased risk of CHD morbidity. Further research is needed to replicate these findings in other populations.

Treatment of non-cardiac chest pain: a controlled trial of hypnotherapy

BACKGROUND

Non-cardiac chest pain (NCCP) is an extremely debilitating condition of uncertain origin which is difficult to treat and consequently has a high psychological morbidity. Hypnotherapy has been shown to be effective in related conditions such as irritable bowel syndrome where its beneficial effects are long lasting.

AIMS

This study aimed to assess the efficacy of hypnotherapy in a selected group of patients with angina-like chest pain in whom coronary angiography was normal and oesophageal reflux was not contributory.

PATIENTS AND METHODS

Twenty eight patients fulfilling the entry criteria were randomised to receive, after a four week baseline period, either 12 sessions of hypnotherapy or supportive therapy plus placebo medication over a 17 week period. The primary outcome measure was global assessment of chest pain improvement. Secondary variables were a change in scores for quality of life, pain severity, pain frequency, anxiety, and depression, as well as any alteration in the use of medication.

RESULTS

Twelve of 15 (80%) hypnotherapy patients compared with three of 13 (23%) controls experienced a global improvement in pain (p = 0.008) which was associated with a significantly greater reduction in pain intensity (p = 0.046) although not frequency. Hypnotherapy also resulted in a significantly greater improvement in overall well being in addition to a reduction in medication usage. There were no differences favouring hypnotherapy with respect to anxiety or depression scores.

CONCLUSION

Hypnotherapy appears to have use in this highly selected group of NCCP patients and warrants further assessment in the broader context of this disorder.

Treatment of noncardiac chest pain of psychological origin

Psychiatric comorbidity is not an uncommon phenomenon in patients with noncardiac chest pain (NCCP). Panic disorder seems to be the most important psychiatric comorbidity for a number of reasons. First, it is the most common psychiatric disorder associated with NCCP. Second, panic disorder is a highly treatable condition that can produce dramatic improvement of NCCP when treatment is appropriate. Finally, the treatment of psychiatric comorbidity, whether panic disorder or other psychiatric disorders, can pay significant dividends in terms of improving the patient's overall well-being and adaptation to illness, even if his/her chest pain symptoms are not alleviated. Adopting a biopsychosocial model to intervene on the stress of these patients' experience is a key concept that can make NCCP a much less formidable challenge for the gastroenterologist.

Outcome of patients with a final diagnosis of chest pain of undetermined origin admitted under the suspicion of acute coronary syndrome: a report from the Rochester Epidemiology Project

STUDY OBJECTIVES

Patients presenting to the emergency department (ED) with chest pain after a recent negative inpatient evaluation for cardiac pathology represent a dilemma for the emergency physician. The purposes of this study were to assess the outcome of patients discharged with a diagnosis of chest pain of undetermined origin and to identify predisposing factors for further cardiac events.

METHODS

The resources of the Rochester Epidemiology Project were used to identify all admitted ED patients with chest pain with suspected acute coronary syndrome who received a discharge diagnosis of chest pain of undetermined origin from 1985 through 1992. Patient records were reviewed for the occurrence of adverse cardiac events and subsequent ED visits for recurrent chest pain within 12 months of discharge. Associations between patient characteristics and an adverse cardiac event were evaluated univariately and summarized by using odds ratios (ORs). Long-term mortality was also determined.

RESULTS

Among 1,973 admitted ED patients with chest pain, 230 were given a diagnosis of chest pain of undetermined origin. Ten (4.4%) of 230 patients experienced an adverse cardiac event. Factors significantly associated with an adverse cardiac event included an abnormal ECG on admission (OR 9.5; 95% confidence interval [CI] 2.0 to 45.8), preexisting diabetes mellitus (OR 7.1; 95% CI 1.8 to 27.2), and preexisting coronary artery disease (OR 28.4; 95% CI 3.5 to 229.0). Thirty-three (14%) patients returned to the ED within 12 months of discharge; 5 patients were given a diagnosis of a cardiac condition, and 5 were given a diagnosis of a gastrointestinal condition. In long-term follow-up, 46 patients died, with a mean time from hospital discharge to death of any cause of 6.1 years and an estimated 5-year survival of 91.4%.

CONCLUSION

Among patients discharged from the hospital with a diagnosis of chest pain of undetermined origin, those with an initial abnormal ECG, preexisting diabetes, or preexisting coronary artery disease are at higher risk of a subsequent adverse cardiac event. In the absence of such factors, cardiac outcome is excellent.

The psychological aspects of noncardiac chest pain

There is some evidence to support a psychosocial link to GERD,although it is a weak one. The little research that has been done in this area is, in general, poor and inconclusive. Better designed studies must be done. The elements that seem to offer the best possibilities for research in GERD are the psychological variables involved in care seeking and the variations between care seekers and non-care seekers. In addition, research on psychosocial predictors of response to proton pump inhibitors, prokinetic agents, and antidepressants and other pain-modulating drugs need to be better understood. The psychosocial link to NCCP is stronger with regard to panic disorder,but much research needs to be done. Despite the paucity of well done,rigorously controlled studies in NCCP patients, that there is a high prevalence of psychiatric disturbance in this group. Parental health and childhood trauma are intriguing areas for further research, particularly in light of the connection between abuse and IBS and other functional GI disorders.Finally, panic disorder has been established as an important comorbidity of NCCP. It also merits more research, particularly into the pathophysiology that may link these two disorders.

Psychological factors influencing results of cholecystectomy

BACKGROUND

Cholecystectomy is a surgical gold-standard procedure for gallbladder diseases, among which gallstones are the most frequent. Despite the introduction of minimally invasive surgery and broad access to ultrasound examination there is a group of patients in whom the surgery ailments persist. Those vague ailments can be perceived from a psychological point of view as somatization or even somatoform disorders.

METHODS

The aim of the study, designed as a case-control study, was to evaluate psychological characteristics that may accompany the incidence of so-called post-cholecystectomy pain syndrome (PCPS). The study focused on 367 patients treated for gallstones in the Dept. of General, Gastroenterological and Endocrinological Surgery, Medical University of Gdańsk, Poland. At about a year after the operation, the patients received a questionnaire that included a structured interview and psychological assessment of social support and rumination. Those who revealed symptoms of PCPS were invited to the department for further medical and psychological evaluations. Psychosocial scores of PCPS and non-PCPS patients were compared.

RESULTS

The PCPS patients did not present any dysfunction at the physical examination or in gastroduodenoscopy or sonography. However, they differed from the remaining. asymptomatic group in terms of lacking social support, as well as increased rumination.

CONCLUSION

It is concluded that psychological variables may play an important role in the onset of subjective symptoms in at least a subgroup of the PCPS patients as a form of somatization. Psychological supportive and explanatory activities (cognitive and behavioural approach) may provide sufficient help.

Non-cardiac chest pain: prevalence, risk factors, impact and consulting--a population-based study

BACKGROUND

Little is known about the prevalence and importance of non-cardiac chest pain in the general population.

AIM

To evaluate the magnitude and impact of this condition.

METHODS

A validated self-report questionnaire was mailed to a sample of 1000 residents of Penrith, selected randomly from the electoral rolls. Symptoms, risk factors, psychological distress, quality of life and demographics were measured.

RESULTS

The response rate was 73% (n = 672; mean age, 46 years; 52% female). Chest pain ever was reported by 39% of the population; 7% reported a history of myocardial infarction and 8% a history of angina. Two hundred and nineteen (33%) cases were classified as non-cardiac chest pain; only 23% had consulted a physician about chest pain in the previous year. The only independent risk factor for non-cardiac chest pain was the frequency of heartburn (odds ratio, 1.74; 95% confidence interval, 1.08-2.79; P = 0.02). None of the gastrointestinal (heartburn, dysphagia, acid regurgitation) or psychological (anxiety, depression, neuroticism) risk factors were significantly associated with consulting for non-cardiac chest pain.

CONCLUSIONS

Non-cardiac chest pain is remarkably common in the general population and negatively impacts on the quality of life. Gastro-oesophageal reflux disease is a key risk factor for non-cardiac chest pain in the community. Health care seeking for non-cardiac chest pain remains unexplained.

Utility of ambulatory 24-hour esophageal pH and motility monitoring in noncardiac chest pain: report of 90 patients and review of the literature

It is unclear whether prolonged motility monitoring improves the diagnostic yield of standard esophageal tests in patients with noncardiac chest pain. Our aim was to assess the diagnostic value of ambulatory 24-hr pH and pressure monitoring in patients with noncardiac chest pain. Stationary manometry, edrophonium testing, and ambulatory pH and motility studies were performed in 90 consecutive patients with recurrent chest pain and normal coronary angiograms. Normality limits of ambulatory 24-hr motility were established in 30 healthy controls. The diagnoses of specific esophageal motility disorders (nutcracker esophagus and diffuse esophageal spasm) by stationary and ambulatory manometry were discordant in 48% of the patients. Edrophonium testing was positive in 9 patients, but correlated poorly with esophageal diagnoses. During ambulatory studies, 144 chest pain events occurred in 42 patients, and 72 (50%) were related to esophageal dysfunction. Strict temporal associations of events with esophageal dysfunction in relation to ambulatory 24-hr pH/motility scores permitted four patient categorizations: true positives (event-related and abnormal tests), N = 15; true negatives (event-unrelated and abnormal tests), N = 10; reduced esophageal pain threshold (event-related and normal tests), N = 4; and indeterminate origin (event-unrelated and normal tests), N = 13. Overall, 19 patients (21%) had a probable esophageal cause for chest pain (14 esophageal motility disorder, 4 acid reflux, 1 both). In conclusion, ambulatory manometry increases the diagnostic yield of standard esophageal testing in noncardiac chest pain, but the gain is small. Causes of chest pain other than high esophageal pressures and acid reflux must still be sought in most patients with chest pain of unknown origin after a negative cardiac work-up.

Symptomatic response to lansoprazole predicts abnormal acid reflux in endoscopy-negative patients with non-cardiac chest pain

AIM

To determine whether symptomatic response to lansoprazole predicts abnormal acid reflux in endoscopy-negative patients with non-cardiac chest pain.

METHODS

Patients who complained of chest pain, but had normal coronary angiography, were asked to undergo upper endoscopy. Those without gastric and oesophageal lesions were recruited for 24-h ambulatory oesophageal pH monitoring, and were randomly given lansoprazole 30 mg or placebo, both daily for 4 weeks. Chest pain symptoms were recorded before and 1 month after treatment on a locally validated questionnaire. The symptom score was calculated by multiplying the severity and frequency of the symptom, and symptom improvement was defined as > 50% reduction in symptom score.

RESULTS

Overall, 68 patients, 36 on lansoprazole and 32 on placebo, completed the trial. The symptom score was reduced significantly in both groups (P < 0.001). In the lansoprazole group, more patients with than without abnormal reflux showed symptom improvement (92% vs. 33%; odds ratio = 22; 95% confidence interval, 2.3-201.8; chi2 = 10.9; P = 0.001), giving a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 92%, 67%, 58%, 94% and 75%, respectively. In the placebo group, the rates of symptom improvement were similar between those with and without abnormal reflux (33% vs. 35%, P = N.S.).

CONCLUSIONS

Treatment with lansoprazole is a useful test in diagnosing endoscopy-negative gastro-oesophageal reflux disease in Chinese patients with non-cardiac chest pain.

Common mental disorder and physical illness in the Renfrew and Paisley (MIDSPAN) study

OBJECTIVE AND METHODS

The relationship between psychological distress measured by the General Health Questionnaire 30 (GHQ-30) and risk factors for coronary heart disease, angina, electrocardiogram (ECG) abnormalities and chronic sputum was modelled using logistic regression on baseline data from a community study of 15,406 men and women.

RESULTS

Psychological distress was associated with low forced expiratory volume (FEV(1)) and low body mass index (BMI) in men, and low systolic blood pressure only in women. There were associations between psychological distress and coronary heart disease and cardiorespiratory outcomes. The associations were particularly strong for angina without ECG abnormalities (Men: OR 3.26, 95% CI 2.52-4.21; Women: OR 2.89, 95% CI 2.35-3.55) and for angina with ECG abnormalities (Men: OR 2.68, 95% CI 2.03-4.52; Women: OR 2.88, 95% CI 1.89-4.39), in both men and women, even after adjusting for classical CHD and cardiorespiratory risk factors. An association between psychological distress and severe chest pain, indicative of previous myocardial infarction, was found in both men and women (Men: OR 1.89, 95% CI 1.44-2.47; Women: OR 1.91, 95% CI 1.48-2.47), respectively, and between psychological distress and ECG ischaemia, but in men only (OR 1.32, 95% CI 1.00-1.76).

CONCLUSION

The association between psychological distress and cardiorespiratory outcomes is likely to be a consequence of the pain and discomfort of the symptoms of the illness. Chest pain may also be a symptom of psychological distress. However, psychological distress, as a predictor and possible risk factor increasing the risk of coronary heart disease, cannot be ruled out.

Chest pain in the emergency department: the broad spectrum of causes

We performed a prospective study to describe the broad spectrum of causes of chest pain in patients presenting to the emergency department and to compare the diagnoses in referred patients, self-referred patients and patients rushed in by ambulance. The final diagnosis in a consecutive case series of 578 chest pain patients was established after discharge from the hospital. The underlying disorders were grouped into cardiac, respiratory, gastro-oesophageal disorders, musculoskeletal pathology, somatization disorders, other diseases and unknown. For comparison of the frequencies of the disease categories the Chi-squared test was used. Out of 578 patients, 161 (27.9%) were self-referred, 369 (63.8%) were referred by the general practitioner and 48 (8.3%) were rushed in by ambulance. Cardiac diseases represented 51.7% of the cases, myocardial infarction and unstable angina 19% and 12.8% respectively Cardiac diseases were statistically significantly less common in self-referred patients (p<0.0005). Pulmonary diseases encompassed 14.2% of the population, followed by somatization disorders (9.2%), musculoskeletal pathology (7.1%) and other causes (4.3%). In 11.1% of the cases no definite final diagnosis could be established. Somatization disorders were significantly more frequent in self-referred and ambulance patients. Cardiac and pulmonary problems are the most frequent underlying disorders in acute chest pain patients in the emergency department. Somatization disorders and musculoskeletal pathology represented respectively 19.1% and 14.8% of the non-cardiac causes. The referral pattern influenced significantly the distribution of the disease categories with more cardiac and less psychiatric disorders in referred patients.

Reflux symptoms are associated with psychiatric disease

AIMS

To evaluate the frequency of reflux symptoms in patients with a diagnosed psychiatric disorder and to assess potential risk factors for symptom occurrence.

METHODS

The presence of reflux symptoms was compared between a case population of 94 psychiatric patients and a control population of 198 non-psychiatric patients.

RESULTS

Heartburn, exercise-induced heartburn, cough and dysphagia were all reported significantly more frequently by subjects with psychiatric disorders than by control subjects. The presence of any psychiatric diagnosis exerted an increased risk for both heartburn (odds ratio, 2.71; 95% confidence interval, 1.01-7.30) and exercise-induced heartburn (3.34; 1.12-9.96). The type of psychiatric disorder, the type of psychotropic medication and the lifestyle did not influence the presence of reflux symptoms.

CONCLUSIONS

Reflux symptoms occur more frequently in patients with than without a diagnosed psychiatric disorder. The reflux symptoms are not associated with any specific type of medication and may reflect a generally reduced threshold for or distorted perception of symptoms.

Recent developments in chest pain of undetermined origin

The syndrome of angina-like pain with normal epicardial coronary vessels is a very common and expensive clinical problem. Patients suffering from this condition frequently present a diagnostic challenge. Cardiac and musculoskeletal disorders must be excluded prior to identifying the esophagus as the source of pain. The term "chest pain of undetermined origin" (UCP) has been proposed to refer to this condition. Esophageal dysmotility was previously considered a major source for chest pain; however, recent studies indicate that esophageal reflux is the most common cause of esophageal pain. Two controlled trials of acid suppressive agents in patients with chest pain have shown that omeprazole provides effective pain relief for the majority of these individuals. Visceral hyperalgesia and psychologic disturbances are also commonly noted in patients with UCP. Much remains to be learned about the etiology of visceral hyperalgesia and the precise role of psychologic abnormalities in these patients. Until further information is available, treatment with imipramine or trazodone has been shown to offer effective relief of chest pain for subgroups of patients with UCP. Psychologic intervention is also valuable in the management of some patients. Studies of other therapeutic regimens continue to be conducted.

Long-term outcome from tricyclic antidepressant treatment of functional chest pain

Antidepressants are of demonstrated value in short-term treatment of functional chest pain, but long-term outcome data are unavailable. Follow-up information over a median of 2.7 years (0.8-8.6 years) was systematically obtained from 21 outpatients treated with tricyclic antidepressants after incomplete response to antireflux therapy. Initial treatment produced at least moderate symptom reduction or remission in 17 subjects (81.0%). Of these, 7 (41.2%) were successfully treated continuously or for symptom relapses over an average of 2.6 years; 5 (29.4%) discontinued successful treatment after >0.5 years with sustained benefits; and 5 (29.4%) eventually discontinued treatment because of side effects or for uncertain reasons (1 having a sustained remission). Low-dose tricyclic antidepressants were considered the most effective long-term chest pain treatment significantly more often than were antireflux medications or calcium-channel blockers in this selected patient group (P<0.05 for each). We conclude from this retrospective review that fully three fourths of subjects with functional chest pain who initially respond to open-label treatment with low-dose tricyclic antidepressants will use them continuously or for symptom relapses over at least the next two to three years and consider them the most effective treatment for their symptoms.

A prospective study of the clinical features, manometric findings, incidence and prevalence of achalasia in Singapore

BACKGROUND

This study aimed to describe the clinical features, manometric findings, prevalence and incidence of achalasia in Singapore.

METHODS

A total of 615 new patients referred for oesophageal manometry between 1989 and 1996 were examined prospectively. Twenty-four men and 25 women fulfilled the manometric and clinical criteria for achalasia.

RESULTS

Their median age of onset of symptoms was 37 years (range 15-71) and 37% first developed symptoms after the age of 50 years. The presenting symptoms were dysphagia (100%), regurgitation (80%), weight loss (67%) and chest discomfort (33%). Five patients (10%) had a history of benign (mostly autoimmune) thyroid disorders. Endoscopy was reported as normal in 10/43 patients (23%) and achalasia was suggested in only 31 (72%) of 43 barium examinations. Lower oesophageal sphincter (LOS) dysfunction was present in 82% of cases. Using data from medical records and from a survey of gastroenterologists and surgeons in Singapore, the prevalence (in 1996) and incidence of achalasia in Singapore were estimated to be 1.8 per 100000, and 0.3 per 100000 per year, respectively. The incidence was significantly lower in Malays than Chinese or Indians. The age-specific incidence of achalasia for both genders followed a bimodal distribution with the larger peak in the sixth decade. No cases of oesophageal carcinoma were identified among these patients.

CONCLUSION

Achalasia is an uncommon condition in Singapore. The clinical and manometric features were similar to those described in Western countries.

Reflux esophagitis patients in Singapore have motor and acid exposure abnormalities similar to patients in the Western hemisphere

OBJECTIVE

Endoscopic esophagitis is less common in the East than in the West. The reason for this is unknown. This study examines prospectively the relationship between endoscopic esophagitis and lower esophageal sphincter pressure, distal esophageal contractility, esophageal peristaltic performance, esophageal acid exposure, gastric acid output, and Helicobacter pylori (H. pylori) status in a consecutive series of Asian patients.

METHODS

Esophageal manometry and ambulatory pH monitoring were carried out in 48 patients with endoscopic esophagitis and 208 patients with symptoms suspicious of gastroesophageal reflux disease but without esophagitis. Gastric acid output and H. pylori serology were determined in 22 of the esophagitis group and 36 of the nonesophagitis group.

RESULTS

Compared to the nonesophagitis patients, esophagitis patients had a higher prevalence of hypotensive lower esophageal sphincter (49% vs 24%, p < 0.001), impaired esophageal contractility (45% vs 22%, p < 0.005), poor peristaltic performance (23% vs 12%, p < 0.05), and pathological acid reflux (48% vs 27%, p < 0.005). However, there was no difference in the two groups with respect to gastric acid output and H. pylori positivity.

CONCLUSIONS

Lower esophageal sphincter competence, esophageal peristaltic contractility, and esophageal acid exposure were important factors in the pathogenesis of reflux esophagitis--results identical to Western studies. Gastric acid output per se and H. pylori infection might not be responsible for susceptibility to esophagitis.

Gastroesophageal reflux disease is a common cause of noncardiac chest pain in a country with a low prevalence of reflux esophagitis

Gastroesophageal reflux disease is believed to be uncommon in the East. This study aimed to determine if such a condition was a significant cause of noncardiac chest pain in Singapore. Eighty consecutive patients with recurrent chest pain, who had cardiac and other obvious causes excluded, underwent esophagogastroduodenoscopy, standard manometry, acid perfusion test, and prolonged ambulatory pH and pressure monitoring. Endoscopic esophagitis, positive acid perfusion tests, pathologic reflux, and positive chest pain-reflux correlation were detected in 7/80 (8.8%), 11/70 (15.7%), 14/61 (23.0%), and 12/25 (48.0%) patients, respectively. Among those with pathologic reflux, endoscopic esophagitis was present in only two (14.3%). Overall, 32 (40%) patients had gastroesophageal reflux disease. Esophageal motility disorder, alone or in association with gastroesophageal reflux disease, was demonstrated in only five (6.3%) patients. Our results confirmed western reports that gastroesophageal reflux disease was a common cause of noncardiac chest pain, whereas motility disorder was an infrequent cause of such pain.