Acute chest pain without obvious organic cause before the age of 40. Respiratory and circulatory response to mental stress

Unexplained acute chest pain in young adults: disease patterns and medication use 25 years later

BACKGROUND

Patients with unexplained chest pain are commonly revisiting an emergency department with various symptoms, but comprehensive long-term studies are lacking.

METHODS

A total of 150 young adults (aged 18-40 years) with unexplained chest pain who presented at an emergency unit for 16 weeks in mid-1980s were included in a prospective cohort study. An age- and sex-matched control group was randomly selected from the same area. Data were retrieved from registers that recorded death, income, education, country of birth, diagnoses, hospitalizations, outpatient visits, and medications dispensed.

RESULTS

Patients with unexplained acute chest pain had lower levels of education and income and were more often immigrants. Long-term mortality rates did not differ between cases (4%) and controls (5%) during 25 years of follow-up, nor were there differences in diagnosis of ischemic heart disease. Patients with unexplained acute chest pain had more outpatient visits (median, 5 versus 2; p < .0001) and had more often been hospitalized (61.6% ever versus 41.8%; p < .001) during the follow-up period. Several disorders were more common among patients 20 to 25 years later, including atrial fibrillation, esophageal/gastric disorders, chest pain, palpitations, abdominal discomfort, musculoskeletal symptoms, sleeping disturbance, and stress reactions (p values < .05). More patients had been given antihypertensives, anticoagulants, antidepressants, analgesics, and hypnotics/tranquilizers (p values < .05).

CONCLUSIONS

Young patients admitted to the emergency department with unexplained acute chest pain showed no increased risk of mortality or ischemic heart disease during 25 years of follow-up, but they had higher incidence of a wide range of disorders and used more medications. Early identification and preventive interventions may improve health outcomes in these patients.

Psychosocial factors in patients with noncardiac chest pain

OBJECTIVE

This study sought to explore some psychosocial factors that distinguished individuals with noncardiac chest pain (NCCP) from those without NCCP, and whether these psychosocial factors were associated with anxiety and depression that are co-morbid factors of NCCP.

METHODS

A matched case-control design was adopted to compare differences in psychosocial factors among a target group of patients with NCCP (N = 70), a pain control group of patients with rheumatism (N = 70), and a community control group of healthy individuals (N = 70).

RESULTS

Compared with subjects from the two control groups, NCCP patients tended to monitor more, use more problem-focused coping, display a coping pattern with a poorer strategy-situation fit, and receive less emotional support in times of stress. Moreover, monitoring perceptual style and problem-focused coping were associated with higher levels of anxiety and depression. Coping pattern with a strategy-situation fit and emotional support were related to lower levels of anxiety and depression.

CONCLUSIONS

The present new findings suggest that monitoring perceptual style and inflexible coping style are risk factors that enhance one's vulnerability to NCCP. Emotional support may be a resource factor that reduces one's susceptibility to NCCP.

Respiratory dysregulation in anxiety, functional cardiac, and pain disorders. Assessment, phenomenology, and treatment

Respiration is a complex physiological system affecting a variety of physical processes that can act as a critical link between mind and body. This review discusses the evidence for dysregulated breathing playing a role in three clinical syndromes: panic disorder, functional cardiac disorder, and chronic pain. Recent technological advances allowing the ambulatory assessment of endtidal partial pressure of CO2 (PCO2) and respiratory patterns have opened up new avenues for investigation and treatment of these disorders. The latest evidence from laboratories indicates that subtle disturbances of breathing, such as tidal volume instability and sighing, contribute to the chronic hypocapnia often found in panic patients. Hypocapnia is also common in functional cardiac and chronic pain disorders, and studies indicate that it mediates some of their symptomatology. Consistent with the role of respiratory dysregulation in these disorders, initial evidence indicates efficacy of respiration-focused treatment.

Therapy-resistant periodontitis (II). Compliance and general and dental health experiences

In this exploratory case-control study, somatic and psychological factors are used for exploring whether the anamnestic information gives support to the hypothesis of a relationship between therapy-resistant periodontitis and stress factors. From retrospective comparisons of pocket probing depth charts, we classified 22 patients as either non-responding or responding to periodontal treatment. The non-responding patient group, in comparison with the responding patient group, showed a profile over time of less pocket probing depth (PPD) reduction in response to periodontal treatment. Information registered in each patient's file regarding periodontal registrations and dental status was gathered, and an interview was conducted aiming at collecting information on dental experiences and attitudes. Bivariate and logistic multivariate regression analyses were performed. The NR-group patients experienced significantly more unpleasant feelings towards dental procedures and a higher tendency to experience pain in connection with dental procedures. This group was found to start smoking at an older age than the R-group. One reason for this may be that smoking debut at an older age is more related to stress conditions than debut at a younger age. The report highlights the possible contribution of stress factors in periodontal disease.

Emergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain

STUDY OBJECTIVES

To determine the feasibility, safety, and reliability of emergency cardiac treadmill exercise stress testing (CTEST) in the evaluation of emergency department patients with atypical chest pain.

DESIGN

Thirty-two patients with atypical chest pain, normal ECGs, and risk factor stratification having low-probability of coronary artery disease were evaluated prospectively using outpatient, emergency CTEST. Study patients were compared with a retrospectively selected sample of admitted patients diagnosed with atypical chest pain who met the study criteria and were evaluated with CTEST as inpatients. All patients had follow-up at three and six months after evaluation.

SETTING

University-affiliated community teaching hospital with 65,000 annual ED visits.

RESULTS

All patients had normal CTEST. No patient had evidence of coronary artery disease, myocardial infarction, or sudden death during the follow-up period. The average length of stay was 5.5 hours for emergency CTEST patients versus two days for inpatients. The average patient charge was $467 for ED evaluation with emergency CTEST versus $2,340 for inpatient evaluation.

CONCLUSION

Emergency CTEST is a safe, efficient, cost-effective, and practical method of evaluating selected ED patients with chest pain. It is a useful aid for clinical decision making and may help to prevent unnecessary hospital admissions.

Five-year follow-up of young adults visiting an emergency unit because of atypical chest pain

A five-year follow-up, by means of a personal interview, was performed on patients below the age of 40 years with acute chest pain without obvious organic cause (n = 64). They had been consecutively admitted to the emergency unit over a period of 8 weeks, and had all been subjected to a thorough medical and psychosocial investigation with feedback soon after the initial consultation (investigation patient group, IP). For comparison, a non-investigation patient (NIP) group (n = 51) was recruited over a period of 8 separate weeks. Half of the patients in each group reported at the follow-up that they continued to suffer from chest pain. Compared to normal subjects, they reported more depression. This means that the initial research programme performed in the investigation group had no sustained therapeutic effect compared to routine care at the emergency unit. Tension, anxiety and number of consultations with a physician, as reported in the initial investigation, were negatively correlated with the outcome at follow-up. We conclude that acute chest pain without obvious organic cause in young adults is a condition with an excellent prognosis in strictly physical terms. However, a high proportion of the patients continue to suffer from chest pain for several years, and many of them continue to be consumers of medical resources. We therefore suggest that therapeutic programmes should be developed, particularly for those who report psychological symptoms and those with a history of many consultations with physicians.

Clinical symptoms in young adults with atypical chest pain attending the emergency department

Clinical symptoms were studied in 69 consecutive patients below the age of 40 years who were attending the emergency unit because of unexplained chest pain. In a structured interview a few weeks after the emergency visit, only one-third of the patients reported that they believed in the doctor's diagnosis; they believed in a psychological or cardiac origin of the pain more often than the doctors. The chest pain was most often described as oppressive and/or stabbing. In 95% of cases it was central or left-sided. Associated symptoms were commonly reported, breathlessness being most commonly reported by two-thirds of the patients, followed by dizziness, palpitation and numbness/tingling. Mental symptoms such as tiredness, anxiety and tension were frequently reported. On the basis of the background literature the aetiology is discussed. We conclude that immediate symptom analysis, including psychosomatic symptoms, particularly breathing problems, is of central importance.

Acute chest pain without obvious organic cause before the age of 40 years: response to forced hyperventilation

A hyperventilation provocation test (HVPT) was performed on a group (n = 63) of consecutive patients, below the age of 40 years, attending an emergency care unit complaining of chest pain without obvious organic cause. The results were compared with those for a control group (n = 32). There was no tendency to hyperventilate in the patient group, either after discontinuing hyperventilation or during the ensuing relaxation period. PETCO2 measurements during this time thus showed no significant differences between the patient group and the control group. During the HVPT, 44% of patients reported three or more listed symptoms familiar to them from earlier occasions and regarded as typical of hyperventilation, compared to 23% of the controls (P less than 0.05). In a previously reported study, 38% of the patients were found to have similar symptoms during standardized mental stress, despite lack of hypocapnia. It is concluded that, on the basis of PETCO2 measurements, there were no signs of abnormal hyperventilation in the patient group. Moreover, the HVPT did not appear to be specific for diagnosis of hyperventilation syndrome, since mental stress itself was able to reproduce symptoms without concomitant hypocapnia, and since the provocation test was 'positive' in many control subjects.