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Alam MJ, Chen JDZ. Non-invasive neuromodulation: an emerging intervention for visceral pain in gastrointestinal disorders. Bioelectron Med 2023; 9:27. [PMID: 37990288 PMCID: PMC10664460 DOI: 10.1186/s42234-023-00130-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023] Open
Abstract
Gastrointestinal (GI) disorders, which extend from the esophagus to the anus, are the most common diseases of the GI tract. Among these disorders, pain, encompassing both abdominal and visceral pain, is a predominant feature, affecting the patients' quality of life and imposing a substantial financial burden on society. Pain signals originating from the gut intricately shape brain dynamics. In response, the brain sends appropriate descending signals to respond to pain through neuronal inhibition. However, due to the heterogeneous nature of the disease and its limited pathophysiological understanding, treatment options are minimal and often controversial. Consequently, many patients with GI disorders use complementary and alternative therapies such as neuromodulation to treat visceral pain. Neuromodulation intervenes in the central, peripheral, or autonomic nervous system by alternating or modulating nerve activity using electrical, electromagnetic, chemical, or optogenetic methodologies. Here, we review a few emerging noninvasive neuromodulation approaches with promising potential for alleviating pain associated with functional dyspepsia, gastroparesis, irritable bowel syndrome, inflammatory bowel disease, and non-cardiac chest pain. Moreover, we address critical aspects, including the efficacy, safety, and feasibility of these noninvasive neuromodulation methods, elucidate their mechanisms of action, and outline future research directions. In conclusion, the emerging field of noninvasive neuromodulation appears as a viable alternative therapeutic avenue for effectively managing visceral pain in GI disorders.
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Affiliation(s)
- Md Jahangir Alam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Jiande D Z Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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Chen J, Oshima T, Kondo T, Tomita T, Fukui H, Shinzaki S, Miwa H. Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study. J Neurogastroenterol Motil 2023; 29:446-454. [PMID: 37814435 PMCID: PMC10577468 DOI: 10.5056/jnm22184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/05/2023] [Accepted: 01/25/2023] [Indexed: 10/11/2023] Open
Abstract
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.
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Affiliation(s)
- Junji Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Takashi Kondo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Toshihiko Tomita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hirokazu Fukui
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Shinichiro Shinzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hiroto Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez R, Remes-Troche J, Abreu-Abreu A, Cerda-Contreras E, Gómez-Castaños P, González-Martínez M, Huerta-Iga F, Ibarra-Palomino J, Icaza-Chávez M, López-Colombo A, Márquez-Murillo M, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez J, Torres-Barrera G, Valdovinos-García L, Valdovinos-Díaz M, Vázquez-Elizondo G, Villar-Chávez A, Zavala-Solares M, Achem S. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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4
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez RI, Remes-Troche JM, Abreu Y Abreu AT, Cerda-Contreras E, Gómez-Castaños PC, González-Martínez MA, Huerta-Iga FM, Ibarra-Palomino J, Icaza-Chávez ME, López-Colombo A, Márquez-Murillo MF, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez JL, Torres-Barrera G, Valdovinos-García LR, Valdovinos-Díaz MA, Vázquez-Elizondo G, Villar-Chávez AS, Zavala-Solares M, Achem SR. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:372-397. [PMID: 31213326 DOI: 10.1016/j.rgmx.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/22/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia Digestiva y Motilidad Gastrointestinal «Endoneurogastro», Hospital Ángeles Puebla, Puebla, Puebla, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México.
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - R I Carmona-Sánchez
- Unidad de Medicina Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A T Abreu Y Abreu
- Gastroenterología y Fisiología Digestiva, Hospital Ángeles del Pedregal, Ciudad de México, México
| | - E Cerda-Contreras
- Medicina Interna, Gastroenterología y Motilidad Gastrointestinal, Hospital Médica Sur, Profesor de Medicina ITESM, Ciudad de México, México
| | | | - M A González-Martínez
- Departamento de Endoscopia, Laboratorio de Motilidad Gastrointestinal, Hospital de Especialidades CMN Siglo XXI IMSS, Ciudad de México, México
| | - F M Huerta-Iga
- Jefe de Endoscopia y Fisiología Digestiva, Hospital Ángeles Torreón, Torreón, Coahuila, México
| | - J Ibarra-Palomino
- Laboratorio de Motilidad Gastrointestinal, Área de Gastroenterología, Hospital Ángeles del Carmen, Guadalajara, Jalisco, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Profesora de Gastroenterología de la UNIMAYAB, Mérida, Yucatán, México
| | - A López-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional «Manuel Ávila Camacho», Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - M F Márquez-Murillo
- Cardiólogo Electrofisiólogo, Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - M Mejía-Rivas
- Gastroenterología, Endoscopia, Neurogastroenterología, Hospital «Vivien Pellas», Managua, Nicaragua
| | | | - J L Rodríguez-Chávez
- Gastroenterología y Neurogastroenterología, Hospital Puerta de Hierro, Guadalajara, Jalisco, México
| | - G Torres-Barrera
- Departamento de Gastroenterología, Hospital Universitario, Universidad Autónoma de Nuevo León, Profesor de cátedra, ITESM, Monterrey, Nuevo León, México
| | - L R Valdovinos-García
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - G Vázquez-Elizondo
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, OnCare Group, Monterrey, Nuevo León, México
| | - A S Villar-Chávez
- Gastroenterología y Motilidad Gastrointestinal, Hospital Ángeles Acoxpa, Ciudad de México, México
| | - M Zavala-Solares
- Unidad de Motilidad Gastrointestinal, Servicio de Gastroenterología, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - S R Achem
- Profesor de Medicina Interna y Gastroenterología, Facultad de Medicina, Mayo College of Medicine, Mayo Clinic, Jacksonville, Florida, Estados Unidos de América
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Heinrich H, Sweis R. The role of oesophageal physiological testing in the assessment of noncardiac chest pain. Ther Adv Chronic Dis 2018; 9:257-267. [PMID: 30719270 PMCID: PMC6348533 DOI: 10.1177/2040622318791392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/14/2018] [Indexed: 12/15/2022] Open
Abstract
Oesophageal physiology testing plays an important role in the diagnosis of noncardiac chest pain (NCCP) after cardiac, structural and mucosal abnormalities have been ruled out. Endoscopy can establish the presence of structural causes of chest pain such as cancer, oesophageal webs and diverticula. Even if macroscopically normal, eosinophilic oesophagitis is a common cause of chest pain and needs to be ruled out with an adequate biopsy regimen. In the remaining cases, diagnosis is focused on the identification of often subtle mechanisms that lead to NCCP. The most common oesophageal aetiologies for NCCP are gastro-oesophageal reflux disease (GORD), oesophageal dysmotility and functional chest pain. Ambulatory pH studies (with or without impedance or wireless measurements) can establish the presence of GORD, nonerosive reflux as well any association with symptoms of chest pain. High-resolution manometry, particularly with the inclusion of adjunctive testing, can rule out major motility disorders such as spasm, hypercontraction or achalasia. The EndoFLIP device can help define disorders with reduced distensibility, not easily appreciated with endoscopy or manometry. When all tests remain negative, a diagnosis of oesophageal hypersensitivity is normally made and therapy is shifted from targeting a disease to treating symptoms and patient affect.
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Affiliation(s)
- Henriette Heinrich
- University Hospital Zuerich, Department for Gastroenterology and Hepatology, Zuerich, Switzerland St Claraspital, Bauchzentrum, Basel, Switzerland
| | - Rami Sweis
- GI Services, University College London Hospital, Ground floor west, 250 Euston Road, London, NW1 2 PG, London, UK
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Abstract
Noncardiac chest pain is an angina-type discomfort without indication of ischemia. Diagnosis can be difficult because of its heterogeneous nature. Classification varies by specialty; gastroenterology uses the terminology gastroesophageal reflux disease related versus non-gastroesophageal reflux disease related. Other disciplines recognize noncardiac chest pain etiologies as having gastrointestinal, musculoskeletal, psychiatric, or pulmonary/other as underlying etiologies. Diagnostics yield a specific cause for effective treatment, which is aimed at the underlying etiology, but it is not always possible. Some patients with noncardiac chest pain have comorbidities and ongoing pain that lead to decreased quality of life and continued health care use.
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Affiliation(s)
- Sharron Rushton
- Duke University School of Nursing, DUMC Box 3322, Durham, NC 27710, USA.
| | - Margaret J Carman
- Georgetown University School of Nursing and Health Studies, St. Mary's Hall, 3700 Reservoir Road Northwest, Washington, DC 20007, USA
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7
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Min YW, Rhee PL. Esophageal hypersensitivity in noncardiac chest pain. Ann N Y Acad Sci 2016; 1380:27-32. [DOI: 10.1111/nyas.13182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/13/2016] [Accepted: 06/20/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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Min YW, Rhee PL. Noncardiac Chest Pain: Update on the Diagnosis and Management. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 65:76-84. [DOI: 10.4166/kjg.2015.65.2.76] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Coss-Adame E, Erdogan A, Rao SSC. Treatment of esophageal (noncardiac) chest pain: an expert review. Clin Gastroenterol Hepatol 2014; 12:1224-45. [PMID: 23994670 PMCID: PMC3938572 DOI: 10.1016/j.cgh.2013.08.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 08/13/2013] [Accepted: 08/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chest pain is a common and frightening symptom. Once cardiac disease has been excluded, an esophageal source is most likely. Pathophysiologically, gastroesophageal reflux disease, esophageal dysmotility, esophageal hypersensitivity, and anxiety disorders have been implicated. However, treatment remains a challenge. Here we examined the efficacy and safety of various commonly used modalities for treatment of esophageal (noncardiac) chest pain (ECP) and provided evidence-based recommendations. METHODS We reviewed the English language literature for drug trials evaluating treatment of ECP in PubMed, Cochrane, and MEDLINE databases from 1968-2012. Standard forms were used to abstract data regarding study design, duration, outcome measures and adverse events, and study quality. RESULTS Thirty-five studies comprising various treatments were included and grouped under 5 broad categories. Patient inclusion criteria were extremely variable, and studies were generally small with methodological concerns. There was good evidence to support the use of omeprazole and fair evidence for lansoprazole, rabeprazole, theophylline, sertraline, trazodone, venlafaxine, imipramine, and cognitive behavioral therapy. There was poor evidence for nifedipine, diltiazem, paroxetine, biofeedback therapy, ranitidine, nitrates, botulinum toxin, esophageal myotomy, and hypnotherapy. CONCLUSIONS Ideally, treatment of ECP should be aimed at correcting the underlying mechanism(s) and relieving symptoms. Proton pump inhibitors, antidepressants, theophylline, and cognitive behavioral therapy appear to be useful for the treatment of ECP. However, there is urgent and unmet need for effective treatments and for rigorous, randomized controlled trials.
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Affiliation(s)
- Enrique Coss-Adame
- Section of Gastroenterology and Hepatology, Georgia Regents University, Augusta, Georgia
| | - Askin Erdogan
- Section of Gastroenterology and Hepatology, Georgia Regents University, Augusta, Georgia
| | - Satish S C Rao
- Section of Gastroenterology and Hepatology, Georgia Regents University, Augusta, Georgia.
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Evaluation of alexithymia, somatosensory sensitivity, and health anxiety levels in patients with noncardiac chest pain. BIOMED RESEARCH INTERNATIONAL 2014; 2014:896183. [PMID: 24967410 PMCID: PMC4055647 DOI: 10.1155/2014/896183] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 05/16/2014] [Indexed: 11/17/2022]
Abstract
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.
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Lefort G, D'Antonio C, Caffery T. A non-ischaemic cause of elevated troponin. BMJ Case Rep 2014; 2014:bcr-2014-203729. [PMID: 24706705 DOI: 10.1136/bcr-2014-203729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 27-year-old woman with chest pain was admitted for elevated troponin levels. Troponin remained mildly elevated upon repeat testing, and a review of the medical record revealed that she had had an elevated troponin level in the past. She had a cardiac catheterisation that revealed angiographically normal coronary arteries. Repeat troponin testing with and without ethylene glycol revealed a negative troponin level after addition of ethylene glycol, suggesting antibodies were interfering with the assay.
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Affiliation(s)
- Guy Lefort
- Department of Emergency Medicine, LSU Health Baton Rouge, Baton Rouge, Louisiana, USA
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Haasenritter J, Stanze D, Widera G, Wilimzig C, Abu Hani M, Sonnichsen AC, Bosner S, Rochon J, Donner-Banzhoff N. Does the patient with chest pain have a coronary heart disease? Diagnostic value of single symptoms and signs--a meta-analysis. Croat Med J 2013; 53:432-41. [PMID: 23100205 PMCID: PMC3490454 DOI: 10.3325/cmj.2012.53.432] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To determine the diagnostic value of single symptoms and signs for coronary heart disease (CHD) in patients with chest pain. METHODS Searches of two electronic databases (EMBASE 1980 to March 2008, PubMed 1966 to May 2009) and hand searching in seven journals were conducted. Eligible studies recruited patients presenting with acute or chronic chest pain. The target disease was CHD, with no restrictions regarding case definitions, eg, stable CHD, acute coronary syndrome (ACS), acute myocardial infarction (MI), or major cardiac event (MCE). Diagnostic tests of interest were items of medical history and physical examination. Bivariate random effects model was used to derive summary estimates of positive (pLR) and negative likelihood ratios (nLR). RESULTS We included 172 studies providing data on the diagnostic value of 42 symptoms and signs. With respect to case definition of CHD, diagnostically most useful tests were history of CHD (pLR=3.59), known MI (pLR=3.21), typical angina (pLR=2.35), history of diabetes mellitus (pLR=2.16), exertional pain (pLR=2.13), history of angina pectoris (nLR=0.42), and male sex (nLR=0.49) for diagnosing stable CHD; pain radiation to right arm/shoulder (pLR=4.43) and palpitation (pLR=0.47) for diagnosing MI; visceral pain (pLR=2.05) for diagnosing ACS; and typical angina (pLR=2.60) and pain reproducible by palpation (pLR=0.13) for predicting MCE. CONCLUSIONS We comprehensively reported the accuracy of a broad spectrum of single symptoms and signs for diagnosing myocardial ischemia. Our results suggested that the accuracy of several symptoms and signs varied in the published studies according to the case definition of CHD.
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Affiliation(s)
- Jorg Haasenritter
- Philipps-Universitat Marburg, Abteilung fur Allgemeinmedizin, Praventive und Rehabilitative Medizin, Karl-von-Frisch-Strasse 4, Marburg, Germany.
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Mourad G, Jaarsma T, Hallert C, Strömberg A. Depressive symptoms and healthcare utilization in patients with noncardiac chest pain compared to patients with ischemic heart disease. Heart Lung 2012; 41:446-55. [PMID: 22652167 DOI: 10.1016/j.hrtlng.2012.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 03/09/2012] [Accepted: 04/08/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We compared depressive symptoms and healthcare utilization in patients admitted for noncardiac chest pain, acute myocardial infarction, and angina pectoris after hospitalization and at 1-year follow-up. METHODS One hundred and thirty-one patients with noncardiac chest pain, 66 with acute myocardial infarction, and 70 with angina pectoris completed a depression screening questionnaire and the Montgomery Åsberg Depression Rating Scale. Healthcare utilization data were collected from a population-based, diagnosis-related database. RESULTS More than 25% of respondents reported depressive symptoms, regardless of diagnosis. At follow-up, 9% had recovered, 19% were still experiencing depressive symptoms, and 13% had developed depressive symptoms. Noncardiac patients with chest pain had similar primary care contacts, but fewer hospital admissions, than patients with an acute myocardial infarction. Patients with angina pectoris and depressive symptoms used the most healthcare services. CONCLUSIONS Depressive symptoms were common. Patients with noncardiac chest pain used as much primary care as did patients with an acute myocardial infarction. Interventions should focus on identifying and treating depressive symptoms.
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Affiliation(s)
- Ghassan Mourad
- Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Norrköping, Sweden.
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Abstract
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.
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Affiliation(s)
- R Fass
- Section of Gastroenterology, Department of Medicine, Southern Arizona VA Health Care System, Tucson, Arizona 85723-0001, USA.
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Abstract
BACKGROUND Treatment of noncardiac chest pain (NCCP) remains a challenge. This is in part due to the heterogeneous nature of this disorder. Several conditions are associated with NCCP including gastro-oesophageal reflux disease (GERD), oesophageal dysmotility, oesophageal hypersensitivity as well as others. AIM To determine the currently available therapeutic modalities for NCCP. METHODS We performed a systematic review of the literature that was published between January, 1980 and March, 2011. We identified 734 studies; 68 of them met entry criteria. RESULTS Patients with GERD-related NCCP should receive proton pump inhibitors (PPI) twice daily for at least 8 weeks. Smooth muscle relaxants are only recommended for temporary relief of NCCP with motility disorders. Botulinum toxin injection of the distal oesophagus may be effective in the treatment of NCCP and spastic oesophageal motility disorders. Studies assessing the value of tricyclic antidepressants, trazodone and selective serotonin reuptake inhibitors in NCCP are relatively small, but suggest an oesophageal analgesic effect in NCCP patients that is limited by their side effects profile. The usage of theophylline to treat patients with non-GERD-related NCCP should be weighed against its potential toxicity. Use of complementary medicine has been scarcely studied in NCCP. Patients with coexisting psychological morbidity or those not responding to any medical therapy should be considered for psychological intervention. Cognitive behavioural therapy and hypnotherapy may be useful in the treatment of NCCP. CONCLUSIONS Patients with GERD-related noncardiac chest pain should be treated with at least double dose PPI. The primary treatment for non-GERD-related noncardiac chest pain, regardless if oesophageal dysmotility is present, is pain modulators.
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Affiliation(s)
- T Hershcovici
- The Neuroenteric Clinical Research Group, Southern Arizona VA Health Care System, Tucson, AZ 85723-0001, USA
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16
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Stochkendahl MJ, Christensen HW, Vach W, Høilund-Carlsen PF, Haghfelt T, Hartvigsen J. Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome. J Manipulative Physiol Ther 2011; 35:7-17. [PMID: 22185955 DOI: 10.1016/j.jmpt.2010.11.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 04/16/2011] [Accepted: 05/01/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The musculoskeletal system is a common but often overlooked cause of chest pain. The purpose of the present study is to evaluate the relative effectiveness of 2 treatment approaches for acute musculoskeletal chest pain: (1) chiropractic treatment that included spinal manipulation and (2) self-management as an example of minimal intervention. METHODS In a nonblinded, randomized, controlled trial set at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain and no clear medical diagnosis at initial presentation were included. After a baseline evaluation, patients with musculoskeletal chest pain were randomized to 4 weeks of chiropractic treatment or self-management, with posttreatment questionnaire follow-up 4 and 12 weeks later. Primary outcome measures were numeric change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale). RESULTS Both groups experienced decreases in pain, self-perceived positive changes, and increases in Medical Outcomes Study Short Form 36-Item Health Survey scores. Observed between-group significant differences were in favor of chiropractic treatment at 4 weeks regarding the primary outcome of self-perceived change in chest pain and at 12 weeks with respect to the primary outcome of numeric change in pain intensity. CONCLUSIONS To the best of our knowledge, this is the first randomized trial assessing chiropractic treatment vs minimal intervention in patients without acute coronary syndrome but with musculoskeletal chest pain. Results suggest that chiropractic treatment might be useful; but further research in relation to patient selection, standardization of interventions, and identification of potentially active ingredients is needed.
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Affiliation(s)
- Mette J Stochkendahl
- Researcher, Nordic Institute of Chiropractic and Clinical Biomechanics and Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Part of Clinical Locomotion Science, Odense, Denmark.
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17
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Fass R, Achem SR. Noncardiac chest pain: epidemiology, natural course and pathogenesis. J Neurogastroenterol Motil 2011; 17:110-23. [PMID: 21602987 PMCID: PMC3093002 DOI: 10.5056/jnm.2011.17.2.110] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 03/17/2011] [Accepted: 03/28/2011] [Indexed: 12/24/2022] Open
Abstract
Noncardiac chest pain is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after a reasonable workup has excluded a cardiac cause. Noncardiac chest pain is a prevalent disorder resulting in high healthcare utilization and significant work absenteeism. However, despite its chronic nature, noncardiac chest pain has no impact on patients' mortality. The main underlying mechanisms include gastroesophageal reflux, esophageal dysmotility and esophageal hypersensitivity. Gastroesophageal reflux disease is likely the most common cause of noncardiac chest pain. Esophageal dysmotility affects only the minority of noncardiac chest pain patients. Esophageal hypersensitivity may be present in non-GERD-related noncardiac chest pain patients regardless if esophageal dysmotility is present or absent. Psychological co-morbidities such as panic disorder, anxiety, and depression are also common in noncardiac chest pain patients and often modulate patients' perception of disease severity.
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Affiliation(s)
- Ronnie Fass
- Section of Gastroenterology, Department of Medicine, Southern Arizona VA Health Care System, Tucson, Arizona, USA.
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18
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Jerlock M, Björkelund C. A cognitive behavior intervention program in women with unexplained chest pain--a pilot study. Eur J Cardiovasc Nurs 2011; 11:183-9. [PMID: 21440508 DOI: 10.1016/j.ejcnurse.2011.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Unexplained chest pain (UCP) affects everyday life, causing fear and anxiety. Patients often have difficulty understanding their symptoms. AIM To test a cognitive behavior group intervention program designed for women with UCP, and investigate its effects in terms of participants' ideas and perceptions of the program as well as their pain experience. METHOD Nine women aged 44-69 participated in the pilot study, which included six group sessions. Three months after the intervention, interviews were conducted, followed by content analysis. RESULTS Narrating and sharing experiences led to awareness and understanding of what may affect chest pain. Knowledge about how stress affects the body and an understanding of one's own situation and what may affect the pain changed participants' patterns of thinking. The treatment provided tools to take control over beginning reactions to stress and thus prevent chest pain. Fewer pain attacks were reported but there was no pronounced decrease in pain intensity. CONCLUSION This pilot study shows that it is possible, through a cognitive behavior group intervention program, to generate positive experiences of managing stress and inner pressure and to change thinking patterns. The possibility to use these strategies and techniques to improve sleeping problems and alleviate pain is also presented.
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Affiliation(s)
- Margaretha Jerlock
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden.
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19
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[Psychiatric syndromes associated with atypical chest pain]. VOJNOSANIT PREGL 2010; 67:530-6. [PMID: 20707046 DOI: 10.2298/vsp1007530n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIM Chest pain often indicates coronary disease, but in 25% of patients there is no evidence of ischemic heart disease using standard diagnostic tests. Beside that, cardiologic examinations are repeated several times for months. If other medical causes could not be found, there is a possibility that chest pain is a symptom of psychiatric disorder. The aim of this study was to determine the presence of psychiatric syndromes, increased somatization, anxiety, stress life events exposure and characteristic of chest pain expression in persons with atypical chest pain and coronary patients, as well as to define predictive parameters for atypical chest pain. METHOD We compared 30 patients with atypical chest pain (E group) to 30 coronary patients (K group), after cardiological and psychiatric evaluation. We have applied: Mini International Neuropsychiatric Interiview (MINI), The Symptom Checklist 90-R (SCL-90 R), Beck Anxiety Invetory (BAI), Holms-Rahe Scale of stress life events (H-R), Questionnaire for pain expression Pain-O-Meter (POM). Significant differences between groups and predictive value of the parameters for atypical chest pain were determined. RESULTS The E group participants compared to the group K were younger (33.4 +/- 5.4: 48.3 +/- 6,4 years, p < 0.001), had a moderate anxiety level (20.4 +/- 11.9: 9.6 +/- 3.8, p < 0.001), panic and somatiform disorders were present in the half of the E group, as well as eleveted somatization score (SOM > or = 63-50%: 10%, p < 0.01) and a higher H-R score level (102.0 +/- 52.2: 46.5 +/- 55.0, p < 0.001). Pain was mild, accompanied with panic. The half of the E group subjects had somatoform and panic disorders. CONCLUSION Somatoform and panic disorders are associated with atypical chest pain. Pain expression is mild, accompained with panic. Predictive factors for atypical chest pain are: age under 40, anxiety level >20, somatization > or =63, presence of panic and somatoform disorders, H-R score >102, and a lack of positive diagnostic test of coronary disease. Defining of these parameters could be useful for early psychiatric evaluation of persons with atypical chest pain.
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20
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Jerlock M, Kjellgren KI, Gaston-Johansson F, Lissner L, Manhem K, Rosengren A, Welin C. Psychosocial profile in men and women with unexplained chest pain. J Intern Med 2008; 264:265-74. [PMID: 18397246 DOI: 10.1111/j.1365-2796.2008.01961.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of this study was to compare men and women with unexplained chest pain (UCP) to a randomly selected population sample free of clinical heart disease with regard to sleep problems, mental strain at work, stress at home, negative life events and health-related quality of life (HRQOL). DESIGN AND SUBJECTS The study was conducted at a university hospital in Sweden including 231 patients aged 25-69 without any organic cause for chest pain. As a reference group, 1069 participants, were recruited from the INTERGENE population-based study. RESULTS Patients with UCP had more sleep problems (OR = 1.8, P < 0.0001), were almost three times more worried about stress at work (OR = 2.9, P < 0.0001), or had more stress at home (OR = 2.8, P < 0.0001), and were twice as likely to have negative life events (OR = 2.1, P < 0.0001). Women, but not men, with UCP, had a higher prevalence of cardiovascular risk factors (obesity, smoking, diabetes and hypertension) compared with references. With regard to HRQOL, UCP patients scored significantly lower than references in all dimensions of the SF-36. CONCLUSIONS In comparison with a healthy reference group, patients with UCP reported more sleep problems, mental strain at work, stress at home and negative life events and had lower health-related quality of life. Aside from immigration the strongest independent psychosocial factors were mental strain at work and negative life events last year in men and stress at home in women.
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Affiliation(s)
- M Jerlock
- Institute of Health and Care Sciences, the Sahlgrenska Academy, Gothenburg, Sweden.
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21
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Abstract
Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.
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22
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Fagring AJ, Gaston-Johansson F, Kjellgren KI, Welin C. Unexplained chest pain in relation to psychosocial factors and health-related quality of life in men and women. Eur J Cardiovasc Nurs 2007; 6:329-36. [PMID: 17581792 DOI: 10.1016/j.ejcnurse.2007.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 05/03/2007] [Accepted: 05/10/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Unexplained chest pain is a frequent and increasingly common complaint among patients admitted to Emergency Departments. Previous studies have defined unexplained chest pain as non-cardiac or non-coronary artery disease, i.e. patients with other organic causes explaining the chest pain could be included. To increase the knowledge of unexplained chest pain, this study only includes patients without any known explanation for their chest pain. AIM To analyze gender differences regarding pain characteristics, psychosocial factors and health-related quality of life among patients diagnosed unexplained chest pain. METHODS AND RESULTS The results are based on 179 patients (101 men, 78 women) between 16 and 69 years old (mean age 45.3) consecutively admitted to Emergency Department. Pain characteristics were assessed by Pain-O-Meter. Social relationships, depression, anxiety, and health-related quality of life were measured by a self-administered questionnaire. There were no gender differences regarding chest pain intensity; however women described their pain as burning (p<0.01) and frightening (p<0.03) more often than men. Men reported less depression (p<0.01) and less trait anxiety (p=0.01) than women. Chest pain intensity did not significantly impact health-related quality of life except physical functioning in men (p=0.05). CONCLUSION Gender differences were few. Chest pain intensity did not significantly impact health-related quality of life.
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Affiliation(s)
- Annika Janson Fagring
- The Sahlgrenska Academy at Göteborg University, Institute of Health and Care Sciences, Box 457, SE 405 30 Göteborg, Sweden.
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