Panic disorder in patients with angiographically normal coronary arteries

Cardiac Syndrome X: Update

Cardiac Syndrome X (CSX), characterized by angina-like chest discomfort, ST segment depression during exercise, and normal epicardial coronary arteries at angiography, is highly prevalent in women. CSX is not benign, and linked to adverse cardiovascular outcomes and a poor quality of life. Coronary microvascular and endothelial dysfunction and abnormal cardiac nociception have been implicated in the pathogenesis of CSX. Treatment includes life-style modification, anti-anginal, anti-atherosclerotic, and anti-ischemic medications. Non-pharmacological options include cognitive behavioral therapy, enhanced external counterpulsation, neurostimulation, and stellate ganglionectomy. Studies have shown the efficacy of individual treatments but guidelines outlining the best course of therapy are lacking.

Cardiac Syndrome X: update 2014

Cardiac Syndrome X (CSX), characterized by angina-like chest discomfort, ST segment depression during exercise, and normal epicardial coronary arteries at angiography, is highly prevalent in women. CSX is not benign, and linked to adverse cardiovascular outcomes and a poor quality of life. Coronary microvascular and endothelial dysfunction and abnormal cardiac nociception have been implicated in the pathogenesis of CSX. Treatment includes life-style modification, anti-anginal, anti-atherosclerotic, and anti-ischemic medications. Non-pharmacological options include cognitive behavioral therapy, enhanced external counterpulsation, neurostimulation, and stellate ganglionectomy. Studies have shown the efficacy of individual treatments but guidelines outlining the best course of therapy are lacking.

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.

Psychiatric and psychological aspects of chronic pain

To gain a better understanding and a more complete assessment of chronic pain syndrome, the psychosocial, psychological, psychodynamic, and psychiatric aspects of this condition should be included in patient evaluation. As illustrated in the two case studies presented, this approach leads to clearer recognition of the biological and psychosocial needs of patients, and allows for more effective treatment measures to be taken.

Abnormal cardiac nerve function in syndrome X

Syndrome X is likely to be caused by a dysfunction of small coronary arteries. Several authors suggested that an increased adrenergic activity could be involved in the pathogenesis of syndrome X, but studies investigating this topic by indirect methods led to conflicting results. We directly investigated cardiac sympathetic nerve function in syndrome X by myocardial radionuclide studies with 123I-metaiodobenzylguanidine (MIBG). Twelve syndrome X patients and 10 healthy controls were enrolled in the study. Cardiac MIBG uptake was assessed calculating the heart/mediastinum (H/M) ratio and a semiquantitative MIBG uptake score. Cardiac MIBG images were normal in all but 1 of controls (10%). Conversely, abnormalities in cardiac MIBG uptake were found in 9 syndrome X patients (75%, p < 0.01). In 5 patients the heart was totally or almost totally invisible on radionuclide MIBG images, while regional defects were found in other 4 patients. The H/M ratio was lower and cardiac MIBG uptake score strikingly higher in syndrome X patients. At 3 hours the H/M ratio was 1.70 +/- 0.6 in patients and 2.19 +/- 0.3 in controls (p = 0.03), while MIBG uptake score was 36.7 +/- 31 and 4.0 +/- 2.5 (p = 0.003) in the 4 groups, respectively. There were no differences between patients and controls in lung and salivary MIBG uptake. Reversible perfusion defects on stress thallium scintigraphy were found in 5 syndrome X patients (45%), all of whom also had abnormal MIBG scintigrams, while all 3 patients with normal MIBG scintigraphy also had normal thallium images. Thus, the function of efferent cardiac adrenergic nerve fibers is strongly impaired in the majority (i.e., 75%) of syndrome X patients. This abnormal function likely contributes significantly to the pathophysiologic and clinical features of syndrome X. We speculate that also the increased perception of cardiac pain reported in these patients could be an expression of the abnormal function of cardiac nerves, reflecting alterations of afferent nociceptive cardiac nerve fibers, as the abnormalities in MIBG uptake reflect alterations of efferent cardiac adrenergic nerve fibers.

Musculo-skeletal pathology in patients with angina pectoris and normal coronary angiograms

PURPOSE

To evaluate the role of the musculo-skeletal apparatus in patients with angina pectoris despite normal coronary angiograms.

DESIGN

A survey of patients and controls investigated by blinded observers.

SETTING

A tertiary cardiologic referral centre.

SUBJECTS

Thirty women and 18 men (mean age 52.9 years) with chest pain of an average duration of 3 years and 11 months were investigated. All had normal resting electrocardiograms. No patients showed evidence of left ventricular hypertrophy or valvular heart disease on echocardiography and all had a normal coronary angiogram. All had left ventricular ejection fraction > 50%, and none had signs of coronary vasospasm. Eighteen healthy persons (10 women and eight men, mean age 51.2 years) served as controls.

MAIN OUTCOME MEASURES

The group frequency of chest wall complaints, spinal radiograph and physical examination findings; pressure pain thresholds.

RESULTS

The patients had significantly more complaints of pain from the neck, chest, and thoracic spine, and sensations and pain radiating to the arms than the controls. The patients had more degenerative findings on radiograph than the controls, mainly at levels C4-C7. Physical examination showed that abnormal findings were significantly more frequent in patients than in the control group in the anterior and posterior chest wall, in the spine at levels Th1-Th6 and in the muscles of the neck and shoulder girdle. There were no statistically significant differences in pain thresholds or in neurological examination.

CONCLUSION

The musculo-skeletal abnormalities observed in the patients could include reflex mechanisms. Whether the abnormal findings are mainly responsible for the angina pectoris symptoms or merely epiphenomena warrants further study.

Role of abnormal pain sensitivity and behavioral factors in determining chest pain in syndrome X

OBJECTIVES

We sought to investigate whether patients with syndrome X have an abnormal perception of cardiac pain.

BACKGROUND

Previous studies have reported an increased sensitivity to potentially painful cardiac stimuli in patients with syndrome X. However, it is not clear whether this increase is due to an increased perception of pain or to an enhanced tendency to complain.

METHODS

We assessed cardiac sensitivity to pain in 16 patients with syndrome X and 15 control subjects by performing right atrial and ventricular pacing with increasing stimulus intensity (1 to 10 mA) at a rate 5 to 10 beats higher than the patient's heart rate. False and true pacing were performed in random sequence, with both patients and investigators having no knowledge of the type of stimulation being administered.

RESULTS

No control subject had pacing-induced pain; conversely, 8 patients with syndrome X reported angina during atrial pacing (50%, p < 0.01) and 15 during ventricular pacing (94%, p < 0.001). During atrial stimulation, both true and false pacing caused chest pain in a similar proportion of patients (50% vs. 63%, p = 0.61), whereas during ventricular stimulation, true pacing caused chest pain in a higher proportion of patients (94% vs. 50%, p < 0.05). Pain threshold and severity of pain (1 to 10 scale) were similar during true and false atrial pacing, whereas true ventricular pacing resulted in a lower pain threshold (mean +/- SD 3.7 +/- 3.0 vs. 7.9 +/- 2.8 mA, p < 0.001) and a higher level of pain severity (7.3 +/- 2.7 vs. 3.1 +/- 3.5, p < 0.001) than did false pacing.

CONCLUSIONS

Patients with syndrome X frequently reported chest pain even in the absence of cardiac stimulation. Yet, in addition to this increased tendency to complain, they also exhibited a selective enhancement of ventricular painful sensitivity to electrical stimulation.

[Psychopathological disorders and coronary diseases]

The role of psychological factors in the genesis of coronary diseases has been considered for a long time. Friedman took it upon himself to describe a personality profile (pattern A) constituting a risk factor for coronary heart disease of which, however, the practical interest seems limited. The association of psychopathological conditions and coronary heart disease has on the other hand not been extensively studied. Recent epidemiological data show that anxiety and depressive states represent a high comorbidity with coronary heart diseases. Panic attacks remain underestimated; they seem to participate in a complex physiopathological mechanism along with ischemic coronary heart diseases. Recent studies have shown that the existence of a depressive illness during coronary heart disease and particularly in the time period following a myocardial infarction, constitutes an independent risk factor, thus increasing the mortality rate. The evolution of coronary heart disease seems greatly influenced by the existence of anxious or depressive states, the diagnosis and the treatment of these states represent a major interest towards a better management of coronary patients.

Normal coronary angiograms: financial victory from the brink of clinical defeat?

OBJECTIVE

To examine the hypothesis that, in patients undergoing coronary angiography for suspected ischaemic heart disease, a normal angiographic result is associated with a fall in consumption of health care resources following the angiogram.

DESIGN

Retrospective cost-benefit analysis comparing the 12 month periods before and after coronary angiography.

SETTING

Tertiary cardiac referral centre.

SUBJECTS

69 consecutive patients investigated in the financial year 1991-92 whose angiograms were normal.

MAIN OUTCOME MEASURES

Drug and hospital admission costs in the 12 month periods before and after angiography; urgent and elective consultations with general practitioner in that time.

RESULTS

The mean cost of care per patient in the year before investigation was 656.89 pounds. A highly significant fall in all indices of resource consumption was observed in the year following investigation, the mean resulting difference in the cost of care being 35.15 pounds per month. The cost of coronary angiography would, if this fall were maintained, be recouped in a mean time of 18 months.

CONCLUSIONS

Patients suspected on clinical grounds to have coronary atherosclerosis who are found at angiography to have normal coronary arteries are heavy consumers of health care resources. Early investigation for these patients is safe and has beneficial resource consequences in the medium term.

Pain perception and brain evoked potentials in patients with angina despite normal coronary angiograms

OBJECTIVE

To evaluate the role of nociception in patients with angina despite normal coronary angiograms and to investigate whether any abnormality is confined to visceral or somatosensory perception.

METHODS

Perception, pain threshold, and brain evoked potentials to nociceptive electrical stimuli of the oesophageal mucosa and the sternal skin were investigated in 10 patients who had angina but normal coronary angiograms, no other signs of cardiac disease, and normal upper endoscopy. Controls were 10 healthy volunteers. The peaks of the evoked potential signal were designated N for negative deflections and P for positive. Numbers were given to the peaks in order of appearance after the stimulus. The peak to peak amplitudes (P1/N1, N1/P2) were measured in microV.

RESULTS

(1) Angina pectoris was provoked in seven patients following continuous oesophageal stimulation. (2) Distant projection of pain occurred after continuous electrical stimulation of the oesophagus in four patients and in no controls. (3) Patients had higher oesophageal pain thresholds (median 16.3 mA v 7.3 mA, P = 0.02) to repeated stimuli than controls, whereas the values did not differ with respect to the skin. There were no intergroup differences in thresholds to single stimuli. (4) Patients had substantially reduced brain evoked potential amplitudes after both single oesophageal (P1/N1, median values: 7.2 microV, controls: 29.0 microV; N1/P2: 16.5 microV, controls: 66.0 microV; P < 0.001 for both) and skin (N1/P2: 13.5 microV; controls: 76.0 microV; P < 0.001) stimuli despite the similar pain thresholds.

CONCLUSION

Central nervous system responses to visceral and somatosensory nociceptive input are altered in patients who have angina despite normal coronary angiograms.

Psychological treatment of noncardiac chest pain: the cognitive approach

Chest pain often accompanies panic attacks. The success of cognitive therapy in the treatment of panic disorder has led to effective cognitive--behavioral therapy for both anxiety about health and noncardiac chest pain accompanied by anxiety. The cognitive hypothesis proposes that, in vulnerable persons, sensations in the chest region can be misinterpreted as a sign of serious illness, such as an impending heart attack, giving rise to anxiety. A variety of responses can contribute to the problem of such misinterpretations and the associated anxiety. First, anxiety-induced autonomic arousal can generate an increase in symptoms. Second, worried patients are more likely to focus on their bodily reactions and to check their bodily functioning, increasing the likelihood that some changes will be detected. Third, patients may seek medical evaluation or other forms of reassurance, which can lead to further misinterpretation and worry. Each of these reactions can increase the perception of chest pain, contributing to a vicious cycle that exacerbates both the chest pain and the anxiety. In most cases, treatment is straightforward. It starts with identification of the patient's particular fears, followed by education about the role of anxiety in producing physical sensations such as chest pain. Demonstration of the processes that produce and maintain physical sensations usually convinces the patient of the harmless nature of symptoms. Although cognitive therapy avoids giving reassurance by "ruling out" feared diseases, patients are encouraged to take actions to disconfirm their worst fears. Some patients require more specialized treatment, particularly if they remain strongly convinced that their problem is solely physical. Such patients must be engaged in active collaboration with the therapist.