Chest Pain Of Noncardiac Origin Research Articles

Clinical Significance of Platelet Indices (Mean Platelet Volume and Mean Platelet Volume-to-lymphocyte Ratio) in Acute Coronary Syndrome: A Hospital-based Observational Study.

The role of platelet indices, such as mean platelet volume (MPV) and MPV-to-lymphocyte ratio (MPVLR), in diagnosing, and predicting the severity, and fatality in acute coronary syndrome (ACS) has not been extensively studied, particularly in Indian patients. Therefore, the study aimed to investigate the clinical significance of MPV and MPVLR in ACS. This hospital-based observational study was conducted from 2020 to 2022. It included 110 ACS cases and an equal number of age- and sex-matched controls with chest pain of noncardiac origin. The primary objective was to compare MPV and MPVLR in ACS patients and controls. Secondary objectives included examining the associations between MPV, MPVLR, and different ACS types, as well as their correlation with the global registry of acute coronary events (GRACE) risk score and inhospital major adverse cardiovascular events (MACE). Higher MPV and MPVLR were observed in ACS cases compared to controls [(11.1 ± 1.1 fL; 10.6 ± 1.3 fL, p < 0.01), (7.63 ± 4.9 fL/mm3; 4.74 ± 1.6 fL/mm3, p < 0.01) respectively]. Significant associations were found between platelet indices (MPV, MPVLR) and various ACS types (p < 0.01). Both indices positively correlated with the severity of heart failure, GRACE score, and inhospital MACE (p < 0.01). MPVLR showed a positive correlation with the duration of hospital stay [(r: 0.21; p = 0.03), but MPV did not (r: 0.13; p = 0.17)]. The GRACE score demonstrated the highest discriminating capacity in predicting inhospital mortality compared to platelet indices. Additionally, MPV serves as a more effective prognostic marker than MPVLR in predicting inhospital mortality. Both MPV and MPVLR are higher in ACS than in healthy individuals. Therefore, both may be used as discriminating markers for differentiating cardiac and noncardiac chest pain when cardiac biomarkers are not available. Additionally, both have good sensitivity for predicting the severity of the disease, inhospital mortality, and MACE in ACS.

Chest pain as an interdisciplinary problem – emphasis on somatoform disorders

Chest pain of a non-cardiac nature is one of the extremely significant problems of clinical medicine, which is associated with the widespread prevalence of this condition and the high healthcare costs for diagnosing and treating such patients. Along with neurological, gastroenterological and pulmonological diseases, mental disorders make a major contribution to the formation of chest pain. Moreover, the formation of pain in the chest area can be associated not only with such well-known psychopathological conditions as depression and anxiety disorders, but also with the pathology of the somatoform circle. This review presents data on the frequency of chest pain associated with mental disorders (pain as a symptom of a mental disorder, mental disorders as a consequence of a previous episode of chest pain, etc.), the nature of the relationship between pain symptoms and mental disorders, as well as the clinical picture somatoform disorders manifesting in the form of thoracalgia. Information is summarized on approaches to diagnosing mental disorders in patients with chest pain and the possibilities for their psychopharmacotherapy and psychotherapy. When discussing psychopharmacotherapy, emphasis is placed on the possibilities of using the atypical tranquilizer tofisopam in this category of patients, and a brief description of its effectiveness and safety is given. To illustrate the main points of the review, a clinical case of a patient with chest pain of non-cardiac origin, which manifested itself after a traumatic event, which in turn provoked a myocardial infarction, is also presented. Positive dynamics with subsequent recovery during therapy with tofisopam are described.

Neprepoznata skolioza kao uzrok bola u grudima - prikaz slučaja

In recent times, most children and adolescents with chest pain of non-cardiac origin are diagnosed with some form of musculoskeletal disorder. Scoliosis is a three-dimensional deformity of the spine and the most common musculoskeletal disease in children. Chest pain in individuals with scoliotic spinal deformities most likely comes from the subluxation of the ribs and the direct and intermittent pressure on the nerve passing under the rib, which is nociceptive in character; the triggers are usually a deep inhale or the performance of the Valsalva manoeuvre. This is a case report of a 15-year-old girl with a scoliotic spinal deformity and chest pain from the General Hospital "Dr Laza K. Lazarević" in Šabac

Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study.

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. 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. 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. 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.

Stomach in the chest or what we know about giant hiatal hernias

A hernia of the esophageal aperture of the diaphragm is considered as one of the factors contributing to the development of gastroesophageal reflux disease and requires a complete and comprehensive examination of the patient. Routine esophagogastroduodenoscopy does not give a complete picture of the disease, and therefore patients receive symptomatic treatment for a long time. Paraesophageal hernia of the esophageal aperture of the diaphragm are not well understood yet due to their relatively low frequency of occurrence, may be asymptomatic or manifest as chest pain of noncardiac origin. A patient with a long history of gastroesophageal reflux disease associated with a giant paraesophageal hernia of the esophageal aperture of the diaphragm is presented as a clinical case.

Protocolo diagnóstico del dolor torácico esofágico

Chest pain of oesophageal origin has similar characteristics to angina. A proper differential diagnosis should therefore be established at the start. This disease is a prevalent disorder that has no impact on patient mortality but entails a high use of healthcare resources. The oesophageal causes of chest pain include gastro-oesophageal reflux (GOR), oesophageal motility disorders and oesophageal hypersensitivity. It is estimated that more than half of the cases of chest pain of noncardiac origin have their origin in GOR. Anxiety and depression frequently coexist in these patients, which modulates the perception of disease severity.

Fibulin‑1 and fibulin‑5 as rule‑out tests for non-ST‑elevation myocardial infarction in the emergency setting.

Fibulin‑1 and fibulin‑5 are extracellular glycoproteins from the fibulin family. Both are expressed in the vessel wall and protect against vascular damage. We aimed to investigate whether fibulin‑1 and ‑5 may be used to exclude non-ST‑segment elevation myocardial infarction (NSTEMI) in the emergency setting. The study included 48 patients in the NSTEMI group and 42 controls who presented with chest pain of noncardiac origin as confirmed by a comprehensive evaluation including coronary angiography. Blood samples for fibulin‑1, fibulin‑5, and troponin I measurements were drawn on admission to the emergency department. Demographic characteristics were similar in patients with NSTEMI and controls. The median levels of both glycoproteins were lower in patients with NSTEMI as compared with controls: fibulin‑1, 96.9 μg/ml (interquartile range [IQR], 20-503 μg/ml) vs 111.5 (IQR, 71-457 μg/ml), P = 0.01, and fibulin‑5, 38 ng/ml (IQR, 15-509 ng/ml vs 57 ng/ml (IQR, 26-631 ng/ml), P <0.001. The receiver operating characteristic curve analysis revealed the cutoff value of 105.6 μg/ml for fibulin‑1 and of 49.4 ng/ml for fibulin‑5 to exclude NSTEMI on admission. The present study demonstrated that fibulin‑1 and -5 measurements might be used to exclude NSTEMI in patients admitted to the emergency department with acute chest pain.

Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study.

BackgroundNon-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out.ObjectiveTo evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED).MethodsSingle-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing.ResultsIn total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation.ConclusionIn this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.

Non-cardiac chest pain: a 2018 update.

Non-cardiac chest pain (NCCP) is defined as recurring, angina-like, chest pain of non-cardiac origin. Studies have estimated that gastroesophageal reflux disease (GERD) is the most common contributing factor for NCCP. In patients with non-GERD related NCCP, esophageal motility disorders, and functional chest pain of presumed esophageal origin are the main underlying mechanisms for symptoms. Epidemiologic studies show a high prevalence of panic disorder, anxiety and major depression in NCCP patients. The diagnostic esophageal workup starts only after that cardiac and pulmonary diseases have been ruled out. NCCP patients with typical reflux symptoms are more likely to have GERD-related NCCP than those without typical reflux symptoms. High-dose proton pump inhibitor trial (PPI test) can be used to confirm the diagnosis of GERD-related NCCP. Negative upper endoscopy is quite common. For patients unresponsive to antireflux treatment and with negative endoscopy, impedance-pH monitoring should be done. Treatment of patients with non-GERD-related NCCP has focused on esophageal (hypercontractile or spastic) motility disorders and esophageal visceral hypersensitivity. In the first case, several trials using calcium channel blockers, nitrates, anticholinergics, or botulinum toxin injection and recent trials with endoscopic myotomy have been conducted. In case of visceral hypersensitivity, studies found that the amelioration, when compared to placebo, was significant with venlafaxine, sertraline, and imipramine. In this context, also cognitive behavioral therapy has been proposed.

The Contribution of High-Resolution versus Conventional Esophageal Manometry to the Assessment of Esophageal Motor Disorders in Patients With Non-Cardiac Chest Pain (NCCP)

Introduction: NCCP is defined as recurring, angina-like, retrosternal chest pain of non-cardiac origin. It has been estimated that up to 30% of the non-GERD related NCCP patients demonstrate an esophageal motor disorder using conventional manometry (CM). Thus, the aim of the study was to determine if high resolution esophageal manometry (HREM), which has become the standard of care, improved the diagnosis of esophageal motor disorders, as compared with CM, in patients with NCCP. Methods: We evaluated 300 consecutive non-GERD related NCCP patients who underwent either HREM or CM. A total of 150 patients had CM and the other 150 patients HREM. The Chicago 3 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of patients undergoing HREM and CM, respectively. Results: In both HREM and CM groups, a normal esophageal motility study was the most frequent finding (47% vs. 36%, respectively). In patients who underwent CM, the most commonly demonstrated esophageal motility disorder was hypotensive lower esophageal sphincter. Hypotensive LES was a significantly more common finding in patients undergoing CM versus HREM (27.3% vs. 4.7%, p<0.001). Other less common motility disorders seen in the CM group were nonspecific esophageal motility disorders (NEMD) (12%), nutcracker esophagus (9.3%), ineffective esophageal motility (IEM) (6.7%), achalasia (2.7%), distal esophageal spasm (DES) (5.3%), and absent contractility (0.67%). In general, hypertensive motility disorders, like DES and nutcracker esophagus, were less common than hypotensive motility disorders (15% vs. 35%, p=0.9) in NCCP patients. There was no significant difference in the number of hypertensive or hypotensive motility disorders diagnosed with CM versus those diagnosed with HREM. In the HREM group, IEM was the most commonly diagnosed motility abnormality. The likelihood of finding an IEM was significantly more common in the HREM group as compared with the CM group (25% vs. 7%, p<0.001). Other motility abnormalities that were less commonly diagnosed with HREM included: achalasia (7.3%), esophagogastric junction outflow obstruction (4%), absent contractility (4%), jackhammer/nutcracker esophagus (3.3%), DES (2.7%) and NEMD (1.3%). Conclusion: HREM did not improve the percentage and type of esophageal motor disorders diagnosed in NCCP patients as compared with CM. This is likely due to limitations of Chicago 3 classification. Normal esophageal motility remains the most common finding.

Noncardiac chest pain: update on the diagnosis and management.

Noncardiac chest pain (NCCP) is defined as recurring, angina-like, retrosternal chest pain of noncardiac origin. Although patients with NCCP have excellent long-term prognosis, most suffer persistently from their symptoms. Several pathophysiological mechanisms have been suggested, including gastroesophageal reflux disease (GERD), esophageal motility disorder, esophageal hypersensitivity, and psychological comorbidity. Among them, GERD is the most common cause of NCCP. Therefore, GERD should first be considered as the underlying cause of symptoms in patients with NCCP. Empirical proton pump inhibitor (PPI) treatment with a preferably double dose for more than 2 months could be cost-effective. PPI test can also be used for diagnosis of GERD-related NCCP, but it should be considered for patients with NCCP occurring at least weekly and its duration should be at least 2 weeks. However, upper endoscopy and esophageal pH monitoring are necessary when the diagnosis of GERD is uncertain. Esophageal impedance-pH monitoring could further improve the diagnostic yield. Patients with GERD-related NCCP should preferably be treated with a double dose PPI until symptoms remit (may require more than 2 months of therapy for optimal symptom control), followed by dose tapering to determine the lowest PPI dose that can control symptoms. However, treatment of patients with non-GERD-related NCCP is challenging. An empirical treatment of antidepressants could be considered. If there are specific esophageal motility disorders, smooth muscle relaxants or endoscopic treatment may be considered in selected cases. If none of these traditional treatments is effective, a psychology consultation for cognitive behavioral therapy should be considered.

Mean platelet volume in patients with acute coronary syndromes: a supportive diagnostic predictor.

Platelets and their activity have a crucial role in acute coronary events. Larger platelets are enzymatically and metabolically more active and have a higher potential thrombotic ability as compared with smaller platelets. The aim of this study is to investigate whether there is an association between mean platelet volume (MPV) measurement and cardiac Troponin I( cTn I ) in patients admitted with a suspected diagnosis of ACS and to assess the potential diagnostic efficiency of MPV in the diagnostic workup for ACS. After thorough evaluation of 215 eligible patients, 3 ml. Venous blood collected using Becton, Dickinson and company vacutainer and MPV measured within 1-2 hr of sample collection. Sample for cTn I collected at 6 hr and at 12 hrs, if required and level measured using Biosite analyzer. Mean platelet volume (MPV) was found to be higher among ACS patients as compared to non ACS, 11.44±1.23 vs 9.91±1.27 fl (p-value<0.001). The NPV of MPV in the diagnostic workup of chest pain suggestive of ACS within 6 hours of presentation were found to be 82.53% . In this study the MPV is significantly higher in patients with ACS than in those with chest pain of non-cardiac origin and its negative predictive value of 82.53%, it might be useful as an assisting rule-out test in conjunction with other markers in the early prediction of the risk of ACS.

Examination of musculoskeletal chest pain – An inter-observer reliability study

Chest pain may be caused by joint and muscle dysfunction of the neck and thorax (termed musculoskeletal chest pain). The objectives of this study were (1) to determine inter-observer reliability of the diagnosis ‘musculoskeletal chest pain’ in patients with acute chest pain of non-cardiac origin using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0.01 to 0.59. Provided adequate training of observers, the examination protocol can be used in carefully selected patients in clinical settings and should be included in pre- and post-graduate clinical training.

Clinical trial: the effect of Johrei on symptoms of patients with functional chest pain

Patients with functional chest pain (FCP) represent a therapeutic challenge for practising physicians. To determine the efficacy of Johrei as compared to wait-list in improving symptoms of FCP patients. Patients with chest pain of noncardiac origin for at least 3 months were enrolled into the study. All patients had to have negative upper endoscopy, pH testing and oesophageal manometry prior to randomization. Subsequently, patients were randomized to either Johrei or wait-list control. Patients received 18 Johrei sessions from a Johrei practitioner for 6 weeks. A total of 21 FCP patients enrolled into the Johrei group and 18 into the wait-list group. There was no difference in symptom intensity score between Johrei group and wait-list group at baseline (20.28 vs. 23.06, P = N.S.). However, there was a significant pre- and post-treatment reduction in symptom intensity in the Johrei group (20.28 vs. 7.0, P = 0.0023). There was no significant reduction in symptom intensity score between baseline and at the end of the study in the wait-list group (23.06 vs. 20.69, P = N.S.). This pilot study shows that Johrei may have a role in improving FCP symptoms; however, future studies are needed to compare Johrei treatment with sham Johrei or supportive care.

Reexamining the Elderly Patient's Presentation With Depression

Sir: We wish to comment on the well-written and well-designed article by Voils et al.1 In our clinical practice in 2 of the major pain centers in the Midwest, we frequently see patients referred from primary care offices who are allegedly suffering from depression and who present with insomnia, anxiety, somatization, low energy, and some sadness. It is difficult for the patient to articulate the word depression, let alone acknowledge its presence. Anxiety, on the other hand, appears to be less vulnerable to the patients’ self-esteem and easier for them to articulate. Another description manifest by the patient includes “I am under some stress.” Insomnia and somatization, noted on the Hamilton Rating Scale for Depression2 as items 12 and 13, however, are seen prominently in our practice. Following months to years of the existence of depression, characteristics manifest by the patient are somatic and include headaches, neck pain, back pain, shoulder pain, hip pain, leg pain, arm pain, abdominal pain, and chest pain of noncardiac origin. Generally with these complaints, the primary care physician reacts in a diagnostic manner and orders radiographic testing, laboratory testing, and workups, including electromyograms and blood tests, in an attempt to document the physical pathology of pain complaints of the patient and to determine the etiology. Patients often will react in a manner as to protect themselves and will not disclose what is true but will rather disclose that which they perceive would be favorable to the clinicians who will be evaluating the outcome of the structural patient evaluation tools or forms of evaluated tools provided to the patients and/or families. Consequently, an additional medication focused at a new complaint or an attempt to abate the patient's pain complaints is often initiated with futile outcomes. It is not uncommon to see the patient change the somatic complaints from one body organ or system or location to that of another. Clinical judgment provides an index of suspicion to discriminate psychopathology (hopelessness, worthlessness, loss of self-esteem, suicidal ideation, and guilt) from that which is revealed by the elderly patient presenting with disseminated somatic pain complaints. DSM-IV-TR provides multiple diagnoses which are imbedded with somatic complaints that reflect pain and psychiatric complaints. Elderly patients may not vocalize or express the psychiatric events underlying their geriatric presentation. Commonly, elderly patients elect to guise these somatic issues as a mask for their psychiatric issues (depression, anxiety, etc.). This masking presentation of somatic symptoms permits the opportunity for presentation into the health care system. To preserve the patient's self-esteem, we often address with equal vigor both the somatic complaints and the underlying psychiatric basis. Consequently, this joint focus of attention at resolution of both the presenting somatic complaints and the psychiatric basis facilitates a more successful and robust remission in the elderly patient. This effort is in realization that painful physical comorbidity may be less than adequately addressed and opens the patient-provider relationship to decremental changes in both their physical painful comorbidity and the consequent psychiatric sequelae. In our clinical practice, we have noticed that the time when depression may be actually declared by the patient as a comorbidity is after he or she has established a fiduciary relationship of trust and confidence with the clinician. We often advise other clinicians, such as fellows and residents, that they “don't talk to the patients but talk with them, stop hearing them and begin listening to them.” Such a clinical pearl assists in building a relationship of trust and confidence with the patient over time until the disclosure of depression may appear. It is also appropriate to remember that when depression and comorbid anxiety exist, the anxiety may persist after the depression has reached remission. This may also occur with insomnia. Insomnia may not uncommonly coexist but additionally may be independent of depression and must be addressed once depression has achieved remission. These observations are based on the hundreds of patients who are sent to a pain center from primary care physicians who appear to have reached academic and professional frustration in not being able to satisfy the patients’ need for amelioration of their somatic complaints. More often than not, treatment has been focused on duration of somatic complaints as opposed to the patient's psychosocial and emotional issues that may remain undisclosed or disguised. Robert L. Barkin, M.B.A., Pharm.D., F.C.P. Rush Pain Center, Rush University Medical Center, Chicago, Illinois NorthShore Pain Center, Skokie, Illinois Stacy J. Barkin, M.Ed., M.A., Psy.D. Scottsdale, Arizona

This Month in Gastroenterology

This Month in Gastroenterology

Ascitic Fluid Lactoferrin for Diagnosis of Spontaneous Bacterial Peritonitis

The diagnosis of spontaneous bacterial peritonitis (SBP) is based on a manual count of ascitic fluid polymorphonuclear cells (PMNs). This procedure is operator-dependent and lysis of PMNs during transport to the laboratory may lead to false-negative results. Furthermore, ascitic fluid culture is insensitive and leads to delays in diagnosis. The aim of this study was to assess the utility of ascitic fluid lactoferrin (AFLAC) for the diagnosis of SBP and to identify a cut-off level that can be used for future development of a rapid bedside test. A total of 218 consecutive ascites samples from 148 patients (1-8 samples per patient) with cirrhosis at 2 tertiary care medical centers were examined for PMN count, bedside culture, and lactoferrin concentration. AFLAC concentrations were determined using a polyclonal antibody-based enzyme-linked immunosorbent assay. An ascitic fluid PMN count of 250 cells/mL or greater with or without a positive culture was used for diagnosis of SBP. Twenty-two (10.1%) samples fulfilled diagnostic criteria for SBP. Samples with SBP had a significantly higher lactoferrin concentration (median, 3744 ng/mL; 25th-75th percentiles [P25-P75], 788-9617) compared with non-SBP samples (median, 31 ng/mL; P25-P75, 12-67; P < .001). By using a cut-off level of 242 ng/mL, the sensitivity and specificity of the assay for diagnosis of SBP were 95.5% and 97%, respectively. The area under the receiver operating characteristic curve was 0.98. AFLAC can serve as a sensitive and specific test for diagnosis of SBP. Qualitative bedside assays for the measurement of AFLAC can be developed easily and may serve as a rapid and reliable screening tool for SBP in patients with cirrhosis.

Angina, “Normal” Coronary Angiography, and Vascular Dysfunction: Risk Assessment Strategies

Chest pain may be associated with coronary arteries that appear “normal.” Normal is defined here as no visible disease or luminal irregularities (less than 50%) as judged visually at coronary angiography. Normal angiography in patients with chest pain is five times more common in women than in men [1]. Among patients with chest pain and normal angiography, an unknown number are suffering from cardiac pain of ischemic origin. Uncertainty is often difficult to allay, for medical attendants as well as for patients, resulting in perpetuation of symptoms, difficulties in management, and establishment of risk of subsequent coronary events [2]. In this article, we discuss how to stratify risk in patients with chest pain and a normal coronary angiogram. We based our article on a literature review, using the key words “angina with normal angiography,” “angina with normal coronary arteries,” “non-obstructive coronary disease,” or “chest pain of non-cardiac origin,” plus “[a]etiology,” “pathophysiology,” “diagnosis,” “classification,” “prognosis,” or “therapy.” A longer, more detailed version of this paper is found in the supplementary file S1.

Detection of chest pain of non-cardiac origin at the emergency room by a new non-invasive device avoiding unnecessary admission to hospital

Recent advances in the treatment of acute coronary syndromes has raised awareness that prompt presentation for chest pain may be life saving. Most patients presenting with chest discomfort have a...

Epidemiological Consequences of Introducing New Biochemical Markers for Detection of Acute Myocardial Infarction

Objective - To evaluate how the use of different biochemical markers of myocardial injury affects the recorded numbers of cases of diagnosed acute myocardial infarction (AMI) and unstable angina pectoris (UAP) and also the observed in-hospital mortality of AMI. Design - 442 patients admitted with suspected acute coronary syndrome (ACS) were studied. Based on the World Health Organization (WHO) criteria, the patients were classified into five categories: acute Q-wave myocardial infarction (QMI); acute non-Q-wave myocardial infarction (NQMI); UAP; stable angina pectoris; and chest pain of non-cardiac origin. Results - Using total creatine kinase (tCK) as the "gold standard" for diagnosis, we found 172 AMI, 100 UAP and 170 with other diagnoses. If we used CK-MB (>6 µg/L) or cTnI (>1 µg/L) for diagnosing AMI, the numbers of AMI increased significantly by 50 (29%) and 64 (37%), respectively. Using tCk, CK-MB or cTnI for diagnosing AMI, the observed in-hospital mortality was 14%, 11% and 10%, respectively. The group of patients with elevated cTnI but negative tCK had similar long-term survival as the group of patients with cTnI >30 µg/L, comprising 95% of the patients with the diagnosis AMI based on tCK. Conclusion - The introduction of new biochemical markers for detection of AMI may lead to significant changes in the recorded incidence and in-hospital mortality of AMI. New biochemical markers of myocardial injury must be validated against the traditional markers as they are introduced into clinical practice by the new diagnostic criteria.