Chest Pain Group Research Articles

Akutes Koronarsyndrom - Auf atypische Symptome achten!

Quelle: Brieger D, Eagle KA, Shaun G et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group - Insights from the Global Registry of Acute Coronary Events. Chest 2004; 126: 461-469

Quelle limite pour la troponine Ic : 99 e percentile ou sensibilité fonctionnelle ? Comparaison des méthodes Beckman vs DPC

This study was designed to compare cTnI levels determined with an Access II assay and an Immulite system in patients with high risk for CAD. CTnIc were determined in 74 patients admitted to emergency unit for acute chest pain (group I), 34 patients submitted to surgical intervention for distal arteriopathy (group II) and 39 Type II diabetes mellitus (group III) with more than two other risk factors. Despite comparable analytical performances, discrepancies between cTnI levels are observed concerning myocardial infarction threshold value (5/147 determinations), 99th percentile (29/147 determinations) and functional sensitivity (6/147 determinations). Functional sensitivity could be an optional threshold value to rule out the presence of circulating CtnI.

Anterior Release and Fusion followed by Posterior Correction in Scoliosis: A Comparison of Open Thoracotomy and the Thoracoscopic Approach

Purpose: To compare the results of the thoracoscopic approach and open thoracotomy retrospectively for scoliosis requiring anterior release and fusion followed by posterior correction. Materials and Methods: Of 22 rigid scoliosis patients, 10 open thoracotomy cases (group I) were compared with 12 thoracoscopic cases (group II) in terms of blood loss, operation time, and chest pain (visual analogue scale, VAS), as checked 1 week after operation and final follow-up, correction ratio of major curve and complications. Posterior correction was performed 2 weeks after anterior release. Statistical analysis of group differences was performed using the t-test or the Mann-Whitney. Results: Blood loss was higher in group I, 268.0 mL (200-530) than in group II, 195.0 mL (100-280) (p=0.047). The operation time was shorter in group I, 108.0 minutes (90-180) than in group II, 175.0 minutes (120-240) (p=0.001), and chest pain (visual analogue scale, VAS) which was checked at 1 week after operation and at final follow-up was milder in group II, 3.9 (3-6), 1.6 (0-3) than in group I, 5.8 (4-8), 3.1 (1-5) (p=0.005, p=0.013, respectively). The correction ratios of the major curve between two groups were similar. The cosmetic aspects of the thoracoscopic approach were favorable. The postoperative complications were 1 pneumothorax in each group and 3 chronic chest pain in group I. Conclusion: The results of thoracoscopic approach for anterior release were compared favorably with standard open thoracotomy in terms of blood loss, chest pain both postoperatively and at final follow-up, and cosmetics, but unfavorably for operation time.

Breathing Patterns During Vaso-occlusive Crisis of Sickle Cell Disease

To determine the effect of sickle cell pain and its treatment on patients' breathing patterns, and to compare the effect of thoracic cage pain to pain at other sites. Prospective, observational study. Sickle Cell Center Day Hospital. Twenty-five patients with sickle cell disease admitted to the Sickle Cell Center Day Hospital for treatment of vaso-occlusive crisis (VOC) [10 patients with chest (thoracic cage) pain]. Breathing patterns were measured by respiratory inductive plethysmography. Tidal breathing data, including respiratory rate, tidal volume (VT), minute ventilation, and the rib cage contribution to VT, were collected at baseline and then following treatment with opioid analgesia. The patients with chest pain had smaller V(Ts) at baseline than those with pain at other sites (355 +/- 37 mL vs 508 +/- 141 mL, p = 0.003), and higher respiratory rates (23.2 +/- 8.2 breaths/min vs 17.6 breaths/min, p = 0.03). These differences became insignificant following opioid treatment. Six patients had respiratory alternans (four patients in the chest pain group, and two patients with pain at other sites). All cases of respiratory alternans resolved following opioid administration. Patients with VOC and chest pain have more shallow, rapid breathing than patients with pain elsewhere. Analgesia reduces these differences. As pain-associated shallow breathing and maldistribution of ventilation may contribute to the pathogenesis of acute chest syndrome, these results support the need for adequate pain relief and monitoring of ventilatory patterns during the treatment of VOC.

Chest Pain after Coronary Artery Bypass: Relation to Coping Capacity and Quality of Life

Objective - To investigate relations between chest pain after coronary artery bypass grafting (CABG), quality of life (QoL), and coping capacity. Design - Two groups were included, Group I ( n = 111) was evaluated before and 1 year postoperatively, and Group II ( n = 102) once, at 3 years. The questionnaire included parts of the Seattle angina questionnaire, one question concerning chest pain, coping capacity (sense of coherence), emotional state, the Psychological general well-being index, and a global QoL question. Results - Chest pain was significantly related to lower coping capacity (at 1 year) and lower QoL scores (at 1 and 3 years). Changes of coping capacity and emotional state from before to 1 year after the CABG did not reach statistical significance in the chest pain group while the no chest pain patients had significantly better emotional state. The relation between chest pain and worse QoL was significantly reduced by high coping capacity. Conclusion - Independent of the direction of causality, the patient's coping capacity and experienced chest pain is highly related.

Experimental pain and psychologic status of patients with chest pain with normal coronary arteries or ischemic heart disease

Background The cause of chest pain in patients with a normal coronary angiogram (NCA) remains an enigma. Also, it is unclear whether psychosocial factors play a role in the etiology of chest pain in these patients. The objective of the current study was to compare psychosocial factors, clinical pain, and responses to experimental pain in NCA patients, patients with ischemic heart disease (IHD), and healthy control subjects. Methods Pain intensity, threshold, and tolerance to cold pressor pain were assessed in 30 NCA patients, 30 IHD patients, and 30 healthy control subjects matched for age, sex, and sociodemographic factors. All subjects completed questionnaires measuring a number of psychosocial factors, including stress, anxiety, depression, extroversion, and neuroticism. NCA and IHD patients also completed questionnaires assessing clinical pain responses and pain-coping strategies. Results With the exception of a lower tolerance to cold pressor pain of IHD patients (P <.05), no significant differences were found between NCA and IHD patients with respect to other clinical pain measures, psychosocial measures, paincoping strategies, and other pain-related behaviors. Healthy control subjects differed significantly (P <.05) from both IHD and NCA patients with respect to maximum cold pressor pain, depression, and state anxiety and from IHD patients with respect to intensity of cold pressor pain, threshold to cold pressor pain, and perceived stress. Conclusions The results suggest that higher scores on various psychosocial measures in both chest pain groups are related to their pain, rather than being the cause of pain, and do not support a psychogenic explanation for chest pain in the presence of normal coronary arteries. (Am Heart J 2001;142:63-71.)

Abnormal esophagocardiac reflex in patients with non-cardiac chest pain.

As the mechanoreceptor stimulation of the esophagus activates an esophagocardiac inhibitory reflex, with possible cardiac hypokinetic arrhythmias, we investigated whether patients with non-cardiac chest pain have this reflex, which could represent a source of risk in predisposed individuals during the intraesophageal balloon distension test. Electrocardiogram readings were recorded in nine patients with non-cardiac chest pain (group A), the esophageal origin of which was diagnosed with cardiac and esophageal examinations, in 10 patients with hyperkinetic esophageal motor disorders without chest pain (group B), and in eight normal subjects used as controls (group C), after swallowing solid boluses and during intraesophageal balloon inflation at 100 mmHg for 10 s. The percent variation of the R-R interval from its mean basal value to its highest value observed after stimulation was calculated. Solid swallows induced an increase in heart rate followed by a decrease that was significantly higher in group B than group C, while group A was not significantly different from group C. Balloon inflation induced a significant decrease in heart rate in all groups, but in group A the degree of decrease was significantly lower than in groups B and C. In conclusion, esophageal wall distension, either as a result of solid bolus or balloon inflation, elicits an inhibitory esophagocardiac reflex that is higher than normal in patients with hyperkinetic esophageal motor disorders without pain and lower than normal in patients with non-cardiac chest pain of esophageal origin, who, consequently, have nothing to fear from this procedure.

Coronary calcium and anti-cardiolipin antibody are elevated in patients with typical chest pain

The aim of this study was to examine whether detection of coronary calcium and the autoimmune response associated with atherosclerosis, either solely or in combination, are different in patients with typical and atypical chest pain. Coronary calcium as detected by spiral computerized tomography and levels of antibodies against cardiolipin (CL), oxidized low-density lipoprotein (ox-LDL), and β2-glycoprotein-I (β2-GPI) were studied in patients with typical chest pain (n = 52), atypical chest pain (n = 19), or without chest pain (n = 21). Patients with typical chest pain had higher mean levels of coronary calcium (expressed as natural transformation of total coronary calcium score) compared with patients with atypical chest pain and controls (5.04 vs 3.21 and 2.75, respectively; p <0.001). The levels of anti-CL were (mean ± SD of optical density multiplied by 1,000): 262 ± 140, 170 ± 82, and 230 ± 115 for patients with typical chest pain, atypical chest pain, and controls, respectively (p = 0.016). No significant difference was found between groups regarding anti-ox-LDL and anti-β2-GPI autoantibody levels. In the typical chest pain group, there was a higher prevalence of high total coronary calcium scores (p = 0.03) and high anti-CL levels (p = 0.01) than in the atypical chest pain group. Eighteen of 52 patients with typical chest pain (35%) had both high calcium scores and high antibody levels, whereas none of the 19 patients (0%) who had atypical chest pain had high levels of both (p = 0.003). A combination of both coronary calcium and anti-CL was associated with higher area under the receiver operator characteristic curves than for each separately. High coronary calcium scores or high anti-CL levels are found more often in typical than in atypical chest pain patients, but a combination of high levels of both can better differentiate typical from atypical chest pain patients.

Reduction of congestive heart failure symptoms by very early fibrinolytic therapy in acute myocardial infarction: A long-term follow-up

Background In patients with acute myocardial infarction (MI), early fibrinolytic therapy results in improved survival and preservation of ventricular function. The purpose of the study was to determine whether very early treatment also reduces the development of congestive heart failure. Methods and Results During the years 1984 to 1989, 358 consecutive patients with acute MI were treated with streptokinase, 161 within the first 1.5 hours from the onset of chest pain (group A) and 197 within 1.5 to 4.0 hours (group B). In 68, fibrinolysis was initiated in the prehospital setting pioneered by our group. Symptoms related to heart failure including dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturia, and peripheral edema, in addition to pulmonary edema events, were assessed during 5 years of follow-up. The evaluation was based on medical records and a detailed questionnaire, which was filled in by the investigators. A favorable significant effect of very early thrombolysis on the development of most of these limiting symptoms appeared 3 months after hospital discharge and persisted thereafter (P <.05). During hospitalization, pulmonary edema attacks occurred less frequently in patients from group A (23% vs 36.5%, P <.01). This difference persisted during 4 years of follow-up (13% vs 36%, P <.001). Conclusions Our data demonstrate that very early fibrinolytic therapy results in a significant long-term reduction of congestive heart failure–related symptoms and thereby improves the quality of life in patients after MI. (Am Heart J 2000;139:1096-100.)

Radionuclide esophageal transit test to detect esophageal disorders in patients with mitra valve prolapse

The origin of chest discomfort in patients with mitral valve prolapse (MVP) is controversial. Our aim was to prospectively determine the incidence of esophageal disorders in MVP patients with or without chest pain. Twenty-five MVP patients with chest pain (group A) and 25 MVP patients without chest pain (group B) underwent evaluation of esophageal motility. None of the total of 50 MVP patients had significant coronary artery disease on cardiac catheterization. Esophageal motility including esophageal mean transit time (MTT), residual fraction (RF), and retrograde index (RI) was analyzed by the radionuclide esophageal transit test (RETT). In comparison with 25 age and sex-matched healthy volunteers, the results showed that: (1) 19 patients in group A (76%) had abnormal RETT findings (48% of cases with prolonged MTT, 44% of cases with higher RF, and 60% of cases with higher RI); (2) 3 patients in group B (12%) had abnormal RETT findings (8% of cases with prolonged MTT, 4% of cases with higher RF, and 8% of cases with higher RI). In addition, mean values of MTT, RF, and RI in group A patients were significantly higher than in group B patients and healthy volunteers. We found that the chest pain in some MVP patients may be related to abnormal esophageal motility, based on the evidence from a simple and noninvasive RETT.

Role of oesophageal manometry in clinical practice.

The present study evaluates the role of oesophageal manometry in clinical practice. Over 5 years, 347 consecutive patients were evaluated in our oesophageal laboratory. The reasons for referral were: dysphagia (11.5%), gastro-oesophageal reflux disease (GORD) (46.7%), non-cardiac chest pain (28.5%), connective tissue disease (6.9%) and other symptomatology (6.3%). Patients were classified into the following five groups according to the referral diagnosis: dysphagia (40 patients), gastro-oesophageal reflux disease (GORD) (162 patients), non-cardiac chest pain (99 patients), connective tissue disease (24 patients) and other symptomatology (22 patients). Abnormalities in oesophageal motility were detected in 90% of patients with dysphagia, in 40.1% of patients with GORD, in 47.5% of subjects with non-cardiac chest pain, in 45.8% of patients with connective tissue disease and in 18.2% of subjects with other symptomatology. The high prevalence of abnormalities in the dysphagia group was statistically significant (p < 0.001), and the range of 95% confidence intervals (0.81-0.99) suggests that the value found may be a reasonably good estimate of percentage of anomalies detectable in the dysphagia patient population. In the dysphagia group, the initial diagnosis was confirmed in 40% of patients and changed in 52.5%; in only 7.5% of cases were the manometry results not relevant for determining an appropriate diagnosis. Manometry substantially contributed to patients receiving the correct treatment in 82.5% of cases (p < 0.001 among all groups). In the GORD group and in the non-cardiac chest pain group, the results of manometry were not relevant for confirming or changing a diagnosis in 59.8% and 53.5% of cases respectively; nevertheless, in both groups, on the basis of manometry results, the treatment was changed in 42.5% of patients (p < 0.01 vs. other symptomatology group). In conclusion, on the basis of the present data, we can emphasize the usefulness of oesophageal manometry assessment in patients with dysphagia or non-cardiac chest pain, with negative routine examinations, and also in patients with refractory GORD who have been considered for antireflux surgery.

Serum Myoglobin as a Biochemical Marker to Rule Out Acute Myocardial Infarction

Background:Diagnosis of AMI in the patients presenting with chest pain of an atypical nature or with a nondiagnostic ECG requires the evaluation of certain biochemical markers. Biochemical markers most often used for the early detection of myocardial damage are CK-MBact, troponin, and myoglobin. The clinical value of measuring serum myoglobin was compared to that of troponin and CK-MBact in the patient with acute chest pain syndrome. Method:We studied timed, sequential measurements of serum myoglobin, CK-MB act and troponin-T obtained from 72 patients who were admitted for the evaluation of suspected AMI within 12 hours after the chest pain onset. Patients with a history of recent trauma, cardiogenic shock, renal failure, or who had received recent cardiopulmonary resuscitation were excluded. We calculated the sensitivity, specificity, negative predictive value, and positive predictive value. Data were analyzed with the Chi-square test for differences in proportion. A value of p<0.05 was considered statistically significant. Result:1) The mean time from symptom onset to arrival at the emergency department was 3.5±0.6 hours. 2) There were no statistical differences in age, sex and risk factors between AMI, angina pectoris and atypical chest pain group. 3) The negative predictive value of myoglobin was significantly higher than those of CK-MB act and troponin-T from 3 to 6 hours after the onset of chest pain. 4) The time to peak of myoglobin level was shorter than those of CK-MBact and troponin-T in AMI patients. Conclusion:Within 3 to 6 hours after the onset of symptoms, myoglobin is a better marker than CKMBact or troponin-T in ruling out AMI for the patient with acute chest pain syndrome. (Korean Circulation J 1998;28(6):915-922)

Sympathetic nerve activity in the spasm-induced coronary artery region is associated with disease activity of vasospastic angina

We assessed the relation between sympathetic nerve activity and disease activity of vasospastic angina. The autonomic nervous system has been proposed to play a key role in attacks of vasospastic angina. A unique feature of vasospastic angina attacks is periodic fluctuation, which complicates the assessment of disease activity. Twenty-five patients with left anterior descending coronary artery (LAD) spasm were studied: 12 with recent onset of chest pain (group 1) and 13 free of angina for more than 3 months after discontinuing medication (group 2). Group 1 underwent iodine-123 metaiodobenzylguanidine (MIBG) imaging (in the active phase) and atropine-stress MIBG imaging early after diagnostic angiography, and repeat MIBG imaging when they were free of angina for more than 3 months with medication (in the stable phase). Group 2 also underwent MIBG imaging (in remission). On a bull's-eye map, quantitative analysis of percent uptake and washout rate of MIBG was performed regionally. In group 1 in the active phase, the washout rate of the LAD territory was significantly lower than the rates in the stable phase, in remission and during atropine-stress MIBG imaging. The regional washout rate of the territories of the right coronary artery and the circumflex artery in the active phase was also significantly lower than that during atropine-stress MIBG imaging. The washout rate of the LAD territory in the active phase was significantly lower than the rates of the other two regions. In contrast, there were no significant differences in the distribution of regional percent uptake in every image. A similar distribution of washout rate was observed among group 1 patients in the stable phase, in group 1 patients during atropine-stress MIBG imaging and in group 2 patients. The MIBG washout rate of the spasm-induced coronary artery territory changed according to the degree of disease activity. Thus, sympathetic nerve activity could reflect disease activity of vasospastic angina.

Ambulatory esophageal manometry/pH-metry discriminates between patients with different esophageal symptoms

Ambulatory esophageal manometry/pH-metry has been used primarily in patients with chest pain of presumed esophageal origin, and it is unclear whether the discriminating power of this test applies to other esophageal symptoms. In the present study, prolonged ambulatory manometry/pH recordings were compared in 17 healthy controls, 12 patients with atypical chest pain, and 11 patients with chest pain and nonstructural dysphagia using the Synectics microdigitrapper system. Chest pain patients tended to have higher values for all the pH variables, but their esophageal motility parameters were no different than controls. On the other hand, the chest pain plus dysphagia group was characterized by a significantly lower proportion of propagated contractions between 10 and 5 cm above the lower esophageal sphincter. This group also tended to have a higher frequency of high-amplitude or prolonged-duration contractions. In comparison to the results of standard stationary esophageal manometry, the prolonged ambulatory recordings were more sensitive in detecting esophageal motor dysfunction in the two patient groups. This study suggests that quantitative analysis of ambulatory pH/motility recordings is a sensitive method of evaluating patients with suspected esophageal dysfunction.

Unexplained dysphagia: Viscous swallow-induced esophageal dysmotility

Dysphagia is a manifestation of several clinical conditions of diverse origin. In spite of the variation in these disease entities in terms of their etiology, clinical presentation, natural history, and treatment, the mechanism of this clinical complaint is not always clear. We studied a group of patients with dysphagia for solids in whom no anatomic or motor abnormalities were encountered on standard studies. The group consisted of 37 patients, 25 women and 12 men, who were complaining of dysphagia of 6 months or longer duration and they did not demonstrate structural or motor abnormalities on barium esophagogram, esophagoscopy, and standard esophageal manometry. A group of 24 age-matched patients, 14 women and 10 men, with noncardiac chest pain served as the patient control. Esophageal contractile activities were studied after 10 wet swallows (5 ml of water) and 10 viscous swallows (5 cubic cm of marshmallow). Resting lower esophageal sphincter pressure and its relaxation response to swallows, amplitude of peristaltic activities, rate of dysphagia provoked during the study, and the frequency of abnormal esophageal contractions were evaluated. Six abnormal esophageal contractile activities-failed peristalsis, dropout, repetitive, simultaneous, spontaneous contractions, and aperistalsis-were utilized to generate an esophageal peristaltic dysfunction index. The mean LESP was 8.1 +/- 4.7 in the dysphagia group and 16.1 +/- 4.3 in the chest pain group. The mean amplitude of peristaltic contractions was 47.1 +/- 16.1 and 89.0 +/- 27.0 mmHg after wet swallows for dysphagia and chest pain groups, respectively. These values were 58.2 +/- 12.4 and 92.4 +/- 22.1 for viscous swallows. Swallowing provoked dysphagia in 89% of the dysphagia group after viscous swallows and 9% after wet swallows. In contrast, only 11% and 3% of control group complained of dysphagia during the study. This group of patients probably represent a cohort of patients with a nonspecific esophageal motor disorder in whom both clinical symptom and their esophageal motor counterpart can only be elicited in response to viscous swallows. We strongly believe in addition of viscous swallows in evaluating dysphagic patients in whom symptoms remain unexplained in light of standard studies.

Increasing pain sensation to repeated esophageal balloon distension in patients with chest pain of undetermined etiology

Previous studies have demonstrated lowered sensory thresholds to esophageal balloon distension in patients with chest pain of undetermined etiology. Whether this finding is specific to patients with chest pain or is simply related to an underlying esophageal motility disorder is unclear. In the present study, distension-induced pain-sensation scores and the effect of repeated balloon distension were compared in patients with chest pain, dysphagia secondary to esophageal dysmotility, and healthy controls. All subjects underwent standard esophageal manometry followed by mid-esophageal balloon distension. Volumes 2.5, 5, 7.5, and 10 ml (each volume repeated three times) were applied in random order in a single-blind fashion, and the pain-sensation score was recorded after each distension. Pain-sensation scores varied directly with balloon volume. Mean pain scores were significantly higher (P < 0.001) in the chest pain group than in either the controls or dysphagia group. There was no significant difference between controls and the dysphagia group, and the motor response to distension was no different between groups. In the controls and dysphagia groups, pain-sensation score was not significantly different between the first, second, or third distension at a given volume. However, in the chest pain group, pain-sensation scores increased significantly with the second (P = 0.004) or third (P = 0.002) distension using the same balloon volume. These studies suggest that abnormal esophageal nociception in patients with chest pain of undetermined etiology is not simply related to underlying esophageal motor dysfunction. In addition, chest pain patients display a conditioning phenomenon, further supporting the presence of a visceral sensory abnormality.

Costochondritis. A prospective analysis in an emergency department setting.

Costochondritis (CC) is a common, but poorly understood condition among patients with chest wall pain. We have prospectively analyzed distinctive features of patients presenting to the emergency department with chest pain and CC. Patients with a chief complaint of chest pain, not due to trauma, fever, or malignancy, were prospectively evaluated for the presence of CC and compared with another chest pain group without CC. Of 122 consecutive patients studied, 36 had CC (30%) and in 17 the pain induced reproduced the original one (15%). Women made up 69% of the patients with CC (vs 31% of control subjects) and Hispanics 47% (vs 24% of control subjects). Only three patients (8%) with CC met the American College of Rheumatology criteria for fibromyalgia, while none of the control subjects did. Widespread pain was more common in the CC group (42% vs 5%). The mean sedimentation rate in the CC group was 44 +/- 31 mm/h vs 41 +/- 31 mm/h in the control group. The acute myocardial infarction rate was 6% in the CC group vs 28% in the control group. Rheumatoid arthritis and osteoarthritis were diagnosed in three and two patients, respectively, of 32 patients with CC cases. One year later, 11 (55%) of 21 patients with CC were still suffering from chest pain, but only one third still had definite CC. Costochondritis is common among patients with chest pain in an emergency department setting, with a higher frequency among women and Hispanics. It is associated with fibromyalgia in only a minority of cases. Patients with CC appear to have a lower frequency of acute myocardial infarction. Spontaneous resolution is seen in most cases at 1 year.

Abnormal cardiac pain perception in syndrome X

Objectives. The purpose of this study was to determine whether a diminished cardiac pain threshold contributes to chest pain in patients with syndrome X.Background. There have been some reports of an altered pain perception in syndrome X.Methods. Intracardiac catheter manipulation was performed in four groups of patients (syndrome X [group 1, 36 patients]; mitral valve disease and normal coronary arteries [group 2, 36 patients]; mitral valve disease and coronary artery disease [group 3, 36 patients]; and heart transplant recipients with normal coronary arteries [group 4, 36 patients]). Coronary flow was measured in patients with syndrome X and in transplant recipients by use of an intracoronary Doppler catheter positioned in the left anterior descending coronary artery at intracardiac catheter manipulation. Coronary flow reserve in response to papverine was also measured in patients with syndrome X and in transplant recipients.Results. Intracardiac stimulation produced typical anginal chest pain in 34 group 1 (syndrome X) patients (94%). However, chest was produced only in five patients (14%) in group 2, seven patients (19%) in group 3 and no patients in group 4. There were no significant changes in coronary blood flow velocity associated with chest pain in group 1 patients. Coronary flow reserve in response to a hyperemic dose of intracoronary papaverine was significantly lower in the syndrome X group. There was no significant difference in the prevalence with which the stimulation tests produced chest in patients with syndrome X with an impaired coronary flow reserve or a positive radionuclide scan.Conclusions. The results of our study suggest that abnormal cardiac pain perception is a fundamental abnormality in syndrome X.

ED length-of-stay and illness severity in dizzy and chest-pain patients

Emergency department (ED) length of stay, illness severity, and patterns of ED-based testing can be used to compare different ED patient populations. To assess the relative significance of ED patients with dizziness and chest pain in emergency medicine practice, the investigators formed a retrospective chart review of 3,864 adults (age ≥16 years) seen at the University of North Carolina Hospitals' ED during May and June of 1991. Patients were eligible if they had any complaint of dizziness (n = 259), nontraumatic chest pain (n = 168), or both (n = 18). ED length of stay and illness severity, as measured by Acute Physiology and Chronic Health Evaluation (APACHE) II score, were not significantly different between the two groups. Dizzy and chest-pain patients were both high users of ED-based testing, but management patterns were different. Chest-pain patients were more likely to undergo electrocardiogram and x-ray testing, whereas dizzy patients more often received testing such as brain computed tomography scanning (10.8% v 3.6%, P = .01). ED patients with dizziness and chest pain were similar with regard to ED length of stay. Given their overall similarities to the chest-pain group, dizzy patients appear to represent a significant population of ED patients and may warrant more clinical study.

Arteriographic incidence of coronary artery disease in black men with chest pain.

To determine the incidence of arteriographically proven coronary artery disease in black men evaluated for chest pain, we retrospectively reviewed the charts of 208 black men, aged 20 to 60, who had coronary arteriography at the Medical Center of Central Georgia (MCCG) from 1985 through January 1990. Age, type of chest pain, and risk factors commonly accepted as associated with coronary disease (hypertension, family history, left ventricular hypertrophy, diabetes, smoking, and hypercholesterolemia) were identified for each patient. Patients were categorized by previous evidence of coronary disease: 145 were studied to evaluate suspected disease and 63 to evaluate previously proven (prior catheterization) or presumptive (prior myocardial infarction) disease. Chest pain groups (typical and atypical angina) were analyzed by Pearson chi-square goodness of fit using the Diamond and Forrester age and chest pain tables as a model. Risk factors were analyzed using a maximum likelihood chi-square test. Coronary artery disease was common in the study group (48.6% of all patients) but significantly less than predicted by the Diamond and Forrester tables. Risk factors were highly prevalent, but only age and smoking were associated with catheterization-proven coronary artery disease in this group. We conclude that coronary artery disease is common in black men evaluated for chest pain but less frequent than would be expected from comparison with findings in white men presenting similar clinical features. Risk factors other than age and smoking were not associated with increased incidence of disease. A prospective study is needed to delineate a more effective means of evaluating black male patients with chest pain.