Diagnosis Of Non-cardiac Chest Pain Research Articles

The use of a point of care high sensitivity troponin in the investigation of patients presenting to the Emergency Department with undifferentiated chest pain

Abstract Background In 2012 in a hospital, New Zealand, a chest pain pathway was instituted for the use in patients presenting to the Emergency Department (ED) with undifferentiated chest pain. This reduced hospital admissions and ED length of stay (LOS) without adversely affecting outcomes. The pathway consists of risk stratification combined with ECG and troponin testing. The pathway suggests, but does not enforce, that low risk patients can be discharged after a single troponin, intermediate risk patients are for serial troponins (which can be done in ED or the next day in the community), with further testing if appropriate, and high risk patients are reviewed by Cardiology or General medicine. In August 2023, Siemens point of care high sensitivity troponin I (POC-hsTnI) was introduced for the use in ED, although Beckman laboratory troponin I (Lab–hsTnI) is still available. A POC test reduces result turnaround times but until recently there has been a lack of POC assays fulfilling criteria for "high sensitivity". Purpose To ascertain whether the availability of a POC-hsTnI in the ED is a viable option for use in the chest pain pathway Methods A 1 month "snap shot" of all consecutive patients presenting to the ED with chest pain was undertaken and the patients followed for adverse events using electronic notes review. October 2023 was selected for the post POC-hsTnI period and compared with April 2022. Results There were 688 patients presenting to ED with undifferentiated chest pain during October 2023 with a type 1 acute myocardial infarction (AMI) rate of 80 (11.6%), median age 58 (41-72), female 335 (48.7%). POC-hsTnI was used in isolation in 377 (54.8%), in conjunction with Lab-hsTnI in 218 (31.7%) and Lab-hsTnI was used alone in 93 (13.5%). The median turnaround time for POC-hsTnI was 11 minutes (10-11) compared with Lab-hsTnI 87 minutes (61-129). The POC-hsTnI was less sensitive for AMI than the Lab-hsTnI on presentation using the upper reference limit, 72.1% (60.6-81.6) versus 91.5% (83.0-96.4). However, when used with risk stratification, there were no excess adverse events (cardiac death or AMI) at 4 months in patients discharged with a diagnosis of non-cardiac chest pain – 7 (1.4%) (n=495) versus 5 (1.2%), (n=424) in 2022. Median LOS in the ED was 4.4 hours (2.9-6.2) versus 4.0h (3.0-5.9) in 2022. However, a higher proportion of patients had a second cTn: 414 (60.2%) versus 309 (48.4%) and a lower proportion had their second troponin the next day in the community, 28 (6.7%) versus 56 (18.1%). Conclusion The use of a POC-hsTnI is a practical solution to reduce turnaround times for troponin results and has the potential to reduce LOS or allow serial troponins to be measured in a timely manner during their ED visit, obviating the need for a next day community troponin. Whilst POC-hsTnI has a lower early sensitivity for AMI, the use of POC-hsTnI as part of a pathway does not adversely affect outcomes.

Effectiveness of Internet-Based Cognitive Behavioral Therapy With Telephone Support for Noncardiac Chest Pain: Randomized Controlled Trial.

BackgroundNoncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain.ObjectiveIn this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain.MethodsWe conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes.ResultsIn the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (–3.4 points, 95% CI –5.7 to –1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (–2.7 points, 95% CI –5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions.ConclusionsThis study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain.Trial RegistrationClinicalTrials.gov NCT03096925; http://clinicaltrials.gov/ct2/show/NCT03096925

Case report: A rare cause of chest pain: Kommerell's diverticulum.

Introduction and importanceKommerell diverticulum is a very rare congenital defect of the aortic arch associated with the aberrant subclavian artery. It can present with signs of dysphagia, chest pain, or distal embolization in the upper limb.Case presentationWe present a case of Kommerell diverticulum with associated large subclavian artery aneurysm in a male patient with chest pain of unknown origin and hypertension. There was an incidental finding of the wide mediastinum on chest X-ray and the patient had a difference in systolic blood pressure in both arms. A right thoracotomy incision was used to successfully excise the aneurysm and reconstruct the subclavian artery. Patient recovery was uneventful.Clinical discussionEndovascular approaches are also an alternative to conventional open surgeries in the treatment of Kommerell diverticulum.ConclusionKommerell diverticulum with subclavian artery aneurysm should be considered in the differential diagnosis of non-cardiac chest pain. A simple investigation such as a chest X-ray can make a difference in these patients. Coarctation related to the right ASA might not always be a true coarctation. Endovascular treatment is an alternative to open repair in selected cases, but it needs further investigation in large randomized control trials.

Proton-pump inhibitor use and the development of new ischemic heart disease in non-cardiac chest pain patients.

The growing reports regarding cardiac-related adverse events of chronic proton-pump inhibitors (PPI) treatment, a mainstay therapy of non-cardiac chest pain (NCCP), have raised concerns about alteration of the natural course in NCCP patients using PPI. We aimed to determine if NCCP patients receiving PPI have a higher risk of developing ischemic heart disease (IHD) compared to those not receiving PPI therapy. Three groups of NCCP patients were included; PPI, histamine-2 receptor antagonist (H2RA), and no antireflux treatment. Diagnosis of NCCP had to precede diagnosis of IHD by at least 30days, and in those receiving antireflux treatment at 30days after starting the medication. Data analysis was corrected for 6 known confounding factors for IHD including hyperlipidemia, hypertension, obesity, smoking status, male gender, and diabetes mellitus. Of the patients on PPI or H2RA, 1280 and 250, respectively, developed IHD. Patients on PPI therapy displayed an increased odd of developing ischemic heart disease compared to patients never placed on therapy (OR 1.14, 95% CI 1.03-1.25, P-value .0093). Patients placed on H2RA therapy did not show a statistically significant change in risk compared to patients who were not placed on therapy (OR 0.90, 95% CI 0.77-1.06, P-value .2049). Number needed to harm in the PPI and H2RA groups was 17 and 45, respectively. PPIs confer a statistically significant, but marginal effect on the risk of IHD development in NCCP patients. Thus, PPI use in NCCP only minimally alters the overall benign natural course of the disease.

Non-Cardiac Chest Pain: A Review of Environmental Exposure-Associated Comorbidities and Biomarkers

The prevalence of non-cardiac chest pain (NCCP) ranges from 13-33%. A majority of those presenting with a chief complaint of chest pain are found to have a diagnosis of NCCP. Aerodigestive diseases are a cause of NCCP, and billions of dollars are spent annually on the treatment of NCCP. Furthermore, NCCP can cause significant psychological stress. NCCP is commonly diagnosed when patients have chest pain despite a normal cardiac evaluation. The leading cause of NCCP is gastro-oesophageal reflux disease (GORD). GORD should be suspected in patients who report a history of acid regurgitation, cough, dysphagia, and bloating. Another common cause of NCCP is obstructive airway disease (OAD). A thorough history and review of the symptoms should be performed for those with suspected NCCP, especially because of the contributing end organs. It is known that environmental exposures can commonly cause GORD and OAD; however, NCCP has not been fully explored in the context of environmental exposure. Patients with a history of exposure to particulate matter can develop environmental-exposure-associated GORD and coexisting OAD. This narrative review aims to provide a practical overview of NCCP, its causes, their relation to environmental exposure, and associated biomarkers. The authors used a PubMed search that spanned 2003-2018 to accomplish this. Additionally, this review provides a broad overview of biomarkers of GORD-associated NCCP and OAD-associated NCCP due to environmental exposure.

Comparison of nine coronary risk scores in evaluating patients presenting to hospital with undifferentiated chest pain.

IntroductionWe compared performance of nine risk scores for coronary heart disease (CHD) among patients presenting to an emergency department (ED) with undifferentiated chest pain of possible coronary origin.MethodsA retrospective study was undertaken of adult patients presenting with chest pain to atertiary hospital ED with no electrocardiographs or troponin results diagnostic of ischemic chest pain (ICP) or acute coronary syndrome at ED presentation, and no clearly evident noncoronary diagnosis. Risk scores were applied using cut-points distinguishing low- from high-risk patients according to discharge diagnosis of noncardiac chest pain (NCCP) or ICP, respectively. A lower odds ratio (OR) for ICP denoted lower risk for ICP. Score performance was compared using area under receiver–operator characteristic curves (AUC) and predictive values.ResultsA total of 401 patients were studied, of whom 123 (30.7%) had ICP as final diagnosis. Among the nine risk scores, those with greatest ability to detect low-risk patients were The North American Chest Pain Rule (NACPR) score (OR=0.35, 95% CI=0.27–0.46); History, ECG, Age, Risk Factors, and Troponin (HEART) score (OR=0.43; 95% CI=0.35–0.52); and Thrombolysis in Myocardial Infarction (TIMI) score (OR=0.49; 95% CI=0.41–0.58). Discrimination between patients with NCCP and those with ICP was greatest for HEART score (AUC=0.82; 95% CI=0.78–0.86) and lowest for Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins (ADAPT) score (AUC=0.63; 95% CI=0.58–0.69). In excluding ICP, ADAPT had negative predictive value (NPV) 100% (miss rate 0%) but classified only 1.7% of patients as low risk, compared to NACPR with NPV 98% (miss rate 2%), classifying 10.2% as low risk, and HEART with NPV 94% (miss rate 6%), classifying 32.4% as low risk.ConclusionThe NACPR risk score maximized yield of low-risk patients with lowest miss rate for ICP, while HEART score classified highest proportion of low-risk patients but with a higher miss rate.

The role of oesophageal physiological testing in the assessment of noncardiac chest pain.

Oesophageal physiology testing plays an important role in the diagnosis of noncardiac chest pain (NCCP) after cardiac, structural and mucosal abnormalities have been ruled out. Endoscopy can establish the presence of structural causes of chest pain such as cancer, oesophageal webs and diverticula. Even if macroscopically normal, eosinophilic oesophagitis is a common cause of chest pain and needs to be ruled out with an adequate biopsy regimen. In the remaining cases, diagnosis is focused on the identification of often subtle mechanisms that lead to NCCP. The most common oesophageal aetiologies for NCCP are gastro-oesophageal reflux disease (GORD), oesophageal dysmotility and functional chest pain. Ambulatory pH studies (with or without impedance or wireless measurements) can establish the presence of GORD, nonerosive reflux as well any association with symptoms of chest pain. High-resolution manometry, particularly with the inclusion of adjunctive testing, can rule out major motility disorders such as spasm, hypercontraction or achalasia. The EndoFLIP device can help define disorders with reduced distensibility, not easily appreciated with endoscopy or manometry. When all tests remain negative, a diagnosis of oesophageal hypersensitivity is normally made and therapy is shifted from targeting a disease to treating symptoms and patient affect.

An overlooked cause of retrosternal pain: Tetracycline-induced esophagitis

Chest pain is one of the most common admission symptoms of emergency services. The differential diagnosis is usually challenging but also very important for emergency physicians. After the exclusion of cardiac sources; noncardiac etiologies must be evaluated. Herein, we report a remarkable case who referred to our emergency department with chest pain and eventually diagnosed as tetracycline-induced esophagitis. Pill esophagitis should be kept in mind in the differential diagnosis of noncardiac chest pain.

98 Longer term outcomes of patients discharged from rapid access chest pain clinic after first consultation

IntroductionThe Rapid Access Chest Pain Clinics (RACPC) system has become an important way of assessing patients who present with chest pain to their primary care physician. Based on standard protocols...

Predictors of Adverse Outcomes of Patients with Chest Pain and Primary Diagnosis of Non-Cardiac Pain at the Time of Discharge from Emergency Department: A 30-Days Prospective Study

Chest pain is a common symptom for referring patients to emergency departments (ED). Among those referred, some are admitted to hospitals with a definite or tentative diagnosis of acute coronary syndrome and some are discharged with primary diagnosis of non-cardiac chest pain. This study aimed at investigating 30 days' adverse outcomes of patients discharged from ED of a major heart center in Iran. Out of 1638 chest pain admissions to the centre during 2010-2011, 962 patients (mean age= 50.9±15.9 years) who were admitted to Afshar Heart Center's ED with chest pain as their chief complaint, and discharged with primary diagnosis of non-cardiac chest pain, were followed for any adverse cardiac events 30 days post discharge. The adverse events were: unstable angina, non-ST-elevated myocardial infarction (NSTEMI), ST elevated myocardial infarction (STEMI), coronary revascularization (percutaneous angioplasty, coronary artery bypass grafting) and death. Adverse cardiac events, including acute coronary syndrome (ACS), revascularization and death were observed in 30 patients (3.1%) including: acute MI n=5 (0.5%, sudden cardiac death inn=1 (0.1%, coronary revascularization in n=8 (0.8%) and hospitalization due to unstable angina/NSTEMI in n=16 (1-7%). Adverse events were seen more frequently in patients with history of hypertension, dyslipidemia and previous coronary artery disease. In univariate analysis, the chance of postdischarge adverse cardiac events was higher in patients with hypertension (OR=9.36, CI=3.24-27.03), previous coronary artery disease (OR= 3.8, CI=1.78-8.0), dyslipidemia (OR=3.5, CI=1.7-7.38) and discharge against medical advice (OR=2.85, CI= 1.37-5.91). The extent of adverse cardiac events in patients with a primary diagnosis of non-cardiac chest pain within 30 days of discharge was significant, mandating nation-wide registries to provide better care for these patients.

PTU-129 Ambulatory High Resolution Oesophageal Manometry: A Novel Tool to Investigate Non-Cardiac Chest Pain

Introduction Non-cardiac chest pain can present a clinical challenge to the gastroenterologist. Many causes remain undiagnosed and untreated. Oesophageal spasm is frequently considered a cause of non-cardiac chest pain, but current diagnostic tools are often poor at making this diagnosis. High resolution oesophageal manometry is now the gold standard oesophageal motility test, and is a swallow-based assessment. Unfortunately most episodes of chest pain in this context are not swallow-related, and are usually sporadic and unpredictable. Thus most manometry assessments occur in the absence of a symptom event. We propose that prolonged, ambulatory high resolution may be a tool that can detect these sporadic chest pain events and allow correlation to symptom episodes. We aimed to test the diagnostic yield of a novel, ambulatory high resolution oesophageal manometry device in the diagnosis of non-cardiac chest pain. Methods We studied 17 patients (7 male, 10 female, age range 14 to 66) with chest pain. All had cardiac pain excluded by cardiology review, and all had been studied with normal upper GI endoscopy. All had also had major oesophageal motor disorder (including spasm) excluded by swallow-based high resolution manometry (with liquid and solid swallows). An ultra-thin high resolution solid-state catheter was inserted transnasally into the oesophagus. This was connected to a small laptop and battery pack carried in a backpack. Patients were sent home and encouraged to mobilise. Patients were asked to keep the catheter in place at least until a symptomatic pain event was perceived. Symptom events were self-marked on a recorder device that was subsequently synchronised with the manometry output. Manometry tracings were read manually, and motor events at the time of symptoms were examined in detail. Results The median duration of recording with the system was 12 hours, 13 minutes (range 5 hours, 30 minutes to 26 hours, 40 minutes). 12 of the 17 patients perceived typical chest pain symptom during recording. Of the 12 with typical symptoms, 3 (25%) had clinically important findings that changed management. They had significant oesophageal spasm, pressurisation and shortening associated with pain events. These have been treated successfully with oesophageal body Botox injections (2 patients) and with long laparoscopic myotomy (1 patient). The remaining 9 patients either had no abnormalities, or minor abnormalities that did not correspond to symptoms. Conclusion Ambulatory high-resolution manometry is a novel tool for investigation of non-cardiac chest pain. In our series, we identified management-altering abnormalities in 3 of 17 patients who had previously been investigated with normal cardiac, endoscopic and stationary manometric evaluation. Disclosure of Interest J. Ooi: None Declared, E. Yazaki: None Declared, K. Nikaki: None Declared, D. Sifrim Grant/research support from: Research grant from Sandhill Scientific, P. Woodland: None Declared

The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain

Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.

Illness representations, psychological distress and non-cardiac chest pain in patients attending an emergency department

Objective: Many patients who attend an emergency department (ED) with chest pain receive a diagnosis of non-cardiac chest pain (NCCP), and often suffer poor psychological outcomes and continued pain. This study assessed the role of illness representations in explaining psychological distress and continued chest pain in patients attending an ED.Methods: ED NCCP patients (N = 138) completed measures assessing illness representations, anxiety, depression and quality of life (QoL) at baseline, and chest pain at one month.Results: Illness representations explained significant amounts of the variance in anxiety (Adj. R² = .38), depression (Adj. R² = .18) and mental QoL (Adj. R² = .36). A belief in psychological causes had the strongest associations with outcomes. At one month, 28.7% of participants reported experiencing frequent pain, 13.2% infrequent pain and 58.1% no pain. Anxiety, depression and poor QoL, but not illness representations, were associated with continued chest pain.Conclusions: The findings suggest that (i) continued chest pain is related to psychological distress and poor QoL, (ii) interventions should be aimed at reducing psychological distress and improving QoL and (iii) given the associations between perceived psychological causes and psychological distress/QoL, NCCP patients in the ED might benefit from psychological therapies to manage their chest pain.

022 A RAPID CHEST PAIN ASSESSMENT PATHWAY INCLUDING HIGH-SENSITIVITY TROPONIN T TESTING REDUCES LENGTH OF STAY

<h3>Introduction</h3> Patients admitted with chest pain represent a major part of the workload of all acute hospitals. Recently available high-sensitivity troponin assays provide an opportunity to accelerate assessment of these patients as they can safely exclude myocardial infarction (MI) much earlier after symptom onset, avoiding the need to wait for a 12 h sample. Both local and national priorities encourage increasing same-day discharge and reducing length of stay for low-risk patients with chest pain. <h3>Methods</h3> In March 2012 we introduced a new pathway to the Chest Pain Assessment Unit of a busy District General Hospital. This combines high-sensitivity troponin T (hsTnT) testing at admission and 6 h after symptom onset with formalised clinical risk-assessment using the ADP score, a modified and well-validated version of the TIMI risk score. The pathway was introduced as a pilot in working hours only. Data on 5271 admissions over the preceding 2 years were used as a baseline. Hospital episode statistics data was used to assess and compare length of stay (Mann-Whitney U test), the proportion of patients discharged on the same day and discharge diagnosis frequency (χ² test) for all patients and for those with a final diagnosis of non-cardiac chest pain (NCCP). hsTnT results (normal level&lt;14 ng/l) were compared with a 3-month sample of previously used point-of-care troponin T test results (normal level &lt;50 ng/l). <h3>Results</h3> 331 patients were admitted and assessed using the new pathway with paired hsTnT testing between March and September 2012. 34% of patients had a discharge diagnosis of non-cardiac chest pain. There was a significant decrease in the number of low-risk patients unnecessarily given anti-platelet agents (50% to 14%, p&lt;0.001). The changes provided a net cost benefit to the unit of approximately £14 000 per year, mainly driven by increased NHS Payment by Results tariffs for patients discharged on the same day. A large increase in the number of abnormal troponin results was seen but there was no significant change in the final rate of diagnosis of MI (16–17%, p=0.24%). <h3>Conclusions</h3> The introduction of a modified pathway for the assessment of chest pain including hsTnT testing was successful in significantly decreasing length of stay and increasing the proportion of same-day discharges, largely in those patients with non-cardiac chest pain. This enhanced patient satisfaction, improved bed availability and had positive financial implications for the unit. Significantly more troponin results were technically abnormal, although this did not result in an increased rate of MI diagnosis in this population, which is an interesting result requiring further investigation.

Diagnostic Imaging to Exclude Acute Coronary Syndrome

On virtually every shift, Emergency Department providers care for patients with chest pain. With each encounter, the provider has the difficult task of determining if the patient’s pain is of cardiac or non-cardiac origin. This is a high-stakes decision, as patients discharged with an incorrect diagnosis of non-cardiac chest pain are at high risk for morbidity and mortality, while the provider is at high risk for a medical malpractice claim (Pope et al., N Engl J Med 342(16):1163–1170, 2000; Amsterdam et al., Circulation 122(17):1756–1776, 2010). Diagnostic imaging studies, such as coronary computed tomography angiography, cardiac magnetic resonance imaging, stress echocardiography, and nuclear imaging, play an important role in the risk stratification of patients presenting with chest pain or other symptoms concerning for acute coronary syndrome (ACS). This article will evaluate and summarize the recent evidence relevant to diagnostic imaging modalities used to exclude ACS.

High Prevalence of a Pathological Response to Acetylcholine Testing in Patients With Stable Angina Pectoris and Unobstructed Coronary Arteries: The ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries)

This study aimed at determining the prevalence of epicardial and microvascular coronary spasm in patients with anginal symptoms, despite angiographically normal coronary arteries. Despite a typical clinical presentation with exercise-related anginal symptoms (chest pain or dyspnea) with or without occasional attacks of resting chest pain suggestive of coronary artery disease, 40% of patients undergoing diagnostic angiography have normal or "near" normal coronary arteriograms. Many of these patients are given a diagnosis of noncardiac chest pain, and some are considered to have microvascular angina. However, we speculate that abnormal coronary vasomotion (reduced vasodilatation with exercise = reduced coronary flow reserve and/or vasospasm at rest) might also represent a plausible explanation for the symptoms of the patient. This was a prospective study in 304 consecutive patients (50% men, mean age 66 ± 10 years) with exertional anginal symptoms undergoing diagnostic angiography. A total of 139 patients (46%) had ≥50% coronary artery disease in at least 1 coronary artery, 21 patients (7%) had luminal narrowings ranging from >20% to 49%, and 144 patients (47%) had normal coronary arteries or only minimal irregularities (<20% diameter reduction). One hundred twenty-four patients of the latter (86%) underwent intracoronary acetylcholine (ACH) testing, which elicited coronary spasm in 77 patients (62%), 35 patients (45%) with epicardial spasm (≥75% diameter reduction with reproduction of the symptoms of the patient) and 42 patients (55%) with microvascular spasm (reproduction of symptoms, ischemic electrocardiographic changes, and no epicardial spasm). Nearly 50% of patients undergoing diagnostic angiography for assessment of stable angina had angiographically normal or near normal coronary arteriograms. The ACH test triggered epicardial or microvascular coronary spasm in nearly two-thirds of these patients. Our results suggest that abnormal coronary vasomotion plays a pathogenic role in this setting and that the ACH test might be useful to identify patients with cardiac symptoms, despite normal coronaries. (Abnormal Coronary Vasomotion in Patients With Suspected CAD But Normal Coronary Arteries; NCT00921856).

The use of the biomarker “copeptin” for the diagnosis of acute chest pain in the Emergency Department

The aim of the study is to assess if copeptin, in combination with negative troponin, is able to accelerate the rule-out of AMI in patients with chest pain. The study was retrospectively conducted on three groups of patients selected according to their discharge diagnoses: patients with non-ST elevation myocardial infarction (NSTEMI), non-cardiac chest pain (NCCP), unstable angina (UA). Comparing the levels of copeptin, we found that the diagnosis of AMI is associated more often with copeptin positive values (> 14 pmol/l) than the diagnosis of NCCP and UA. However, about a quarter of our patients in which the combination of copeptin and troponin in the first blood sample was negative, the final diagnosis was AMI. According to our results, the combination of the two negative markers does not allow a safe rule out of AMI at time zero.

Distensibility testing of the esophagus

The following contains commentaries on distensibility testing using the functional lumen imaging probe (FLIP); the use of the distention test of the esophageal body in the clinic diagnosis of noncardiac chest pain; the functional lumen imaging in gastroesophageal reflux disease-impaired esophagogastric junction; a multimodal pain model for the esophagus; the rationale for distensibility testing; and further developments in standardized distension protocols.

Comparison of the Impact of Wireless Versus Catheter-based pH-metry on Daily Activities and Study-related Symptoms

To evaluate the variation in tolerance to wireless pH-metry compared with catheter-based pH-metry, and to determine clinical characteristics that might predict reduced tolerance to wireless pH-metry. Consecutive outpatients (n=341) completing wireless (n=234) or catheter-based pH-metry (n=106) were evaluated. All patients completed the pH-Metry Impact Scale and the pH-Metry Symptoms Scale to assess the impact of the pH-metry on activities of daily living and pH-metry associated changes in study-related symptoms. All data are presented as mean (SD) or odds ratios (95% confidence interval). The impact of pH-metry on activities of daily living were modest, but wireless pH-metry had less impact than catheter-based pH-metry (P=0.01). A sense of foreign body in the chest, chest discomfort, and chest pain were reported more frequently during wireless pH-metry. Difficulty swallowing and painful swallowing were more common during catheter-based pH-metry. Noncardiac chest pain was associated with increased symptom severity. Patients with poor tolerance were twice as likely to have a diagnosis of noncardiac chest pain (odds ratio=2. 53; 95% confidence interval, 1.4-4.6). Wireless pH-metry has less of an impact on activities of daily living but is not associated with fewer study-related symptoms compared with catheter-based pH-metry. The prevalence of specific study-related symptoms does differ between the 2 groups and noncardiac chest pain seems to be the primary risk factor for more severe study-related symptoms and reduced tolerance for wireless pH-metry. This information may be useful in helping to decide which patients should undergo the wireless pH-metry or receive additional counseling on procedural expectations.

Increased cardiovascular risk associated with non-cardiac chest pain in patients with a prior psychiatric hospitalization: an opportunity and challenge for both the psychiatrist and the cardiologist

This editorial refers to ‘Prior psychiatric hospitalization is associated with excess mortality in patients hospitalized with non-cardiac chest pain: a data linkage study based on the full Scottish population (1991–2006)’[†][1], by M. Gillies et al. , on page 760 The evaluation of patients with chest pain is a common problem for every cardiologist and one of the most frequent reasons for presentation to the emergency room. After diagnostic evaluation, only 15–25% of patients with chest pain are found to have an acute coronary artery syndrome (ACS).1,2 Improved strategies for stress testing, myocardial imaging, and the availability of sensitive biomarkers for myocardial damage such as high sensitivity troponin have reduced the risk of missing the diagnosis of an ACS. Once coronary artery disease, myocardial ischaemia, and/or injury are ruled out, both the patient and the physician often feel relieved. A specific diagnosis such as oesophageal reflux, peptic ulcer disease, herpes zoster, costochondritis, pulmonary embolism, or panic disorder often leads to specific therapy and pain relief. However, in many instances, despite intensive evaluation and reassurance as to the usually benign nature of non-cardiac chest pain (NCCP), the cause of the pain remains uncertain and/or the pain may reoccur with consequent patient frustration and distress. In these instances, the patient may be prescribed an antidepressant and/or enrolled in pain coping skills training (CST). For example, in a recent study, Keefe et al .3 randomized patients with a diagnosis of NCCP to one of four treatments: (i) CST plus the antidepressant sertraline; (ii) CST plus placebo; (iii) sertraline alone; or (iv) placebo alone. CST and sertraline either alone or in combination were found to reduce pain intensity and pain unpleasantness significantly. The authors suggest that the combination of CST and sertraline may have the greatest promise in … [1]: #fn-2