Difficult problems in the diagnosis of chest pain

[Pulmonary causes of chest pain]

Chest pain represents one of the most frequent symptoms of pulmonary diseases, in addition to dyspnea and cough. The broad differential diagnostics include the intensely painful but prognostically benign acute pleurisy as well as potentially life-threatening events, such as acute pulmonary embolism or malignant chest diseases. Primary spontaneous pneumothorax is characterized by acute chest pain. Pain associated with a respiratory infection, such as pneumonia rarely poses a difficult diagnostic problem. Painful diseases of the lungs can be differentiated in an initial approach by asking the patient if the pain is related to breathing, which is characteristic of pleuritic chest diseases. Pulmonary hypertension, lung cancer and mesothelioma show more constant pain unrelated to respiratory movements. It is most important to differentiate pain associated with acute exacerbation of chronic obstructive pulmonary disease (COPD), whereby a possible cardiac comorbidity, such as acute coronary syndrome (ACS) should always be considered.

ST-Segment Depression in Hyperventilation Indicates a False Positive Exercise Test in Patients with Mitral Valve Prolapse

Objectives. Mitral valve prolapse (MVP) is a known cause for false positive exercise test (ET). The purpose of this study was to establish additional electrocardiographic criteria to distinguish the false positive exercise results in patients with MVP. Methods. We studied 218 consecutive patients (53 ± 6 years, 103 males) with MVP (according to echocardiographic study), and positive treadmill ET was performed due to multiple cardiovascular risk factors or angina-like symptoms. A coronary angiography was performed to detect coronary artery disease (CAD). Results. From 218 patients, 90 (group A) presented with normal coronary arteries according to the angiography (false positive ET) while the rest 128 (group B) presented with CAD. ST-segment depression in hyperventilation phase was present in 54 patients of group A (60%) while only in 14 patients of group B (11%), P < .05. Conclusions. Presence of ST-segment depression in hyperventilation phase favors a false positive ET in patients with MVP.

Endothelial function predicts future development of coronary artery disease: a study of women with chest pain and normal coronary angiograms

BACKGROUND

The prognosis for women with chest pain and angiographically normal coronary arteries is believed to be totally benign. Previous studies, however, did not account for the delay of a decade or so in the development of coronary artery disease that women may experience.

METHODS AND RESULTS

This study assessed long-term follow-up of 42 women with de novo angina, evidence of reversible myocardial perfusion defects on SPECT, and normal coronary angiograms. At recruitment, all women underwent endothelial function testing (intracoronary acetylcholine) during catheterization. Patients were followed up for >10 years. Angiography was repeated at the end of the follow-up in 37 patients. At recruitment, 22 patients developed diffuse vasoconstriction during acetylcholine in the absence of identifiable focal coronary spasm (acetylcholine-positive group). The remaining 20 patients showed vasodilation (acetylcholine-negative group). At the end of follow-up, in the acetylcholine-positive group, 1 patient developed cardiac death, 13 still complained of chest pain, and 8 had remission of symptoms. In the acetylcholine-negative group, all patients showed complete resolution of chest pain beginning 6 to 36 months after baseline assessment. Angiography showed development of coronary artery disease in the 13 symptomatic patients in the acetylcholine-positive group.

CONCLUSIONS

In women with angiographically normal-appearing coronary arteries, persistence of chest pain over the years often relates to development of coronary artery disease. Endothelial dysfunction in a setting of normal coronary arteries is a sign of future development of atherosclerosis.

"Tombstone" anterior ST-segment elevations secondary to acute pericarditis: the role of two-dimensional echocardiogram

Prompt and appropriate administration of thrombolytic therapy is important for patients with acute myocardial infarction. However, in addition to contraindications, alternative causes of ST-segment elevation should be considered before thrombolytic therapy is instituted. A patient with marked ST-segment elevation in the anterior leads suggestive of acute ischemia is presented. Because of lack of ischemic symptoms, an echocardiogram was performed. This showed mild generalized hypokinesis, and thrombolytic therapy was not administered. Subsequent ECGs demonstrated evolutionary findings consistent with pericarditis. In selected patients a two-dimensional echocardiogram, which can be easily performed at patient bedside, will help in appropriate patient management.

Improvement of ED prediction of cardiac mortality among patients with symptoms suggestive of acute myocardial infarction

A study was undertaken to evaluate the 1-year risk of cardiac death for patients with chest pain/suspected acute myocardial infarction in the emergency department (ED) and express the prognosis in a statistical model. Clinical variables and electrocardiogram were correlated to cardiac death during 1 year. Cox regression model was used to estimate the risk of death as a continuous function of a risk score and the time interval. From these, the prognosis for each patient can be calculated. There were 6,794 visits by 5,303 patients followed for 1 year, during which 604 patients died. The absolute risk of cardiac death can be calculated from the independent predictors for cardiac death: age; sex; histories of diabetes mellitus, hypertension, and congestive heart failure; and symptoms, electrocardiographic pattern, and degree of suspicion of acute myocardial infarction on admission. This model allows estimation of the prognosis for every patient with chest pain/suspected acute myocardial infarction from data easily available in the ED.

Ventricular gradient variability. New ECG method for detection of ischemic heart disease

The usefulness of ventricular gradient variability for detecting the presence of ischemic heart disease was evaluated in 38 patients with coronary artery disease (group 1), 21 patients with chest pain and no coronary artery disease (group 2), and 33 healthy control subjects. The ventricular gradient of each consecutive heartbeat at rest over a 22-second interval was calculated using a microcomputer. The SD and coefficient of variation for azimuth, elevation, and magnitude were used as indices of ventricular gradient variability. The SD and coefficient of variation of both the magnitude and elevation of ventricular gradient in group 1 were significantly greater than those of the other two groups (P < .01, respectively). When the normal upper limit was defined as 2SD above the mean value in the control group, a comparison between the findings for group 1 and group 2 revealed that the coefficient of variation of magnitude of the ventricular gradient was the most sensitive (82%) and specific (91%) index for coronary artery disease (chi-square test, P < .001). This study suggests that the variability in the magnitude of the ventricular gradient is a reliable index of ischemic heart disease.

The puzzle of normal coronary arteries in the patient with chest pain: what to do?

Over one million Americans undergo cardiac catheterization each year because of chest pain, with the expectation that coronary artery disease will be found. However, up to 30%--a subgroup that includes patients with both cardiac and noncardiac pathology--will have angiographically normal coronary arteries. While the prognosis of the group as a whole is excellent, successful management requires a clear understanding of the multiple and varied conditions that can cause this syndrome.

Xiphodynia: a report of three cases

Xiphodynia is an uncommon musculoskeletal disorder that mimics a number of common abdominal and thoracic diseases. We report three cases of xiphodynia. The diagnosis is suggested when a given patient's chest or abdominal discomfort is completely or almost completely reproduced with light pressure on the xiphoid process. Local injection with an anesthetic-steroid combination is frequently curative. No more than 5 to 7 mL of solution should be injected, and results are variable when several trigger points are found on the anterior chest wall. Tack hammer deformity of the xiphoid, another cause of xiphoid pain, has been successfully treated with surgical excision.

Comparison of "Rose Questionnaire Angina" to exercise thallium scintigraphy: different findings in males and females

Validation of the London School of Hygiene (Rose) Questionnaire with objective measures of myocardial ischemia is incomplete. Therefore, we compared the Rose Questionnaire with exercise thallium-201 myocardial scintigraphy in 147 male and 97 female patients with chest pain referred for clinical exercise testing. Of those with "Rose Questionnaire angina", 26% of the females and 73% of the males had positive thallium-201 scans. Negative results on both the Rose Questionnaire and thallium-201 scintigraphy were observed in 71% of the females and 47% of the males. The sensitivity of the Rose Questionnaire was similar in females (41%) and males (44%). The specificity was 77% in males, while in females it was significantly lower at 56%. The specificity values reflect the higher (p less than 0.05) prevalence of "false positive" Rose Questionnaire results in females (75%) compared with males (27%). In addition, males had a greater (p less than 0.05) number of "false negative" results (53%) than females (29%). The accuracy of the Rose Questionnaire for myocardial ischemia was 0.19 in females, 0.48 in males, and 0.29 overall when including both males and females. Our results indicate a generally poor relationship between Rose Questionnaire angina and thallium-201 scintigraphy, an objective measure of myocardial ischemia in patients with chest pain referred to clinical exercise testing. Further, there are gender-specific differences in this relationship between the questionnaire and exercise thallium-201 imaging.

Patients admitted to the emergency room with symptoms indicative of acute myocardial infarction

All 7157 patients (55% men) admitted to the emergency room with chest pain or other symptoms indicative of acute myocardial infarction during a period of 21 months were registered consecutively. Chest pain was reported by 93% of the patients. On the basis of history, clinical examination, and electrocardiogram in the emergency room, all patients were prospectively classified in one of four categories: (i) obvious infarction (4% of all patients); (ii) strongly suspected infarction (20%); (iii) vague suspicion of infarction (35%); and (iv) no suspected infarction (41%). In patients with no suspected infarction (n = 2910), musculoskeletal (26%), obscure (21%) and psychogenic origins (16%) of the symptoms occurred most frequently. We conclude that few of the patients had an obvious infarction on admission, and that a musculoskeletal origin of the symptoms occurred most frequently in patients with no suspected infarction.

Long-term follow-up of health-related quality of life in patients with suspected acute myocardial infarction when the diagnosis was not confirmed

This study describes the outcome in terms of health-related quality of life (QL) five years after onset of symptoms in 397 patients with an initial suspicion of acute myocardial infarction (MI) but in whom the diagnosis was not confirmed. The patients were approached by means of a postal inquiry that comprised two questionnaires. The most pronounced impairment in health-related QL was expressed as decreased energy, whereas social life was the least affected area. The overall QL was very similar to that in patients who had a confirmed MI. Subsets of patients with impaired QL were those given the diagnosis of angina pectoris or possible infarction.

Myocardial infarction pain: systematic description and analysis

The aim of the study was to describe various components of pain in suspected acute myocardial infarction (MI). Ninety-four patients admitted to a Coronary Care Unit (CCU) complaining of chest pain with the preliminary diagnosis suspect MI were included in the study. Thirty-eight subjects were eventually diagnosed as having MI and 56 subjects as non-MI. A comparison of chest pain description was performed between MI and non-MI subjects. The Pain-o-meter (POM) and the Visual Analogue Scale (VAS) were used to assess pain intensity. MI patients reported more intense sensory and affective pain than non-MI patients. MI patients also reported more intense affective pain than sensory pain, whereas non-MI patients reported just the opposite. The number of affective words chosen by MI patients differentiated them more clearly from non-MI patients than any other factor in the pain description. Pain intensity was significantly correlated to the estimated size of the infarct.

Non-traumatic chest pain in young adults: a medical audit

Four hundred consecutive young patients who attended an accident and emergency department with non-traumatic chest pain as their primary complaint were reviewed. They represented 0.7% of total new attendances. Most were self-referrals, but ambulance transport was requested for over 25%. The majority of investigations (mainly chest radiography and electrocardiography) performed in this group of patients were normal; however, almost one in six investigations was judged to be abnormal. Although this group of patients is at low risk for serious cardiorespiratory disease, a small but significant number of underlying (mainly non-cardiac) disorders was found and 22.5% (90) required in-patient admission. In contrast, almost one-fifth of patients received no specific diagnosis, while almost 40% were deemed to require no follow-up.

Atypical chest pain: coronary or esophageal disease?

Retrosternal pain can be caused both by cardiac and esophageal disease. This work presents the results of cardiac and esophageal investigations in 55 patients, who had atypical chest pain. Isolated esophageal disease was found in 45% of the subjects while 14.5% had significant coronary arterial disease. Both diseases were found in 10.9% of the patients and neither disease in 29%. We conclude that esophageal disease is very frequent in patients with atypical chest pain but it does not always completely account for the symptoms. Such patients should, in our opinion, be submitted to an electrocardiographic stress test. If the result is positive or non-diagnostic, coronary cineangiography should be performed, irrespective of the results of esophageal investigations. If the electrocardiographic stress test is negative, coronary investigations can be deferred. Esophageal investigations can account for the symptoms in about half of such cases.