Different long-term course between chest pain and exercise-induced ST depression in syndrome X

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

Chest Pain Characteristics in Cardiac Syndrome X Compared to Coronary Artery Disease

AIM

This study aimed to assess if clinical remarks gained by analysis of the present and past medical history of patients undergoing elective coronary angiography (ECA) due to typical chest pain can help to predict the outcome of ECA.

MATERIAL AND METHODS

One hundred and fifty-four ECA candidates with a history of typical chest were seen on the same day intended for ECA in the cardiac centre of AlShaab Teaching Hospital, Khartoum, Sudan. The details of the present complaints, characteristics of chest pain, past medical and socioeconomic history were recorded from each subject guided by a questionnaire. ECA confirmed CAD in 112 of the studied patients and were considered as the test group. The remaining patients (N = 42) were diagnosed as CSX after exclusion of significant narrowing of the coronary vessels and were considered as the control group.

RESULTS

Univariate analysis of pain characteristics among patients undergoing coronary angiography revealed that pain is less likely to radiate to the neck (OR = 0.44, 95% CI = 0.21 - 0.91, P = 0.027) and the back (OR = 0.48, 95% CI = 0.23 - 1.00, P = 0.049) in patients with CAD. Presence of shortness of breathing and/or dizziness significantly decrease the odds of having abnormal coronary angiography (OR = 0.30 and 0.48, 95% CI = 0.12 - 0.77 and 0.22 - 0.92, P = 0.013 and 0.030 respectively). Past history of diabetes mellitus significantly increases the odds of having abnormal coronary angiography (OR = 3.96, 95% CI = 1.68 - 9.30, P = 0.002). In contrast, past medical history of migraine decreases the odds of having positive finding in ECA (OR = 0.31, 95% CI = 0.13 - 0.72, P = 0.006).

CONCLUSION

Characteristics of chest pain are comparable in CAD and CSX. However, pain is less likely to radiate to the neck and/or the back in the first group. Presence of dyspnea and dizziness during angina attacks as well as the history of migraine significantly decreases the odds of having abnormal coronary angiography.

Long-term prognosis of patients with cardiac syndrome X: a review

Aims

Follow-up studies of patients with cardiac syndrome X (CSX) generally report good prognosis. However, some recent studies report an adverse outcome for women.

Methods and results

Structured literature search and meta-analysis for studies regarding prognosis of cardiac syndrome X patients. We identified 85 studies, ultimately selecting 16 for inclusion. Meta-analysis yielded a pooled major cardiac event percentage of 1.5% per 5 years and a pooled vascular event percentage of 4.8% per 5 years (n = 16 studies, n = 1694 patients). Fourteen studies reported upon the recurrence rate of angina pectoris: the pooled percentage of angina recurrence was 55% (n = 1336 patients).

Conclusion

The present review of recent archival literature demonstrates an overall major cardiac event rate of 1.5% per 5 years. Although this is an excellent prognosis for CSX patients, the quality of life is impaired because of the high recurrence rate of angina pectoris (55%).