Diagnosis Of Non-cardiac Chest Pain Research Articles

050 A novel role for b-type natriuretic peptide (BNP) as a safe and effective rule-out test in patients referred to rapid access chest pain clinics; results of a large, prospective 1-year follow-up study

<h3>Background</h3> Rapid access chest pain clinics (RACPCs) are commonplace but studies have shown that at least half of RACPC referrals have a final diagnosis of non-cardiac chest pain. A safe and effective pre-screening test before RACPC referral might reduce referrals by general practitioners, reduce costs and relieve unnecessary patient anxiety. The ability of BNP to help diagnose CAD has been confirmed in several recent studies. Its ability as a rule-out test in patients presenting with all-cause chest pain is not known. <h3>Aims/Objectives</h3> We aimed to determine if a near-patient pre-screening BNP would be a simple but effective rule-out test to safely exclude a cardiac cause for chest pain and reduce unnecessary referrals to RACPCs. An additional objective was to determine whether a particular BNP level at presentation is able to identify those RACPC patients who suffer cardiac events in the following 12 months. Other studies in different populations suggest BNP is very accurate at predicting future events. <h3>Methods</h3> Six hundred and twenty-five patients attending Rapid Access Chest Pain clinics in Tayside were recruited into the study over a 2-year-period. Each patient had demographic data, a near patient BNP level (Biosite^TM), clinical and laboratory measurements documented. The initial diagnosis was considered positive for IHD if the patient had a positive troponin T, was referred for angiography or coronary artery bypass grafting. All patients were then followed up 1-year after their initial RACPC attendance using hospital medical records, primary care records and telephone calls to document further RACPC attendance, hospitalisations for chest pain and survival data. <h3>Results and Discussion</h3> The average age of the patients was 60.0 years and 45% were female. The Negative predictive value (NPV) and Sensitivity of a BNP level ≤10 pg/ml for ruling out cardiac chest pain was 97.9% and 94% respectively. For the 1-year follow-up study, when corrected for age, sex and established risk factors such as hypertension, hypercholestrolaemia, diabetes, smoking and BMI, a BNP cut-off of greater than 10 pg/ml significantly predicted further hospitalisations for chest pain in the following 12-months compared to patients who presented with a BNP of less than 10 pg/mL (p&lt;0.001). Of 141 (23%) patients with a BNP of less than 10 pg/ml, 3 (0.02%) were re-admitted for chest pain in the following year and of those none (0%) had a positive troponin T on re-admission. <h3>Conclusion</h3> A near patient BNP level ≤10 pg/ml is a safe and effective rule-out test for possible ischaemic heart disease in patients presenting with chest pain. Patients with BNP levels &lt;10 pg/ml are significantly less likely to be admitted with cardiac chest pain in the following 12 months. In this study, a cut-off value of 10 pg/ml would safely reduce RACPC referrals by 23%.

Patients Dismissed From the Hospital With a Diagnosis of Noncardiac Chest Pain: Cardiac Outcomes and Health Care Utilization

To determine the proportion of patients with noncardiac chest pain (NCCP) who see a gastroenterologist, the type and frequency of gastrointestinal (GI) and cardiac tests performed, and the frequency of cardiac death. A cohort of Olmsted County, Minnesota, residents presenting to the emergency department (ED) with chest pain between January 1, 1985, and December 31, 1992, was identified through the Rochester Epidemiology Project. We assessed the frequency of ED, cardiology, and gastroenterology visits and corresponding tests after a diagnosis of NCCP (n=320). We also assessed the frequency of cardiac events. During follow-up, 49% of patients sought care in the ED, 42% had repeated cardiology evaluations, and 15% were seen by a gastroenterologist. Thirty-eight percent underwent esophagogastroduodenoscopy, but very few underwent manometry or a pH probe. Patients with NCCP of unknown origin had 3 times the rate of GI consultations as their counterparts with a GI disorder. Survival free of cardiac death in the subset with NCCP with a GI disorder was 90.2% at 10 years and 84.8% at 20 years, compared with 93.7% at 10 years and 88.1% at 20 years for the subset with NCCP of unknown origin. The frequency of health care utilization in NCCP patients is high, but relatively few GI consultations and even fewer GI tests are performed. Patients dismissed from the hospital with NCCP continue to experience cardiac events, which may highlight a need for more aggressive cardiovascular risk factor management in this population.

Prognostic value of adenosine stress cardiovascular magnetic resonance in patients with low-risk chest pain.

BackgroundApproximately 5% of patients with an acute coronary syndrome are discharged from the emergency room with an erroneous diagnosis of non-cardiac chest pain. Highly accurate non-invasive stress imaging is valuable for assessment of low-risk chest pain patients to prevent these errors. Adenosine stress cardiovascular magnetic resonance (AS-CMR) is an imaging modality with increasing application. The goal of this study was to evaluate the negative prognostic value of AS-CMR among low-risk acute chest pain patients.MethodsWe studied 103 patients, mean 56.7 ± 12.3 years of age, with chest pain and no electrocardiographic evidence of ischemia and negative cardiac biomarkers of necrosis, who were admitted to the Cardiac Decision Unit of our institution. All patients underwent AS-CMR. A negative AS-CMR was defined as absence of all the following: regional wall motion abnormalities at rest; perfusion defects during stress (adenosine) and rest; and myocardial scar on late gadolinium enhancement images. The patients were followed for a mean of 277 (range 161-462) days. The primary end point was defined as the combination of cardiac death, nonfatal acute myocardial infarction, re-hospitalization for chest pain, obstructive coronary artery disease (>50% coronary stenosis on invasive angiography) and coronary revascularization.ResultsIn 14 patients (13.6%), AS-CMR was positive. The remaining 89 patients (86.4%), who had negative AS-CMR, were discharged. No patient with negative AS-CMR reached the primary end-point during follow-up. The negative predictive value of AS-CMR was 100%.ConclusionAS-CMR holds promise as a useful tool to rule out significant coronary artery disease in patients with low-risk chest pain. Patients with negative AS-CMR have an excellent short and mid-term prognosis.

Acupuncture as a Potential Treatment for Non-Cardiac Chest Pain – a Survey

To establish the level of interest in acupuncture as a treatment option for non-cardiac chest pain and to identify the factors associated with this interest. Non-cardiac chest pain is known to be a prevalent condition in the general population. Treatment options are limited. Given that acupuncture has a potential role in the treatment of chronic pain, this study was designed to establish the levels of interest in acupuncture among people with continuing non-cardiac chest pain. This small study formed part of a larger retrospective cohort study, and was conducted with all 235 people who were given a diagnosis of non-cardiac chest pain at the Rapid Access Chest Pain Unit in York within a 14 month period. We collected data on whether people continued to experience chest pain, and if so, whether they had considered, or would consider, acupuncture as a treatment. We used ordinal logistic regression to investigate potential covariates, including sex and age, that might be associated with this interest. In total, 161 (69%) participants returned questionnaires, 75 (47%) of whom were experiencing continued chest pain with a median duration of 5.4 months. Of these participants, 42% reported that they would consider acupuncture, 36% reported that they would not, and 22% did not know. In the ordinal regression model, we found no covariates significantly associated with the strength of participants' interest in acupuncture. People with continuing non-cardiac chest pain after attending a Rapid Access Chest Pain Unit have shown considerable interest in acupuncture as a primary care treatment option.

How do we define non‐cardiac chest pain?

Noncardiac chest pain (NCCP) is a heterogeneous disorder associated with substantial health-care costs and resource utilization. NCCP is defined by recurrent episodes of substernal chest pain in patients lacking a cardiac cause after a comprehensive evaluation. The magnitude of the problem is quite high because of fear of serious or life-threatening heart diseases. Patients with chest pain who present for the first time to ambulatory care or to the emergency room, only 11% to 39% are ultimately diagnosed with coronary artery disease. The likely causes of NCCP are numerous and often overlap. Diagnosing NCCP is difficult because NCCP remains a diagnosis of exclusion that encompasses heterogeneous patient populations. First, cardiac ischemic must be excluded and coronary angiography remains the gold standard. Once cardiac causes have been ruled out, a diagnosis of NCCP is made. Mostly, the source for NCCP originates in essence from the esophagus. Gastroesophageal reflux disease (GERD) is the most common esophageal diseases present in patients with NCCP. An initial empiric trail of high-dose acid suppression is the most cost-effective measure in the management of these patients. When a diagnostic workup is chosen, it centers on upper gastrointestinal endoscopy, 24-hr esophageal pH monitoring and esophageal manometry.

Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain

Research suggests that anxiety sensitivity may be an important component in the negative response to pain sensations, especially those with cardiopulmonary origin. Furthermore, there is experimental evidence to suggest that such effects may be stronger in women than men. The primary aim of the current investigation was to determine the relative roles that anxiety sensitivity and gender have on the pain reports of patients referred to a hospital clinic with chest pain. A total of 78 female and 76 male adults were recruited on entry to a Rapid Access Medical Clinic. All patients had been referred with chest pain, and were administered a range of pain and anxiety measures prior to diagnosis. Results indicate that males were more likely to receive a diagnosis of cardiac chest pain, whereas females were more likely to receive a diagnosis of non-cardiac chest pain. Additionally, anxiety sensitivity was related to pain in women but not men. Finally, evidence was found for the mediating effect of negative interpretative bias on the relationship between anxiety sensitivity and pain. However, this mediating effect was only found in women. These results not only confirm that anxiety sensitivity is related to greater negative pain responses in women, but that this may be due to an increased tendency to negatively interpret sensations.

Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care.

To ascertain the value of a range of methods - including clinical features, resting and exercise electrocardiography, and rapid access chest pain clinics (RACPCs) - used in the diagnosis and early management of acute coronary syndrome (ACS), suspected acute myocardial infarction (MI), and exertional angina. MEDLINE, EMBASE, CINAHL, the Cochrane Library and electronic abstracts of recent cardiological conferences. Searches identified studies that considered patients with acute chest pain with data on the diagnostic value of clinical features or an electrocardiogram (ECG); patients with chronic chest pain with data on the diagnostic value of resting or exercise ECG or the effect of a RACPC. Likelihood ratios (LRs) were calculated for each study, and pooled LRs were generated with 95% confidence intervals. A Monte Carlo simulation was performed evaluating different assessment strategies for suspected ACS, and a discrete event simulation evaluated models for the assessment of suspected exertional angina. For acute chest pain, no clinical features in isolation were useful in ruling in or excluding an ACS, although the most helpful clinical features were pleuritic pain (LR+ 0.19) and pain on palpation (LR+ 0.23). ST elevation was the most effective ECG feature for determining MI (with LR+ 13.1) and a completely normal ECG was reasonably useful at ruling this out (LR+ 0.14). Results from 'black box' studies of clinical interpretation of ECGs found very high specificity, but low sensitivity. In the simulation exercise of management strategies for suspected ACS, the point of care testing with troponins was cost-effective. Pre-hospital thrombolysis on the basis of ambulance telemetry was more effective but more costly than if performed in hospital. In cases of chronic chest pain, resting ECG features were not found to be very useful (presence of Q-waves had LR+ 2.56). For an exercise ECG, ST depression performed only moderately well (LR+ 2.79 for a 1 mm cutoff), although this did improve for a 2 mm cutoff (LR+ 3.85). Other methods of interpreting the exercise ECG did not result in dramatic improvements in these results. Weak evidence was found to suggest that RACPCs may be associated with reduced admission to hospital of patients with non-cardiac pain, better recognition of ACS, earlier specialist assessment of exertional angina and earlier diagnosis of non-cardiac chest pain. In a simulation exercise of models of care for investigation of suspected exertional angina, RACPCs were predicted to result in earlier diagnosis of both confirmed coronary heart disease (CHD) and non-cardiac chest pain than models of care based around open access exercise tests or routine cardiology outpatients, but they were more expensive. The benefits of RACPCs disappeared if waiting times for further investigation (e.g. angiography) were long (6 months). Where an ACS is suspected, emergency referral is justified. ECG interpretation in acute chest pain can be highly specific for diagnosing MI. Point of care testing with troponins is cost-effective in the triaging of patients with suspected ACS. Resting ECG and exercise ECG are of only limited value in the diagnosis of CHD. The potential advantages of RACPCs are lost if there are long waiting times for further investigation. Recommendations for further research include the following: determining the most appropriate model of care to ensure accurate triaging of patients with suspected ACS; establishing the cost-effectiveness of pre-hospital thrombolysis in rural areas; determining the relative cost-effectiveness of rapid access chest pain clinics compared with other innovative models of care; investigating how rapid access chest pain clinics should be managed; and establishing the long-term outcome of patients discharged from RACPCs.

Validity of the Hospital Anxiety and Depression Scale for Use With Patients With Noncardiac Chest Pain

Consecutive patients seen in the first-heart-aid service of a university hospital and given a diagnosis of noncardiac chest pain completed the self-report Hospital Anxiety and Depression Scale. Patients with a score >or=8 on either the anxiety or depression subscale (N=266, mean age=55.81 years, SD=13.03, 143 male patients) were compared with patients scoring <8 (N=78, mean age=60.55 years, SD=10. 84, 50 male patients) by means of the Mini International Neuropsychiatric Interview. Panic disorder and/or depression identified by the diagnostic interview were highly prevalent in the group with a score >or=8 (73.3% versus 3.9% in the comparison group). The Hospital Anxiety and Depression Scale is an adequate screening instrument for the detection of affective disorders in patients with noncardiac chest pain.

Chest pain evaluation units

Chest pain is a common cause of emergency department (ED) presentation. In the United States, it accounts for 5% to 6% of new ED attendances.1,2 The principal challenge in these patients is to identify those with an acute coronary syndrome. Early diagnosis allows effective treatment, and premature discharge may have disastrous consequences for patient and doctor: in the United States, between 2% and 5% of patients with acute myocardial infarctions are discharged from the ED, and 20% of malpractice claims against emergency physicians relate to the management of acute coronary syndrome.3 The problem with the emergency assessment of these patients lies in the limitations of diagnostic tests for acute coronary ischemia—electrocardiography (ECG) is diagnostic of acute myocardial infarction in only 40% to 65% of patients and is even less useful in those with unstable angina.4 Despite recent advances, serum markers for myocardial necrosis detect, at best, 66% of patients with acute myocardial infarction on arrival.5 Faced with these diagnostic difficulties and the consequences of misdiagnosis, ED physicians have a low threshold for admitting patients with chest pain in whom the diagnosis is not immediately clear. Some 60% to 65% of these patients have an eventual diagnosis of noncardiac chest pain,3 and although serious disease is diagnosed in a few, this traditional approach to chest pain is both time-consuming and expensive. It is against this background that the concept of ED-based chest pain evaluation units emerged, with the aim to provide medically equivalent care at a lower cost for patients presenting to an ED with chest pain with a probability for acute coronary syndrome that is low, but not sufficiently low to allow discharge. The concept originated in, and has been almost exclusively confined to, the United States. The first chest pain evaluation unit was set up in 1981 and, by 1997, 15% of EDs in the United States had followed suit.6 In this article, I review the literature on chest pain evaluation units to answer the following questions: How are patients managed on chest pain evaluation units? Is there evidence for their clinical effectiveness? Are they cost-effective? Is there evidence of patient satisfaction?

Etiology and outcome of patients with a final diagnosis of noncardiac chest pain admitted from the emergency department under suspicion of acute coronary syndrome

Etiology and outcome of patients with a final diagnosis of noncardiac chest pain admitted from the emergency department under suspicion of acute coronary syndrome

Tc-99m sestamibi esophageal activity during myocardial imaging.

A 75-year-old woman with atypical chest pain was referred for a two-day protocol stress/rest dipyridamole Tc-99m sestamibi myocardial perfusion study. Myocardial perfusion was normal, but, unexpectedly, extensive linear activity in a distribution corresponding to the esophagus was detected on both studies. A diagnosis of noncardiac chest pain due to duodeno-gastro-esophageal bile reflux was made in view of normal myocardial perfusion and the recurrent copious esophageal activity on the two separate examination days. This case stresses the importance of actively searching for ancillary findings when performing functional nuclear medicine imaging.

Continuous ambulatory esophageal pH monitoring in the evaluation of patients with gastroesophageal reflux. Diagnostic and Therapeutic Technology Assessment.

To provide clinicians with a technology assessment of the safety and effectiveness of continuous ambulatory esophageal pH monitoring (CAEpHM) in the diagnosis of pathologic gastroesophageal reflux in adults. A literature review and a Diagnostic and Therapeutic Technology Assessment (DATTA) survey questionnaire were mailed to 118 physicians with special interest in gastroesophageal reflux, esophageal disease, or the use of CAEpHM in the diagnosis of noncardiac chest pain. These panelists had been nominated to the DATTA panel by appropriate specialty societies and medical schools. A total of 93 panelists (79%) responded. Assessment was based on the expert opinion of the panelists, as well as on published scientific and medical literature (available as of June 1, 1994). Published studies were identified by a MEDLINE search using the terms esophagitis, reflux, and gastroesophageal reflux and by review of the references cited in these primary sources. The respondents completed a DATTA survey questionnaire; the survey results were tabulated, analyzed, and interpreted by an American Medical Association medical scientist. The safety of CAEpHM was considered to be established in adults with chronic heartburn, chronic hoarseness, persistent acid reflux refractory to therapy, laryngeal lesions, or noncardiac substernal chest pain. The safety of CAEpHM was considered to be promising in adults with episodes of apnea. The effectiveness of CAEpHM was considered to be established in adult patients with clear primary symptoms that reflect esophageal damage, such as chronic heartburn, persistent acid reflux refractory to therapy, or noncardiac substernal pain; promising in adults with chronic hoarseness; and investigational in adults with episodes of apnea.

Chest pain in women: clinical, investigative, and prognostic features

To characterise clinical, investigative, and prognostic features of women referred with chest pain who subsequently underwent coronary angiography. Analysis of all women with angina referred to one consultant during 1987-91 who subsequently underwent coronary angiography, with follow up to present day. Cardiothoracic centre. Women with normal coronary arteries; women with coronary artery disease shown on angiography; men with coronary artery disease matched for age; men referred with chest pain during the same period subsequently found to have normal coronary arteries. Risk factor analysis; results of exercise testing and coronary angiography; intervention; morbidity and mortality. Women comprised 23% (202/886) of patients referred with chest pain who subsequently underwent angiography. 83/202 women had normal coronary angiograms compared with 55/684 men (41% v 8%, P < 0.01). Diabetes mellitus was the only risk factor more frequently encountered in women with coronary artery disease (P = 0.001). The specificity and positive predictive value of exercise testing before angiography were significantly lower in women than men (71% v 93%, P < 0.001 and 76% v 95%, P < 0.001, respectively). Revascularisation procedures were as common in women with coronary artery disease as in men (81 (68%) v 70 (59%)), and there was no difference in event rate during follow up. Many patients with normal coronary arteries, irrespective of sex, had symptoms during follow up (61 (73%) women, 36 (65%) men) and continued to take antianginal drugs (27 (33%) women, 14 (28%) men); 14 (17%) women and six (11%) men required hospital readmission for severe symptoms. In this series, although women comprised the minority of patients referred with chest pain, a diagnosis of normal coronary arteries was five times more common in women than men. Risk factor analysis and exercise testing were of limited value in predicting coronary artery disease in women. There was no sex bias regarding revascularisation procedures, and outcome was similar. A diagnosis of non-cardiac chest pain in patients with normal coronary arteries was of little benefit to the patient with regard to morbidity.

Unexplained Chest Pain and Breathlessness

Complaints of chest pain and breathlessness are common in both primary care and medical outpatient settings. A subgroup of these patients who find their way into tertiary care settings and subsequently are found to have no relevant organic pathology are at risk of continuing morbidity. One possible reason for this is that diagnostic strategies often focus on establishing an organic cause of pain and ignore psychosocial factors. In this article I have attempted to describe not only the prevalence but also the clinical characteristics of patients with medically unexplained cardiorespiratory symptoms. A method of establishing a positive diagnosis of noncardiac chest pain has also been outlined. This is based on an interactive and overlapping model that takes into account not only a number of psychological and social factors but also current physical and cardiac risk factors. It is important for nonpsychiatric physicians to diagnose noncardiac pain at an earlier stage in the evolution of the disorder. This would have major beneficial effects for patients, including (1) fewer unnecessary investigations; (2) less distress and functional disability; (3) reduced cost to the hospital; and (4) fewer iatrogenic complications.

High-Amplitude Peristaltic Esophageal Contractions Associated With Chest Pain

Review of esophageal motility tracings performed during a three-year period yielded 112 patients who underwent the test because of chest pain of unclear etiology. Thirteen patients had high-amplitude peristaltic contractions. All 13 patients had pressurelike pain, ten had dysphagia, and six had symptoms of gastroesophageal reflux. The presence of an elevated lower esophageal sphincter pressure in five patients suggested a spectrum of hypertensive disorders of the esophagus variously affecting the body, the sphincter, or both. This latter subgroup responded to esophageal bougienage. Six patients had objective evidence for gastroesophageal reflux. These patients had at least partial relief from antireflux measures. High-amplitude peristaltic contractions should be considered in the differential diagnosis of noncardiac chest pain, since recognition of this entity can lead to appropriate management and symptom relief.

Value and limitations of technetium-99m stannous pyrophosphate in the detection of acute myocardial infarction

Technetium-99m stannous pyrophosphate ( 99mTc-PYP) myocardial imaging was performed in 436 consecutive patients for the evaluation of chest pain and suspected acute myocardial infarction (AMI). Scintigrams were assessed independently by three observers with a 90% interobserver agreement. In 134 patients with documented AMI (97 transmural, 37 nontrasmural), the sensitivity of 99mTc-PYP imaging was significantly lower in patients with nontransmural AMI (41%) than in patients with transmural AMI (78%). 99mTc-PYP imaging correctly localized the site of transmural infarction in 53 patients (70%). A diffuse 99mTc-PYP uptake was found in nine (10%) of 91 patients with positive scintigrams: six of these had a transmural AMI and three nontransmural AMI. In 226 patients without AMI, the specificity of infarct imaging was 95%. A false-positive scintigram was found in 0%, 8%, 9%, and 2% of patients with unstable angina, progressive angina, stable angina, and noncardiac chest pain, respectively. A diffuse uptake was found in six (54%) of 11 patients with false-positive scintigrams. No patient with the clinical diagnosis of noncardiac chest pain showed discrete uptake. In 76 patients with uncertain diagnosis for AMI, 99mTc-PYP imaging was considered of value in 11 patients with ventricular conduction defects (two patients with WPW syndrome, nine patients with LBBB). These data suggest that: 1. 1. 99mTc-PYP imaging is moderately sensitive in detecting and localizing transmural AMI and is insensitive in detecting nontransmural AMI; 2. 2. A discrete 99mTc-PYP uptake is highly specific for AMI; 3. 3. a diffuse uptake is neither sensitive to, nor specific for AMI. Myocardial imaging with 99mTc-PYP is of clinical value when the standard electrocardiographic and enzymatic techniques are inadequate for an accurate diagnosis of AMI.