Usefulness of chest pain character and location as diagnostic indicators of an acute coronary syndrome

Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study

Background/Aims

Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population.

Methods

Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed.

Results

Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis.

Conclusions

The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.

Missed Acute Coronary Syndrome During Telephone Triage at Out-of-Hours Primary Care: Lessons From A Case-Control Study

OBJECTIVES

Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hindsight bias. This study compared the recorded triage calls of patients with chest discomfort contacting the OHS-PC in whom an ACS was missed (cases), with triage calls involving matched controls with chest discomfort but without a missed ACS (controls), with the aim to assess the predictors of missed ACS.

METHODS

A case-control study with data from 2013 to 2017 of 9 OHS-PC in the Netherlands. The cases were matched 1:8 with controls based on age and sex. Clinical, patient, and call characteristics were univariably assessed, and general practitioner experts evaluated the triage while blinded to the final diagnosis or the case-control status.

RESULTS

Fifteen missed ACS calls and 120 matched control calls were included. Cases used less cardiovascular medication (38.5% versus 64.1%, P = 0.05) and more often experienced pain other than retrosternal chest pain (63.3% versus 24.7%, P = 0.02) compared with controls. Consultation of the supervising general practitioner (86.7% versus 49.2%, P = 0.02) occurred more often in cases than in controls. Experts rated the triage of cases more often as "poor" (33.3% versus 10.9%, P = 0.001) and "unsafe" (73.3% versus 22.5%, P < 0.001) compared with controls.

CONCLUSIONS

To facilitate learning from serious adverse events in the future, these should also be bundled and carefully assessed without hindsight bias and within the context of "normal" clinical practice.

[Managing STEMI before the hospital : let's identify our enemies!]

Managing a patient with chest pain suspected to be a ST segment elevation myocardial infarction is a race against time. This management is based on a chain, like what is presented for cardiac arrest. Three phases follow one another, with potential loss of time successively attributable to the patient, the emergency physician and then the cardiologist. It would be tempting to consider that the main culprit in the event of delayed treatment is the patient. This review is the opportunity to show that it is not the case. The emergency physician, the cardiologist and their interconnection are the main providers of delay and, as such, the main enemies of myocardial reperfusion.

The Mexican consensus on non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases.

AIM

To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients.

METHODS

Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system.

RESULTS AND CONCLUSIONS

The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

The Quality of Symptoms in Women and Men Presenting to the Emergency Department With Suspected Acute Coronary Syndrome

INTRODUCTION

More than 5.5 million patients present to emergency departments in the United States annually for potential acute coronary syndrome (ACS); however, diagnosing ACS remains a challenge in emergency departments. Our aim was to describe the quality of symptoms (chest discomfort/description of pain, location/radiation, and overall symptom distress) reported by women and men ruled-in and ruled-out for ACS in emergency departments.

METHODS

The sample consisted of 1,064 patients presenting to emergency departments with symptoms that triggered cardiac workups. Trained research staff obtained data using the ACS Patient Information Questionnaire upon patient presentation to emergency departments.

RESULTS

The sample (n = 1,064) included 474 (44.55%) patients ruled-in and 590 (55.45%) patients ruled-out for ACS. Symptom distress was significantly higher in patients ruled-in versus ruled-out for ACS (7.3 ± 2.6 vs. 6.8 ± 2.5; P = 0.002) and was a significant predictor for an ACS diagnosis in men (odds ratio [OR], 1.10; confidence interval [CI], 1.03-1.17; P = 0.003). Women also reported more chest pressure (51.75% vs. 44.65; P = 0.02) compared with men, and chest pressure was a significant predictor for a diagnosis of ACS (OR, 1.61; CI, 1.03-2.53; P = 0.02).

DISCUSSION

Higher levels of symptom distress may help ED personnel in making a decision to evaluate a patient for ACS, and the presence of chest pressure may aid in making a differential diagnosis of ACS.

Sex differences in presenting symptoms of acute coronary syndrome: the EPIHeart cohort study

OBJECTIVES

Prompt diagnosis of acute coronary syndrome (ACS) remains a challenge, with presenting symptoms affecting the diagnosis algorithm and, consequently, management and outcomes. This study aimed to identify sex differences in presenting symptoms of ACS.

DESIGN

Data were collected within a prospective cohort study (EPIHeart).

SETTING

Patients with confirmed diagnosis of type 1 (primary spontaneous) ACS who were consecutively admitted to the Cardiology Department of two tertiary hospitals in Portugal between August 2013 and December 2014.

PARTICIPANTS

Presenting symptoms of 873 patients (227 women) were obtained through a face-to-face interview.

OUTCOME MEASURES

Typical pain was defined according to the definition of cardiology societies. Clusters of symptoms other than pain were identified by latent class analysis. Logistic regression was used to quantify differences in presentation of ACS symptoms by sex.

RESULTS

Chest pain was reported by 82% of patients, with no differences in frequency or location between sexes. Women were more likely to feel pain with an intensity higher than 8/10 and this association was stronger for patients aged under 65 years (interaction P=0.028). Referred pain was also more likely in women, particularly pain referred to typical and atypical locations simultaneously. The multiple symptoms cluster, which was characterised by a high probability of presenting with all symptoms, was almost fourfold more prevalent in women (3.92, 95% CI 2.21 to 6.98). Presentation with this cluster was associated with a higher 30-day mortality rate adjusted for the GRACE V.2.0 risk score (4.9% vs 0.9% for the two other clusters, P<0.001).

CONCLUSIONS

While there are no significant differences in the frequency or location of pain between sexes, women are more likely to feel pain of higher intensity and to present with referred pain and symptoms other than pain. Knowledge of these ACS presentation profiles is important for health policy decisions and clinical practice.

A new score for the diagnosis of acute coronary syndrome in acute chest pain with non-diagnostic ECG and normal troponin

BACKGROUND

Acute coronary syndrome (ACS) represents a difficult diagnostic challenge in patients with undifferentiated chest pain. There is a need for a valid clinical score to improve diagnostic accuracy.

OBJECTIVES

To compare the performance of a model combining the Thrombolysis in Myocardial Infarction (TIMI) score and a score describing chest pain (ACS diagnostic score: ACSD score) with that of both scores alone in the diagnosis of ACS in ED patients with chest pain associated with a non-diagnostic ECG and normal troponin.

METHODS

In this observational cohort study, we enrolled 809 patients admitted to a chest pain unit with normal ECG and normal troponin. They were prospectively evaluated in order to calculate TIMI score, chest pain characteristics score and ACSD score. Diagnosis of ACS was the primary outcome and defined on the basis of 2 cardiologists after reviewing the patient medical records and follow-up data. Mortality and major cardiovascular events were followed for 1 month for patients discharged directly from ED. Discriminative power of scores was evaluated by the area under the ROC curve.

RESULTS

ACS was confirmed in 90 patients (11.1%). The area under the ROC curve for ACSD score was 0.85 (95% CI 0.80 to 0.90) compared with 0.74 (95% CI 0.67 to 0.81) for TIMI and 0.79 (95% CI 0.74 to 0.84) for chest pain characteristics score. A threshold value of 9 appeared to optimise sensitivity (92%) and negative predictive value (99%) without excessively compromising specificity (62%) and positive predictive value (23%).

CONCLUSIONS

The ACSD score showed a good discrimination performance and an excellent negative predictive value which allows safely ruling out ACS in ED patients with undifferentiated chest pain. Our findings should be validated in a larger multicentre study.

Evaluation of alexithymia, somatosensory sensitivity, and health anxiety levels in patients with noncardiac chest pain

Objective. Noncardiac chest pain (NCCP) is seen more frequently in young population and in these patients loss of function is evolving in social and professional areas. The aim of the study is to evaluate the levels of anxiety and somatic perception in patients with chest pain presenting to cardiology clinic. Methods. Fifty-one patients with noncardiac chest pain and 51 healthy controls were included in the study. All participants performed self-report based health anxiety inventory (HAI), somatosensory amplification scale (SAS), and Toronto alexithymia scale (TAS). Results. The patient group had significantly higher scores on the SAS, HAI-1, and HAI-T scales compared to controls (P < 0.001, P = 0.006, and P = 0.038, resp.). SAS, HAI-1, and HAI-T scores were significantly higher in female patients than male (P = 0.002, 0.036, and 0.039, resp.). There were significant differences in all TAS subscale scores between two groups. Patients, who had total TAS score more than 50, also presented higher levels of health anxiety (P = 0.045). Conclusions. Anxiety, somatic symptoms, and the exaggerated sense of bodily sensations are common in patients with NCCP. These patients unnecessarily occupy the cardiology outpatient clinics. These negative results can be eliminated when consultation-liaison psychiatry evaluates these patients in collaboration with cardiology departments.

Sensitivity, specificity, and sex differences in symptoms reported on the 13-item acute coronary syndrome checklist

Background

Clinical symptoms are part of the risk stratification approaches used in the emergency department (ED) to evaluate patients with suspected acute coronary syndromes (ACS). The objective of this study was to determine the sensitivity, specificity, and predictive value of 13 symptoms for a discharge diagnosis of ACS in women and men.

Methods and Results

The sample included 736 patients admitted to 4 EDs with symptoms suggestive of ACS. Symptoms were assessed with the 13‐item validated ACS Symptom Checklist. Mixed‐effects logistic regression models were used to estimate sensitivity, specificity, and predictive value of each symptom for a diagnosis of ACS, adjusting for age, obesity, diabetes, and functional status. Patients were predominantly male (63%) and Caucasian (70.5%), with a mean age of 59.7±14.2 years. Chest pressure, chest discomfort, and chest pain demonstrated the highest sensitivity for ACS in both women (66%, 66%, and 67%) and men (63%, 69%, and 72%). Six symptoms were specific for a non‐ACS diagnosis in both women and men. The predictive value of shoulder (odds ratio [OR]=2.53; 95% CI=1.29 to 4.96) and arm pain (OR 2.15; 95% CI=1.10 to 4.20) in women was nearly twice that of men (OR=1.11; 95% CI=0.67 to 1.85 and OR=1.21; 95% CI=0.74 to 1.99). Shortness of breath (OR=0.49; 95% CI=0.30 to 0.79) predicted a non‐ACS diagnosis in men.

Conclusions

There were more similarities than differences in symptom predictors of ACS for women and men.

Clinically distinct characteristics in patients younger than 40 years old with non-cardiac chest pain

BACKGROUND AND AIM

Little is known about non-cardiac chest pain (NCCP) in young patients. We aimed to examine the proportion of gastroesophageal reflux disease (GERD) in young patients with NCCP compared to the average-aged NCCP patients and to evaluate their symptomatic characteristics and the clinical efficacy of a 2-week proton pump inhibitor (PPI) trial.

METHODS

Ninety-six patients with NCCP≥1/week were classified into the young-aged (≤ 40 years, n =38) and the average-aged groups (>40 years, n=58). Typical reflux symptoms were assessed. The patients were defined into a GERD group and non-GERD group according to reflux esophagitis on esophagogastroduodenoscopy and/or pathologic acid exposure on 24-h esophageal pH monitoring. Then the patients were treated with 30mg of lansoprazole bid for 14 days.

RESULTS

Nine patients (23%) in the young-aged group and 22 patients (38%) in average-aged group were diagnosed with GERD-related NCCP (P=0.144). The proportion of typical reflux symptoms was higher in the GERD group compared with the non-GERD group in both age groups. A PPI test improved symptoms in the GERD group irrespective of age, but this improvement was not observed in non-GERD group.

CONCLUSIONS

In young NCCP patients, the prevalence of GERD was relatively low compared to average-aged NCCP, but the difference was insignificant. The PPI test was very effective in diagnosing GERD in the NCCP patients in both age groups. Therefore, in young NCCP patients, if there is a negative response to a 2-week PPI trial, the possibility of extra-esophageal disease origin needs to be considered.

Noncardiac chest pain: diagnostic evaluation

Noncardiac chest pain (NCCP) is a common and challenging clinical problem. It is estimated that more than 70 million Americans (23% of the population) suffer from this condition yearly. Patients with NCCP represent a diagnostic dilemma. Their chest pain is often indistinguishable from cardiac pain leading to extensive and expensive evaluations. Once coronary artery disease and other cardiac and pulmonary sources of chest pain are excluded, patients are frequently referred to gastroenterologists to look primarily for esophageal sources of pain. A variety of diagnostic tests are available to the practicing clinician to identify the origin of pain, including ambulatory pH testing, esophageal motility, upper endoscopy, provocative testing and even therapeutic trials.

Recent advances in noncardiac chest pain in Korea

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and is present in up to 60% of patients with NCCP in Western countries. In Korea, after a reasonable cardiac evaluation, GERD is reported to underlie 41% of NCCP cases. Typical reflux symptoms are frequent in Korean patients suffering from NCCP. Therefore, a careful history of the predominant symptoms, including heartburn and acid regurgitation, is relatively indicative of the GERD diagnosis in Korea. In Korea, in contrast to Western countries, patients aged 40 years and over who have been diagnosed with NCCP but who are without alarming features should undergo endoscopy to exclude gastric cancer or peptic ulcers because of the higher prevalence of peptic ulcer disease and gastric cancers in the region. In a primary care setting, in the absence of any alarming symptoms, a symptomatic response to a trial of a proton pump inhibitor (PPI) is sufficient for the presumptive diagnosis of GERD. In addition, the optimal duration of a PPI test may be at least 2 weeks, as GERD symptoms tend to be less frequent or atypical in Korean patients than in patients from Western countries. In patients diagnosed with GERD-related NCCP, long-term therapy (more than 2 months) with double the standard dose of a PPI is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement of chest pain control in non-GERD-related NCCP. Most traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects (for example, the serotonin - norepinephrine reuptake inhibitors) may be needed.

Multivariate modeling to identify patterns in clinical data: the example of chest pain

BACKGROUND

In chest pain, physicians are confronted with numerous interrelationships between symptoms and with evidence for or against classifying a patient into different diagnostic categories. The aim of our study was to find natural groups of patients on the basis of risk factors, history and clinical examination data which should then be validated with patients' final diagnoses.

METHODS

We conducted a cross-sectional diagnostic study in 74 primary care practices to establish the validity of symptoms and findings for the diagnosis of coronary heart disease. A total of 1199 patients above age 35 presenting with chest pain were included in the study. General practitioners took a standardized history and performed a physical examination. They also recorded their preliminary diagnoses, investigations and management related to the patient's chest pain. We used multiple correspondence analysis (MCA) to examine associations on variable level, and multidimensional scaling (MDS), k-means and fuzzy cluster analyses to search for subgroups on patient level. We further used heatmaps to graphically illustrate the results.

RESULTS

A multiple correspondence analysis supported our data collection strategy on variable level. Six factors emerged from this analysis: "chest wall syndrome", "vital threat", "stomach and bowel pain", "angina pectoris", "chest infection syndrome", and " self-limiting chest pain". MDS, k-means and fuzzy cluster analysis on patient level were not able to find distinct groups. The resulting cluster solutions were not interpretable and had insufficient statistical quality criteria.

CONCLUSIONS

Chest pain is a heterogeneous clinical category with no coherent associations between signs and symptoms on patient level.

Differences in mortality in acute coronary syndrome symptom clusters

BACKGROUND

The timely and accurate identification of symptoms of acute coronary syndrome (ACS) is a challenge for patients and clinicians. It is unknown whether response times and clinical outcomes differ with specific symptoms. We sought to identify which ACS symptoms are related-symptom clusters-and to determine if sample characteristics, response times, and outcomes differ among symptom cluster groups.

METHODS

In a multisite randomized clinical trial, 3522 patients with known cardiovascular disease were followed up for 2 years. During follow-up, 331 (11%) had a confirmed ACS event. In this group, 8 presenting symptoms were analyzed using cluster analysis. Differences in symptom cluster group characteristics, delay times, and outcomes were examined.

RESULTS

The sample was predominantly male (67%), older (mean 67.8, S.D. 11.6 years), and white (90%). Four symptom clusters were identified: Classic ACS characterized by chest pain; Pain Symptoms (neck, throat, jaw, back, shoulder, arm pain); Stress Symptoms (shortness of breath, sweating, nausea, indigestion, dread, anxiety); and Diffuse Symptoms, with a low frequency of most symptoms. Those in the Diffuse Symptoms cluster tended to be older (P = .08) and the Pain Symptoms group was most likely to have a history of angina (P = .01). After adjusting for differences, the Diffuse Symptoms cluster demonstrated higher mortality at 2 years (17%) than the other 3 clusters (2%-5%, P < .001), although prehospital delay time did not differ significantly.

CONCLUSION

Most ACS symptoms occur in groups or clusters. Uncharacteristic symptom patterns may delay diagnosis and treatment by clinicians even when patients seek care rapidly. Knowledge of common symptom patterns may facilitate rapid identification of ACS.

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.

The Italian validation of the Montreal Global definition and classification of gastroesophageal reflux disease

BACKGROUND AND AIMS

Recently, a Global definition and a classification of gastroesophageal reflux disease (GERD) were developed by Montreal Consensus Group, composed of international expert gastroenterologists. Guidelines and consensus documents are, however, infrequently accepted and adopted at a local level. The aim of this study was to measure the acceptance of Montreal Global definition of GERD consensus document by specialists in a single country (Italy) and to measure the linguistic, scientific, and practical differences between the international consensus document and the Italian version.

METHODS

A 2-day meeting was held in June 2007 in Rome, Italy, attended by 147 Italian physicians who were experts in gastroenterology. They reviewed the individual original statements in their Italian translation and then voted on the statement using the scoring system used by the Montreal Consensus Group (6-point Likert scale). Voting was performed at baseline and after an analytical discussion on each statement, led by six internationally renowned experts. Consensus was defined as an agreement with a statement by at least two-thirds of the group. Results were compared with the Montreal statements.

RESULTS AND DISCUSSION

The level of consensus was already extremely high at the first vote (>90% with the two-thirds threshold). The level of agreement at the second vote increased slightly. The maximum variation between two votes was 33% (of increase from first to second round, 59-92%). The high level of agreement could be because of both the general acceptance of Montreal Consensus by scientific community, and the new scientific evidences published after the Montreal report, which fit with the original statements.

CONCLUSION

This study is the first national linguistic validation of the Montreal Global definition of GERD and is also proof of its scientific validity, based on the same methodology used to create the Montreal statements. It also suggests that evidence-based International disease classification systems can be applied to local settings after validation by local experts.

Chest wall syndrome among primary care patients: a cohort study

Background

The epidemiology of chest pain differs strongly between outpatient and emergency settings. In general practice, the most frequent cause is the chest wall pain. However, there is a lack of information about the characteristics of this syndrome. The aims of the study are to describe the clinical aspects of chest wall syndrome (CWS).

Methods

Prospective, observational, cohort study of patients attending 58 private practices over a five-week period from March to May 2001 with undifferentiated chest pain. During a one-year follow-up, questionnaires including detailed history and physical exam, were filled out at initial consultation, 3 and 12 months. The outcomes were: clinical characteristics associated with the CWS diagnosis and clinical evolution of the syndrome.

Results

Among 24 620 consultations, we observed 672 cases of chest pain and 300 (44.6%) patients had a diagnosis of chest wall syndrome. It affected all ages with a sex ratio of 1:1. History and sensibility to palpation were the keys for diagnosis. Pain was generally moderate, well localised, continuous or intermittent over a number of hours to days or weeks, and amplified by position or movement. The pain however, may be acute. Eighty-eight patients were affected at several painful sites, and 210 patients at a single site, most frequently in the midline or a left-sided site. Pain was a cause of anxiety and cardiac concern, especially when acute. CWS coexisted with coronary disease in 19 and neoplasm in 6. Outcome at one year was favourable even though CWS recurred in half of patients.

Conclusion

CWS is common and benign, but leads to anxiety and recurred frequently. Because the majority of chest wall pain is left-sided, the possibility of coexistence with coronary disease needs careful consideration.

Clinical usefulness of subgrouping of patients with non-cardiac chest pain according to characteristic symptoms in Korea

BACKGROUND

Non-cardiac chest pain (NCCP) is a heterogeneous disorder. There is controversy about the associations between symptoms and causes in NCCP patients. The purpose of the present study was to evaluate the clinical usefulness of subgrouping according to characteristic symptoms in NCCP patients.

PATIENTS AND METHODS

Fifty-eight patients were classified into two groups, as patients with typical reflux symptoms (group I, n = 24) and those without typical reflux symptoms (group II, n = 34). They underwent upper endoscopy, manometry, and 24-h esophageal pH monitoring.

RESULTS

Twenty-four (41%) of the patients were diagnosed with gastroesophageal reflux disease (GERD) at upper endoscopy or 24-h esophageal pH monitoring. Eleven (19%) were diagnosed with GERD-associated esophageal motility disorder and 13 (22%) were diagnosed with non-GERD-associated esophageal motility disorder. The two groups did not differ significantly in age, sex, weight, smoking history, history of chronic alcoholism, or the severity, duration and frequency of symptoms. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of group I for GERD-related NCCP were significantly higher than those of group II. Group I had a higher proportion of patients with GERD-associated esophageal motility disorder (55%) than non-GERD-associated esophageal motility disorder (23%).

CONCLUSION

Typical reflux symptoms can be used to distinguish patients with GERD-related NCCP from patients with NCCP, and subgrouping according to characteristic symptoms may assist the diagnosis of these patients in Korea.

Pain characteristics in patients with unexplained chest pain and patients with ischemic heart disease

BACKGROUND

Little scientific attention has been paid to providing a comprehensive multidimensional description of chest pain in patients with unexplained chest pain.

AIMS

The aims of the present study were: (1) to describe the symptom chest pain, including the dimensions of intensity, quality, duration and location in patients with unexplained chest pain (UCP); and (2) to identify similarities and differences in how patients with UCP and patients with ischemic heart disease (IHD) describe chest pain.

METHOD

A descriptive, correlational and comparative design. Totally 208 consecutive UCP patients and 40 IHD patients below 70 years of age participated. Pain was assessed using the instrument Pain-O-Meter.

RESULTS

The occurrence of chest pain was 79% (n=165) in UCP patients versus 60% (n=22) in the IHD patients (p=0.001). Patients with UCP reported greater pain intensity and used more sensory and affective words than IHD patients (p<0.01). Relationships between pain location and amount of body surface involved in the pain and pain intensity in both groups were found (p<0.001).

CONCLUSIONS

Our results showed some defining characteristics of the UCP group, but the many similarities between the two groups in their experience of chest pain made it impossible to clearly differentiate the groups' pain profiles.

Risk factors for non-cardiac chest pain in the community

BACKGROUND

Non-cardiac chest pain is a common and expensive condition. Risk factors for non-cardiac chest pain are poorly understood and lack description in the USA community.

AIM

To explore risk factors and health-seeking behaviour in non-cardiac chest pain in a USA community.

METHODS

Olmsted County, MN subjects who reported at least monthly or severe chest pain in response to a validated questionnaire were compared with controls. All the Mayo Clinic medical records were reviewed; those with cardiac disease or relevant organic conditions were excluded.

RESULTS

Of 2118 eligible subjects, 1524 (72%) returned a questionnaire, 389 subjects (26%) reported any chest pain and 186 (12.2%) at least monthly or severe chest pain. Of these, 62 were excluded for a cardiac diagnosis or another organic cause. Thus, 124 subjects (9.1%, 95% CI: 7.6-10.8%) reported at least monthly or severe non-cardiac chest pain, of which 65 (52.4%) had frequent reflux symptoms. Independent risk factors for non-cardiac chest pain were obesity (OR 3.0, 95% CI: 1.64-5.50), family history of reflux (OR 2.8, 95% CI: 1.73-4.32), previous cigarette use (OR 2.0, 95% CI: 1.27-3.18), aspirin use (OR 1.5, 95% CI: 1.00-2.31) and use of antiarthritis medicines (OR 2.0, 95% CI: 1.27-3.16). Compared with subjects with non-cardiac chest pain and associated gastro-oesophageal reflux symptoms, subjects with non-cardiac chest pain without associated gastro-oesophageal reflux symptoms were less likely to have a family history of reflux, more likely to be younger, and less likely to be obese. Compared with controls, subjects with non-cardiac chest pain without gastro-oesophageal reflux symptoms were younger (OR 0.97, 95% CI: 0.95-0.99), reported higher somatic symptom scores (OR 1.1, 95% CI: 1.08-1.73) and were more likely to be obese (OR 2.6, 95% CI: 1.15-5.93).

CONCLUSIONS

Recurrent or severe non-cardiac chest pain is common in the community. Half of the people with significant non-cardiac chest pain have frequent reflux symptoms, thus, risk factors for non-cardiac chest pain are similar to risk factors for gastro-oesophageal reflux disease. People with non-cardiac chest pain without reflux symptoms have a slightly different risk factor profile.

Diagnosis and treatment of noncardiac chest pain

Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.