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

Impact of a correct breathing stereotype on pulmonary minute ventilation, blood gases and acid-base balance in post-myocardial infarction patients

STUDY OBJECTIVE

The aim of the study was to evaluate the impact of a long-term (6-month) correct breathing stereotype on minute ventilation, capillary blood gases and acid-base balance in post-myocardial infarction patients.

METHODS

Fifty-five men (age 57.2 +/- 12.5) were examined 2 months later after myocardial infarction. Spirometry and assessment of acid-base balance and capillary blood gases were performed at rest and repeated after 10 days and 6 months. Breathing correction was taught over 5 days. A session for the control and maintenance of the correct breathing skills was hosted once a month (during the 6-month period).

RESULTS

Changes of minute ventilation, capillary blood gases and acid-base balance were revealed in 55% of patients 2 months later after myocardial infarction. Twenty patients (group I) were randomly selected for breathing correction while 10 patients made up the control group (group II). After breathing correction minute ventilation significantly decreased (18.5 +/- 5.5 versus 9.8 +/- 2.5 l/min), oxygen ventilatory equivalent decreased (39.8 +/- 5.2 versus 22.5 +/- 3.8), partial pressure of blood carbon dioxide increased (33.2 +/- 1.7 versus 44.2 +/- 2.5 mmHg), plasma bicarbonate concentration augmented (19.1 +/- 2.2 versus 24.5 +/- 1.8 mmol/l), base excess normalized (-2.90 +/- 2.5 versus +1.3 +/- 2.1 mmol/l), and pH shifted to more alkaline value (7.36 +/- 0.01 versus 7.43 +/- 0.02).

CONCLUSIONS

A long-term correct breathing stereotype improved respiratory function and could be an additional measure in rehabilitation programmes for post-myocardial infarction patients.

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.

An observational investigation of dysfunctional breathing and breathing control therapy in a problem asthma clinic

OBJECTIVES

Dysfunctional breathing (DB) is recognized as an associated problem in patients with asthma and may be identified by the Nijmegen questionnaire. We conducted an observational study to determine if breathing control therapy (BCT) improved Nijmegen scores or asthma-related quality of life in patients attending a problem asthma clinic.

METHODS

Nijmegen and Mini Asthma Quality of Life (Mini-AQLQ) questionnaires were completed. Patients with a positive Nijmegen (> or = 23, DB) were referred for BCT and progressive exercise testing (PET) to seek confirmation of dysfunctional breathing. Follow-up questionnaire data were collected at 6 months.

RESULTS

A total of 102 patients were studied. The total mean Nijmegen score was 26.4 (range 1-61). Those with a score > or = 23 (DB group, n = 65, 64%) had significantly lower Mini-AQLQ (mean 2.83) than the non-DB group (n = 37, mean 4.12, 95% CI for difference 0.87, 1.87, p < 0.0001). There was a strong relationship between Nijmegen score and Mini-AQLQ (r = -0.63, p < 0.001) at baseline; 10 of 17 DB patients who completed PET showed inappropriate hyperventilation. Follow-up data, available for Nijmegen and Mini-AQLQ in 44 and 46 patients respectively, showed no significant change in either of these parameters.

CONCLUSIONS

The strong relationship between Mini-AQLQ and Nijmegen scores and poor relationship between Nijmegen scores and PET-identified inappropriate hyperventilation suggest that a positive Nijmegen score overestimates the presence of dysfunctional breathing in patients with moderate to severe asthma. We found no evidence that a moderate intensity breathing control intervention had any impact on Nijmegen scores or asthma-related quality of life in this patient group.

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.

Spinal pain syndromes: nociceptive, neuropathic, and psychologic mechanisms

BACKGROUND

Pain continues to be the main symptom reported by patients. Frequently, clinicians incorrectly diagnose patients and resulting treatments are ineffective, which may promote the development of chronic pain. This situation may arise as a result of a lack of clarity in the literature regarding pain syndromes.

OBJECTIVE

To discuss the differences between nociceptive, neuropathic, and psychologic induction of pain and provide important clinical correlates to aid in diagnosis and treatment.

DATA SOURCES

The data were accumulated over a period of years by reviewing contemporary articles and books and subsequently retrieving relevant papers. Articles also were selected from MEDLINE searches and from manual library searches.

DATA SYNTHESIS

Nociceptive pain syndromes are responsible for the majority of pain complaints in clinical practice. Care must be taken to avoid the common mistake of the diagnosis of neuropathic pain, which can lead to inappropriate treatments.

CONCLUSION

Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.

Presence of hyperventilation in patients with asthma-like symptoms but negative asthma test responses: provocation with voluntary hyperventilation and mental stress

BACKGROUND

A group of patients reporting asthma-like symptoms but with negative asthma tests has been identified.

OBJECTIVE

The objective of this study was to determine whether hyperventilation might explain these symptoms and whether the tests could be used as diagnostic tools.

METHODS

A hyperventilation provocation test (HVPT), a mental stress test, and the Word Color Conflict Test (WCCT) were performed on 10 patients with asthma-like symptoms, 10 patients with asthma, and 10 healthy subjects. End-tidal PCO 2 (PETCO2) was recorded 10 minutes after the HVPT and during the WCCT. Blood pressure, heart rate, and respiratory rate were also studied. The Nijmegen symptom questionnaire was used in the assessment of symptoms.

RESULTS

After the HVPT, the PETCO2 values recovered most slowly in the study group, the difference being significant compared with the healthy group (P <.01). During the WCCT, the study group had the lowest PETCO2 values at the 10- and 15-minute measurements, the difference again being significant compared with the healthy group (P <.05). The study group more often experienced symptoms before the test than the group with asthma (P <.05) and the healthy group (P <.001). The study group recognized significantly more symptoms previously experienced during the HVPT than the group with asthma (P <.05) and the healthy group (P <.01) and during the WCCT than the healthy group (P <.05). The study group showed a negative correlation between the PETCO2 level and the number of symptoms after the HVPT at 8 (r = -0-72; P <.05) and 10 minutes (r = -0.76; P <.05) and after the WCCT (r = -0.59; P <.05). Blood pressure, heart rate, and respiratory rate showed small differences between the groups.

CONCLUSION

Patients with asthma-like symptoms may experience hyperventilation when provoked. Mental stress might be 1 trigger factor. The HVPT and WCCT can be used as diagnostic instruments.

Subjective symptoms and breathing pattern at rest and following hyperventilation in anxiety and somatoform disorders

The purpose of the present study was to investigate the diagnostic specificity of bodily symptoms and respiratory behavior at rest and after a hyperventilation provocation test (HVPT) in patients that were either grouped according to the DSM classification or diagnosed as suffering from hyperventilation syndrome. Nine hundred three anxiety and somatoform patients, showing symptoms supposedly caused by psychogenic hyperventilation, and 170 healthy subjects, were studied. Breathing pattern and end-tidal CO2 concentration were recorded during breathing at rest and following a HVPT. Subjective symptoms in daily life and after HVPT were measured. A principal-components analysis was performed on both the symptoms and breathing variables and their specificity levels were compared in the two classifications of patients. Some symptoms in daily life were grouped together with the same symptoms after the HVPT, other symptoms were not. This suggests that the HVPT elicited partly specific symptoms, and partly reproduced the symptoms experienced in daily life. Similar findings were observed with respect to the breathing variables. Patients with panic differed from other patients with anxiety disorders by an increased level of symptoms and a FETCO2 decline at rest. The HVPT may be informative for diagnosis because it provokes some of the typical somatic and psychological symptoms, and it identifies the breathing instability that is characteristic of both patients with HVS and with anxiety. The same symptoms and breathing variables characterized the patients, whatever their classification. Overall, the specificity of breathing variables is rather low.

Hyperventilation syndrome: a chimera?

There is now an impressive body of research to suggest that the concept of a discrete hyperventilation syndrome is no longer tenable. The evidence for this has been carefully gathered and the scientific studies have employed innovative methodological techniques and have introduced a key psychological dimension. Both have led to a greater understanding of the respiratory correlates of anxiety, but in the process have revealed the "hyperventilation syndrome" to be a chimera. Furthermore, there is no evidence to support the view that panic attacks and hyperventilation are synonymous: on the contrary, hyperventilation rarely accompanies panic and, when it does, it is more likely to be a consequence than a cause of the panic. Finally, there is no evidence that "breathing therapy" works by normalizing pCO2; its nonspecific effects on anxiety appear to be mediated in part by slowing respiratory rate. Further research in this field might be more profitably focused on the nature of the association between anxiety disorders and organic lung disease, especially asthma.

The low specificity of the Hyperventilation Provocation Test

The Hyperventilation Provocation Test (HVPT) has become a routine procedure in the diagnosis of hyperventilation syndrome (HVS). During an HVPT the patient voluntarily overbreathes for several minutes to produce hypocapnia. The test is considered positive if the induced symptoms are recognized by the patient as similar to those experienced in daily life. The present study tests the assumption that hypocapnia is the primary trigger for symptoms during an HVPT. In a randomized double-blind crossover design. 115 patients suspected of HVS and 40 healthy controls performed an HVPT and a placebo test (PT, isocapnic overbreathing). The HVPT induced more symptoms than the PT, especially more neuromuscular symptoms, cerebral symptoms, paresthesias, and temperature sensations. However, the absolute difference between the number of symptoms induced by the HVPT and PT was small. In patients, the PT induced 66% of symptoms induced by the HVPT. In the control group this percentage was 60%. The low specificity of the HVPT implies that symptom recognition during the HVPT is invalid as a diagnostic criterion for HVS.

Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome

BACKGROUND

Hyperventilation syndrome (HVS) describes a set of somatic and psychological symptoms thought to result from episodic or chronic hyperventilation. Recognition of symptoms during the hyperventilation provocation test (HVPT) is the most widely used criterion for diagnosis of HVS. We have investigated the validity of the HVPT and of the concept of HVS.

METHODS

In a randomised, double-blind, crossover design, the ability of 115 patients with suspected HVS to recognise symptoms during the HVPT was compared with the ability to recognise symptoms during a placebo test (isocapnic overbreathing, with carbon dioxide levels maintained by manual titration). 30 patients who had positive results on the HVPT underwent ambulatory transcutaneous monitoring of pCO2 to ascertain whether they hyperventilated during spontaneous symptom attacks.

FINDINGS

Of the 115 patients who underwent the HVPT and the placebo test, 85 (74%) reported symptom recognition during the HVPT (positive diagnosis HVS). Of that subset, 56 were also positive on the placebo test (false-positive), and 29 were negative on the placebo test (true-positive). False-positive and true-positive patients did not differ in symptom profile or in physiological variables. During ambulatory monitoring (15 true-positive, 15 false-positive) 22 attacks were registered. Transcutaneous end-tidal, pCO2 decreased during only seven. The decreases were slight and apparently followed the onset of the attack, which suggests that hyperventilation is a consequence rather than a cause of the attack. There were no apparent differences between false-positive and true-positive patients.

INTERPRETATION

The HVPT is invalid as a diagnostic test for HVS. Hyperventilation seems a negligible factor in the experience of spontaneous symptoms. The term HVS should be avoided.

Voluntary hyperventilation: the influence of duration and depth on the development of symptoms

Hyperventilation is considered an important factor in the development of somatic symptoms or even panic attacks, though its role has recently been disputed. Arguments are often based on findings from the so-called Hyperventilation Provocation Test (HVPT), which is a procedure consisting of voluntarily overbreathing. The HVPT has been widely used for diagnosing Hyperventilation Syndrome and for experimentally eliciting panic attacks. Almost no attention, however, has been paid to standardizing the test and determining critical values with respect to depth and duration of hyperventilation. In the present study, symptom development was examined in 16 healthy subjects who underwent four HVPTs that differed in depth of hyperventilation (end-tidal PCO2 < 2.4 kPa or < 1.9 kPa), as well as duration of hyperventilation (2 or 5 min). Both depth and duration appeared to have an independent effect on the development of symptoms. In the 5-min condition, symptoms appeared mainly within the first 3 min. To be sure that the HVPT is long enough and deep enough to elicit symptoms in most people, a minimum duration of 3 min is advised, with end-tidal PCO2 decreasing to at least 1.9 kPa or dropping well over 50% of baseline.

Effects of high and low anxiety provoking instructions on the responses to the hyperventilation provocation test

This study examined the effect of high and low anxiety provoking instructions in subjects submitted to a Hyperventilation Provocation Test (HVPT). Subjects were 43 out-patients referred to our clinic for a diagnostic examination of Hyperventilation Syndrome (HVS). Results showed that anxiety levels were affected by the instruction manipulation, but the magnitude of this effect was less than expected and the instruction manipulation had no effect on intensity arid type of reproduced symptoms, nor on symptom recognition. Subjects who met Diagnostic and Statistical manual of Mental Disorders (3rd ed., rev,; American Psychiatric Association, 1987) criteria for Panic Disorder (PD) were not more responsive to the instruction manipulation than non-PD patients. It is argued that the small effect of the manipulation is probably not due to the solidity of the HVPT but to the pervasiveness of pretest cognitions and expectations. In line with this, the report of HVS symptoms appeared highly related to psychological trait measures like anxiety, fear of bodily sensations, and a general tendency to report somatic symptoms.

The covariation of common psychosomatic symptoms among children from socio-economically differing residential areas. An epidemiological study

Psychosomatic symptoms among children are believed to be commonplace. In this investigation by questionnaire, 47% of 1333 schoolchildren reported one or several symptoms, such as recurrent abdominal pain, headache, chest pains, loss of appetite and disturbances in bowel function. Coexistence of such symptoms was considerable and if a child had one of these, the probability that it would have one or more other symptoms was significantly increased. This correlation may strengthen both the suspicion that these symptoms are often psychosomatic and the idea that they have common CNS origin. There were appreciable differences in the frequency of the symptoms, between children at the more socially stable schools and schools with social problems. In the latter, the frequencies of symptoms differed between Swedish and immigrant children, which was not the case in the more socially stable schools.

Preliminary findings on increased muscle tension and tenderness, and recurrent abdominal pain in children. A clinical study

Recurrent abdominal pain of "non-organic origin" is a common pediatric problem. In most instances it is related to psychological factors. The origin of the pain itself, however, is still unknown. In this study, we question whether or not the complaint could have a muscular origin. In this clinical study of recurrent abdominal pain of probable "psychosomatic origin", all 27 children had tense and tender abdominal muscles, which was not the case in a control group. The children with recurrent abdominal pain also had a typical pattern of muscular tension and tenderness in other muscles. These children often have tension headache, "tension" chest pains and also more general symptoms such as loss of appetite and disturbed bowel function.

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.