Chest pain with normal coronary arteries. Another perspective

The relationship between coronary artery disease and depression and anxiety scores

Coronary artery disease (CAD) is one of the severe diseases that may cause significant moral and financial burden on society today. There are many studies in the literature on whether psychiatric disorders may cause CAD or an increase in prevalence after CAD. Although many studies have emphasized the importance of early diagnosis and treatment of depression in CAD patients, clinicians do not attach much attention to depression in daily practice. Several scales have been developed that are comfortable to use to describe anxiety and depression in CAD patients. High depression and anxiety scores predicted by psychological symptom scales following CAD treatment are closely related to treatment success and prognosis of the CAD. We believe that patients with CAD should be followed carefully for the diagnosis of depression and anxiety disorders; since the treatment of them may improve the prognosis of CAD.

Coronary Artery Spasm as Related to Anxiety and Depression: A Nationwide Population-Based Study

OBJECTIVE

Anxiety and depression are risk factors for obstructive coronary artery disease (CAD), but their effects on coronary artery spasm (CAS) remain unestablished.

METHODS

Patient records in this population-based study were retrospectively collected from the Taiwan National Health Insurance Research Database. Using propensity score matching, we used 1:1:1 ratio stratification into a control group of 10,325 individuals without CAS or CAD, a CAS group comprising 10,473 patients, and a CAD group comprising 10,473 patients during 2000-2012.

RESULTS

The prevalence of CAS and CAD was 0.067% and 8.7%, respectively, in the general population. The prevalence of anxiety and depression diagnoses was significantly higher in patients with new-onset CAS than in those with new-onset CAD and controls without CAS/CAD, even after propensity score matching. Compared with CAD, anxiety and depression diagnoses conferred a higher risk of developing CAS (odds ratio [OR] = 2.29, 95% confidence interval [CI], 2.14-2.45, p < .001, and OR = 1.34, 95% CI, 1.08-1.66, p = .007, respectively). The association was even stronger when comparing CAS with the control group without CAD or CAS (OR = 5.20, 95% CI, 4.72-5.74, p < .001, and OR = 1.98, 95% CI, 1.50-2.62, p < .001, respectively). The increased risk of new-onset CAS as related to previous anxiety and depression diagnoses was comparable between males and females.

CONCLUSIONS

Compared with CAD or the general population, anxiety and depression diagnoses confer a higher risk of developing CAS. No sex differences are found for the association of anxiety and depression with CAS.

Randomized trial of sertraline in patients with unexplained chest pain of noncardiac origin

BACKGROUND

Between 10% and 30% of patients with symptoms similar to angina and sufficient to justify cardiac catheterization are found to have normal coronary angiograms. Treatment of patients with chest pain with no apparent cardiac cause is a major clinical problem. Our hypothesis was that sertraline would reduce the severity of pain in patients with chest pain of noncardiac origin.

METHODS AND RESULTS

This was a single-site, double-blind, placebo-controlled study of the efficacy, tolerability, and safety of sertraline in the treatment of noncardiac chest pain in outpatients. Thirty patients were enrolled in the study. After 1 week of single-blind placebo washout, patients were randomly assigned in a double-blind fashion either to drug or placebo. The Beck Depression Inventory was administered at baseline and at completion of study. Daily pain diaries (visual analogue scale, rating pain on a scale of 1 to 10) were selfadministered and evaluated at baseline and at follow-up visits. Statistical measures were performed with an intention-to-treat approach. Patients who received sertraline over the course of the study showed a statistically significant reduction in pain compared with those who were receiving placebo.

CONCLUSIONS

The use of sertraline in patients with noncardiac chest pain produced clinically significant reduction of daily pain. These results suggest the need for further studies of the efficacy and tolerability of sertraline and other selective serotonin reuptake inhibitors in the long-term management of noncardiac chest pain.

17-beta-Estradiol therapy lessens angina in postmenopausal women with syndrome X

OBJECTIVES

We sought to investigate the hypothesis that estrogen replacement therapy ameliorates symptoms in postmenopausal women with syndrome X.

BACKGROUND

Syndrome X (angina pectoris, positive findings on exercise electrocardiography and normal results on coronary angiography) frequently occurs in menopausal women. This observation, in conjunction with the known vasoactive properties of estrogens, suggests that estrogen depletion may contribute to the pathogenesis of syndrome X in some women.

METHODS

Twenty-five postmenopausal patients with syndrome X completed a double-blind, placebo-controlled study of the effect of 17-beta-estradiol cutaneous patches (100 micrograms/24 h) on the frequency of chest pain and on exercise tolerance. Patients were randomly assigned to receive either placebo or 17-beta-estradiol patches for 8 weeks and were then crossed over to the other treatment.

RESULTS

During the placebo phase, patients had a mean of 7.3 episodes of chest pain/10 days. A reduction to 3.7 episodes/10 days was observed during the 17-beta-estradiol phase (p < 0.05). No significant differences were observed between the effects of 17-beta-estradiol and placebo on exercise duration or the results of other cardiologic investigations.

CONCLUSIONS

Estrogen replacement reduces the frequency of chest pain and may be a useful new therapeutic option for treating postmenopausal women with syndrome X.

Psychological symptom profiles in patients with chest pain

Five-hundred and thirty-two patients with ischaemic-like chest pain referred for symptom-limited exercise thallium myocardial perfusion studies, were assessed on a range of psychosocial measures. Three groups of patients were identified on the basis of their perfusion studies: (1) normal thallium perfusion; (2) current myocardial ischaemia; and (3) past myocardial infarction (but no current ischaemia). There were no significant psychological differences between these groups on a wide range of measures which included depression, state and trait anxiety, Type A behaviour, personality, suppression of affect, locus of control, alexythymia, and hypochondriasis. Significant differences were identified, however, on measures of anger and coping style. Subjects with no current ischaemia (normal thallium perfusion and those with past myocardial infarction) had higher scores on 'immature coping' and 'anger in', than subjects with current myocardial ischaemia. These findings are discussed in the light of other published research.

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'.

Noncardiac chest pain due to acute gastric anisakiasis

This paper described the first confirmed case of acute anginalike chest pain caused by gastric anisakiasis. A 55-year-old male, with a history of a sudden onset of chest pain and also a history of eating raw mackerel and tuna 9 hr prior to the onset of chest pain, was found upon endoscopy to have an imbedded parasite in the mucosal lining of his stomach. The chest pain disappeared after the endoscopic removal of larva. Endoscopy is highly recommended at the earliest possible time for patients who are suspected to have acute gastric anisakiasis.

Current medical therapy for esophageal motility disorders

Treatment of patients with an esophageal source of chest pain remains a challenging problem. Although a variety of measures--including nitrates, anticholinergics, sedatives, calcium channel antagonists, esophageal dilation, and psychological reassurance--are available for the management of esophageal chest pain, none has emerged as the treatment of choice. Studies of nitrate preparations for the treatment of painful motility disorders are limited by a small number of patients and the lack of randomized, placebo-controlled investigations. The efficacy of anticholinergic drugs in hypercontractile esophageal motility disorders has not been reported. In the only prospective placebo-controlled trial using an anti-depressant, trazodone was superior to placebo in relieving symptoms in patients with a variety of esophageal motility disorders. Conflicting results have been described in placebo-controlled trials of the calcium channel antagonists nifedipine and diltiazem in patients with "nutcracker esophagus" or diffuse spasm. Information about the efficacy of verapamil and hydralazine is limited. Esophageal dilation has been useful in selected patients. For many patients, esophageal chest pain may be associated with gastroesophageal reflux. Treatment of these patients with nitrates, calcium channel antagonists, or anticholinergics may aggravate their reflux. The mechanisms of esophageal chest pain remain unknown. Recent studies have suggested that abnormal motility may not be the only factor associated with chest pain. An important number of patients have behavioral abnormalities, increased nociception, impaired coronary vasodilatory reserve, or a diffuse abnormality of smooth muscle. Research into rational therapy for chest pain patients should take into account the contribution of these other factors.

Provocation testing in noncardiac chest pain

The ability to reproduce chest pain and to identify the esophagus as the source of this pain are the major reasons why provocation testing has become standard in the evaluation of patients with noncardiac chest pain. Recent studies that challenge the validity of performing provocation tests have polarized experts into two camps: those who would abandon such testing because of its low sensitivity and low specificity, and those who would use testing judiciously because of moderate increases in diagnostic yield. Use of 24-hour pH and pressure testing has shown a high number of chest pain events associated with acid reflux in patients with positive cholinergic stimulation tests and esophageal dysmotility, as well as pain with esophageal dysmotility in patients with positive acid infusion tests. Mechanisms of esophageal chest pain are not known. All provocation agents can decrease coronary flow reserve (i.e., induce microvascular angina), thus raising the question of a cardiac source of pain even in patients with positive presumed esophageal provocation. Acid infusion, cholinergic stimulation, and balloon distention are discussed in light of 24-hour pH and pressure monitoring. Esophageal distention and the role of acid in inducing chest pain are emphasized. The role of stress, the use of defined stressors to induce chest pain, and altered pain perception as a final common pathway for chest pain are examined.

Chest pain in patients with normal coronary arteries. A new look at potential causes

Recurrent chest pain in patients with normal coronary arteries is a difficult clinical problem. Although long-term studies have shown that these patients have an excellent prognosis in terms of cardiac morbidity and mortality, many patients remain physically debilitated and continue to visit emergency departments. Recent information suggests that microvascular angina, esophageal disorders (including reflux disease and dysmotility), and panic disorder may be important causes of pain in such patients. It is particularly important to consider the diagnosis of gastroesophageal reflux disease, which is easier to diagnose and treat than most other causes of recurrent chest pain.