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At least 19 recordsLinked to original sources
PubMed1991

Practical approach to the diagnosis of unexplained chest pain.

Chest pain is a frequent medical problem causing concern for both patients and physicians. A multidisciplinary meeting recently developed algorithms for evaluating these patients in the two most common scenarios for the presentation of chest pain: (1) new onset of chest pain in the primary care setting, and (2) recurrent chest pain in the the referral setting. In both situations, the primary care physician, rather than specialists, should direct the evaluation and treatment of patients with chest pain and normal coronary angiograms.

Algorithms↗
PubMed1975

Hyperventilation syndrome: a frequent cause of chest pain.

Chest pain is frequently a prominent symptom of the hyperventilation syndrome (HVS) and must be distinguished from angina pectoris due to coronary atherosclerotic heart disease (CAHD). The association between hyperventilation and chest pain may be apparent if psychoneurotic traits or anxiety are present. Many patients with HVS are not overtly anxious or neurotic, but in the great majority, a careful history and physical examination will indicate whether chest pain is due to HVS or CAHD. The failure to make this clinical differential diagnosis, which often leads to unnecessary coronary angiography, should not be as frequent as generally experienced. Fifteen of 95 consecutive patients had chest pain and additional typical HVS symptoms. Reassurance and detailed explanation about the cause of the chest pain gave significant relief, so that all patients were less symptomatic 24 to 44 months later, and none had developed new signs or symptoms to suggest that symptomatic CAHD had been overlooked. The risk and expense of coronary angiography was avoided.

Adolescent↗
PubMed1987

Coccidioidomycosis in adolescents presenting as chest pain.

Chest pain is a relatively common complaint in adolescents and is most often attributed to anxiety or musculoskeletal conditions. Pleuritic chest pain in association with fever and cough are frequently reported in adults with primary pulmonary coccidioidomycosis. We describe three cases in which chest pain mimicking costochondritis was the predominant initial presenting symptom of pulmonary coccidioidomycosis. In addition, in each case, recent tuberculin skin test reactivity complicated the diagnostic assessment and treatment. We conclude that, in endemic areas, coccidioidomycosis should be considered in the differential diagnosis of acute chest pain in teenagers as well as in adults.

Adolescent↗
PubMed1989

Thallium myocardial scanning in the emergency department evaluation of chest pain.

Chest pain is a common complaint of patients seen in the emergency department. The causes are legion, and range from the non-life threatening to the potentially catastrophic. Thallium heart scanning was done prospectively in 20 patients with a "classic" history for myocardial infarction (eight patients) or atypical chest pain and/or associated symptoms plus an abnormal ECG (12 patients) to discern a subset of patients from whom thallium scintography may be indicated in the emergency department. Although further investigation is needed, our preliminary study suggests that myocardial scanning with thallium can be a safe, fairly rapid, and useful objective parameter in the emergency department detection of suspected myocardial infarction, and in differential diagnosis of chest pain when other data such as the history, physical examination, ECG, or enzymes are inconclusive.

Adult↗
PubMed1992

Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic.

OBJECTIVE: To evaluate a clinic set up specifically to assess patients with recent onset chest pain, particularly those presenting with a normal resting electrocardiogram. DESIGN: Retrospective review of case notes. SETTING: Cardiac department of a tertiary referral cardiothoracic centre. PATIENTS: 250 consecutive patients with recent onset chest pain seen within 24 hours of general practitioner referral. OUTCOME MEASURES: Clinical diagnosis and management. RESULTS: 40% of patients were seen within seven days of the onset of symptoms. Twenty seven per cent had non-cardiac symptoms and could be discharged while 60% were considered to have cardiac pain. Sixty six patients (26%) were admitted directly from the clinic and 48 of these underwent coronary angiography within three weeks. Seventy patients (28%) have so far undergone intervention (angioplasty or coronary artery surgery), 22 within one month of presentation. One hundred and nine patients (44%) presented with a normal resting electrocardiogram, 21 of whom were considered to have unstable angina. Forty one of these patients were investigated of whom 37 were found to have significant coronary disease and 26 have undergone intervention. CONCLUSIONS: This experience highlights the inadequacy of a routine electrocardiogram reporting service in patients with recent onset of chest pain. An alternative facility offering immediate and complete cardiac assessment produced patient benefit with early diagnosis and intervention. Investigation of these patients, however, accounted for 5% of cardiac catheterisation laboratory throughput; this was a significant additional and unscheduled workload.

Adult↗
PubMed1987

[Leading symptom of angina pectoris. Psychophysiologic mechanisms of pain perception in chest pain complaints].

Anginal chest pain represents an important cardiac symptom which proved to have a high pretest probability for the existence of potential heart disease. The occurrence of clinically unapparent or atypically exposed myocardial ischemia, as well as discrepancies in effort angina, provide evidence that the release of a nociceptive stimulus does not guarantee pain perception of the same proportion. The connections between sequential nociceptive nerve impulses at different central nervous regions and particularly at non-specified thalamic nuclei allow learning processes in the development of pain perception. The intensity of pain may be altered to a great extent by the anxiety level. The patient might develop habits of vigilance for low threshold abnormal signals generated from the interior of the body; he might, however, also reach a stage of complete pain suppression by centrifugal control of the nociceptive input. Heart pain is probably one of the moderators in a more complex warning system.

Angina Pectoris↗
PubMedDate not supplied

The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group.

OBJECTIVE: To identify differences in the incidences of myocardial infarction in women and men with chest pain. DESIGN: Prospective multicenter cohort study. SETTING: Emergency rooms of three university and four community hospitals. PATIENTS: 7,734 emergency room patients with acute chest pain. MEASUREMENTS AND MAIN RESULTS: Myocardial infarction was diagnosed in 10% of the 3,896 women, compared with 19% of the 3,838 men, yielding an age-adjusted relative risk of myocardial infarction for women of 0.54 (95% confidence interval 0.48, 0.60). Physicians were equally adept at admitting women and men with myocardial infarctions, but men without myocardial infarction or unstable angina were significantly more likely to be admitted than were women without these diagnoses. Most clinical and electrocardiographic features indicating a risk of myocardial infarction were present in both women and men, but several high-risk features were less commonly present in women. After adjusting for the other factors that correlate with each patient's probability of having acute myocardial infarction, the relative risk of myocardial infarction was the same in women as men when the emergency department electrocardiogram showed the classic changes associated with acute myocardial infarction, but the risk was 40% lower in women when such electrocardiographic changes were not present. CONCLUSIONS: Clinical features that predict myocardial infarction in men predict myocardial infarction in women to a similar extent. However, female gender is associated with about a 40% lower rate of myocardial infarction except when classic electrocardiographic evidence is present on the emergency department electrocardiogram.

Adult↗
PubMed1989

Esophageal chest pain.

Recurrent chest pain frequently results in significant disability and anxiety, even after cardiac disease has been excluded. A stepwise approach is recommended for the diagnosis of pulmonary conditions, musculoskeletal disorders and structural problems of the upper gastrointestinal tract that can produce chest pain. If a search for these disorders proves negative, an esophageal source of chest pain should be strongly suspected. Although gastroesophageal reflux disease is the most common and easily treated cause of esophageal chest pain, esophageal motility disorders should also be considered. Motility disorders include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter and nonspecific motility disorders.

Chest Pain↗
PubMed1990

Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain.

In a prospective study of 278 consecutive patients admitted to an emergency ward for chest pain, the 115 clinical and paraclinical parameters available at the time of admission were evaluated by computer comparison with the final diagnoses. The most valuable items for making the diagnosis were classified according to their sensitivity, specificity and predictive value. Among the 278 patients, 100 individuals had myocardial infarctions (MI), 47 had unstable angina, 25 had stable angina and 106 patients had a non-coronary disease. The twelve most sensitive items for distinguishing MI from other conditions were the following: sudden onset of pain (70%); duration of more than 60 min (88%); constriction and squeezing (79%); oppression (75%); prior anginal attacks (61%); sex male (72%); age over 60 years (74%); abnormal heart auscultation (62%); abnormal electrocardiogram (ECG) (98%); segment (ST) disturbances (86%); increased glucose level (77%); CKMB fraction greater than 6% of total creatine kinase (CK) level (63%). Among the twelve most specific items, also with the best positive predictive value, irradiation in the right arm is of most importance; among the 51 patients with right arm involvement, 48 suffered from a coronary disease and 41 from a myocardial infarction. The largest extension of pain was reported in the latter group. It is concluded that chest pain with a wide irradiation involving the right arm strongly suggests that a myocardial infarction is ongoing.

Arm↗
PubMed1989

Chest pain--no difference in severity between those having a myocardial infarction and chest pain from other causes.

In considering nonpleuritic chest pain, the severity of the maximal pain as indicated by the patients on a visual analogue scale does not significantly differ for myocardial infarction or chest pain of other origin. There is also no significant change with time in the severity score of the maximal pain for either group. Thus, the time course is not diagnostically useful.

Angina Pectoris↗
PubMed1988

Pulmonary embolism in outpatients with pleuritic chest pain.

Pleuritic chest pain is a frequent complaint in patients coming to the emergency room, but the proportion of such patients with pulmonary embolism is uncertain. In a prospective study, we evaluated the diagnostic outcomes in 173 consecutive patients who came to the emergency room with pleuritic chest pain. Pulmonary embolism, as demonstrated by angiography or autopsy, was present in 36 (21%). The need for objective testing is clearly indicated by our finding that the sensitivity (85%) and specificity (37%) of predetermined clinical variables for pulmonary embolism were insufficient to allow a definitive treatment decision. Optimal sensitivity and specificity are obtained by using pulmonary angiography in combination with lung scanning. The proportion of patients requiring angiography is substantially reduced, from 43% to 26%, without significant loss of accuracy, if ventilation imaging and impedance plethysmography are used together with perfusion scanning.

Adult↗
PubMed1975

Chronic myofascial pain-dysfunction syndrome with chest pain.

A patient with a myofascial pain-dysfunction (MPD) syndrome with pain radiating into the chest has been described. A direct relationship between a dental malocclusion and the chest pain was confirmed by tests. The patient was treated for MPD syndrome related to the malocclusion, and the chest pain symptoms were relieved. This report demonstrates the need for the dentist to consider not only the muscles of mastication in the management of problems of the neuromuscular apparatus but also the delicate balance which exists between the masticatory apparatus and the postural muscles of the head and neck.

Adult↗
PubMed1991

Hospitals battle heart attacks with new chest pain centers.

Chest pain emergency centers are among the most popular new ambulatory care services being added in U.S. hospitals. In the past year, at least 80 hospitals have added such facilities, bringing the total to about 103 in 33 states, according to the Maryland cardiologist who pioneered the concept. Still, it remains to be seen whether these facilities will become a reliable long-term source of increased admissions.

Cardiology Service, Hospital↗
PubMed1991

Investigation and management of non-cardiac chest pain.

Recurring substernal chest pain is an important clinical problem, causing anxiety for patients and their physicians because of the fear of possible cardiac disease. The differential diagnosis includes coronary artery disease, oesophageal disorders such as acid reflux disease and motility disturbances, musculoskeletal problems, psychological disorders including panic attacks, and a new 'fly in the ointment'--microvascular angina. History alone usually cannot distinguish cardiac from non-cardiac chest pain. After exclusion of significant coronary artery disease, attention must be turned to oesophageal disorders, which may be seen in as many as 50% of these patients. Oesophageal motility disorders, particularly the nutcracker oesophagus, are common, but the relationship between pain and abnormal contraction pressures is not well established. Provocative tests such as edrophonium (Tensilon) and balloon distension help to identify the oesophagus as the source of chest pain but do not direct therapy. Recent studies with ambulatory oesophageal monitoring suggest that gastro-oesophageal reflux may be a more common cause of chest pain than motility disorders. This is an important finding as acid reflux is a treatable problem, while therapies for motility disorders may only worsen reflux disease. The recent observation that oesophageal disorders are frequently associated and interact with psychological disorders such as anxiety, depression, somatization and panic attacks complicates the evaluation and understanding of chest pain. How these various abnormalities may be linked is an unresolved issue. Increased central nervous system stimulation and altered visceral and/or central pain sensitivity could be the common factors. It is hoped that further research into these areas will lead to new understandings of and possible solutions to the complex problem of non-cardiac chest pain.

Angina Pectoris↗
PubMed1989

Chest pain of esophageal origin.

Chest pain is a cause of significant anxiety in a patient. Even those who have no evidence of cardiac disease may have many visits to the emergency department and even repeated hospitalizations because of chest pain. Atypical chest pain is now the commonest reason for patients to be referred for esophageal manometry studies. The development of provocative studies has led both to an increased demonstration of esophageal origin of chest pain, as well as an increased awareness of the complexity of the esophageal response to a variety of stimuli. The possibility of a generalized smooth muscle disorder has been considered on the basis of studies demonstrating that many patients with microvascular angina have esophageal motor disorders. This review examines some of the issues related to the use of provocative agents to study patients with chest pain, in addition to briefly reviewing gastroesophageal reflux disease and esophageal mucosal disorders.

Chest Pain↗
PubMed1992

Pain profiles of patients with nonorganic chest pain: a preliminary report of the Multidimensional Pain Inventory.

The primary purpose of this report is to extend the range of the Multidimensional Pain Inventory (MPI) to include patients with nonorganic chest pain. Previous research with the MPI has not included this patient population, although this instrument has been used to derive an empirically based taxonomy of patient responses to chronic pain. Scale scores are provided for a sample of 43 chest pain patients and compared with normative scores from samples of chronic lower back pain patients and patients suffering from temporomandibular disorder. The MPI taxonomy was applicable for only 34.8% (N = 15) of this sample. Scale intercorrelations are examined and compared with those derived during development of the MPI, to explore reasons for this low classification rate. The results are discussed in light of cognitive-behavioral factors present in persistent chest pain, with implications for scale development and use of the MPI.

Adult↗
PubMed1991

Gastroesophageal reflux disease as a cause of chest pain.

Patients with recurrent chest pain free of significant coronary artery disease account for 10% to 30% of patients undergoing coronary angiography. Recent studies suggest that gastroesophageal reflux disease may be very common in these patients. The cause of this chest pain seems to be related primarily to an acid-sensitive mucosa regardless of the presence of esophagitis. Unfortunately, a careful history will not distinguish chest pain arising from a cardiac versus an esophageal source. Therefore, all patients must undergo a thorough cardiac evaluation before assuming that acid reflux is the cause of their complaints. Initial gastroenterology evaluation will usually include upper GI endoscopy or barium studies, possibly with acid perfusion (Bernstein) testing, or both. However, the more sensitive and specific test for acid-related disease is prolonged esophageal pH monitoring. This study quantifies the amount of acid reflux but, more importantly, identifies the relationship between chest pain and acid reflux episodes. Patients should be studied in the outpatient setting with emphasis placed on performing activities that replicate their chest pain. Although we presume that acid-induced chest pain responds as well as heartburn to vigorous antireflux regimens, there are few studies to address this issue. Nevertheless, I have had great success in treating these patients with either high-dose H2 blockers or omeprazole therapy.

Chest Pain↗