Oesophageal sensitivity to acid in patients with non-cardiac chest pain: is the oesophagus hypersensitive?

During the past decade, gastro-oesophageal reflux disease has been shown to be the most common identifiable cause of non-cardiac chest pain of oesophageal origin. The development of combined pH-pressures recording systems has also contributed to a better understanding of the underlying mechanisms of pain perception. Beside typical gastro-oesophageal reflux disease, many patients with non-cardiac chest pain appear to have an hypersensitivity to acid or mechanical stimuli, or both. Despite new insights into the pathophysiology of gastro-oesophageal reflux disease, therapy is limited to the suppression of noxious stimuli by antisecretory drugs or surgery. New therapeutic approaches using drugs affecting visceral perception, and well-controlled placebo trials are urgently needed.     

The neu-oncogene product in serum and tissue of patients with breast carcinoma

Patients with non-cardiac chest pain (NCCP) (n = 387) and cardiac chest pain (CCP) (n = 93) were compared with community controls (n = 81), using a symptom questionnaire that assessed the presence of irritable bowel syndrome (IBS), functional dyspepsia, and oesophageal dysfunction and chest pain characteristics. A significantly (p < 0.05) increased prevalence of symptoms compatible with IBS occurred in NCCP patients when compared with those with CCP and with controls. Dysphagia was more frequent in both those with non-cardiac and cardiac chest pain than in controls; this was not apparent, however, when patients with concomitant IBS were excluded. The presence of oesophageal or gastrointestinal symptoms did not enable discrimination with regard to the chest pain characteristics. We conclude that unselected referred patients with documented NCCP are more likely to have IBS and that the presence of oesophageal symptoms such as dysphagia may merely reflect the spectrum of the 'irritable gut'.     

Predictive value of symptom profiles in patients with suspected oesophageal dysmotility

The main aim of the study was to determine prospectively, in patients referred for oesophageal manometry, whether certain combinations of oesophageal symptoms are more likely than others to predict the presence of oesophageal dysmotility or a positive response to acid perfusion testing. In 524 consecutive patients, presenting predominantly with (non-cardiac) chest pain (n = 277), dysphagia (n = 186), or heartburn (n = 61), a standardized symptom assessment was completed before oesophageal manometry and acid perfusion testing. Half the patients in each group reported additional ('secondary') oesophageal symptoms as well as the predominant symptom. Oesophageal dysmotility was categorized in accordance with standard manometric criteria for achalasia, diffuse oesophageal spasm, nutcracker oesophagus, hypertensive lower oesophageal sphincter, or non-specific oesophageal motility disorder. In the predominant chest pain group, the prevalence of abnormal manometry was 33%; in the presence of secondary symptoms, especially dysphagia rather than heartburn, however, the prevalence was significantly (p < 0.01) increased. Also in the predominant chest pain group the prevalence of positive acid perfusion testing (44%) was significantly greater (p < 0.05) in those with than in those without secondary symptoms. In the predominant dysphagia group, the prevalence of abnormal manometry was higher than in the other two groups (56%; p < 0.001) but was not affected by the presence or absence of secondary symptoms; this latter finding was also true for the predominant heartburn group. The distribution of specific manometric disorders in any group was not related to the presence or type of secondary symptoms, although a combination of dysphagia and chest pain discriminated achalasia from other manometric disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

Abnormal gastro-oesophageal reflux in Chinese with atypical chest pain

Although atypical chest pain has been well described in the Western population, its frequency in Chinese is unknown. Over a period of 42 months, we studied 521 Chinese patients with chest pain and identified 108 patients (20.7%) whose pain was not related to cardiac causes, as determined by exercise ECG or cardiac catheterization. Using 24 h ambulatory pH monitoring and baseline oesophageal manometry, 28.7, 19.4 and 5.6% of these patients were found to have abnormal reflux parameters, abnormal manometric findings or both, respectively. There were significantly more patients complaining of chest pain during the study in the gastro-oesophageal reflux disease (GERD) group than in the non-GERD group (16/31 vs 20/77; P < 0.001). The lower oesophageal sphincter pressure was lower in those with abnormal reflex parameters than in those with normal reflux parameters (12.7 +/- 5.4 vs 17.8 +/- 5.8 mmHg; P < 0.05). There was no significant difference in symptoms, such as heartburn (54.8 vs 42.9%), regurgitation (38.7 vs 35.1%) and dysphagia (19.4 vs 24.7%), among the two groups. Non-specific changes were the most frequent baseline motility pattern. In conclusion, atypical chest pain and gastro-oesophageal reflux disease are not uncommon in Chinese and this deserves special emphasis as the continuation of anti-anginal drugs may aggravate their condition.     

Air oesophagogram: a frequent, but not a specific sign of oesophageal involvement in connective tissue diseases

OBJECTIVE: This study investigates the role of the air oesophagogram in conventional chest X-rays for the diagnosis of oesophageal dysmotility in patients with connective tissue diseases. METHODS: Fifty-one patients with connective tissue diseases were studied by oesophageal manometry and lateral and posterior-anterior chest X-rays. The presence or absence of oesophageal air on chest X-rays were evaluated separately in the upper, middle and distal segment of the oesophagus. Forty-seven chest X-rays of patients without connective tissue diseases, who had undergone manometry for the evaluation of oesophagus-related symptoms and who had normal oesophageal function, were analysed as a control. RESULTS: A total of 23/51 patients with connective tissue diseases showed oesophageal dysfunction in manometry; 16/51 patients (31%) had air in two or more oesophageal segments on the lateral chest X-ray. There was a significant association of manometrically proven oesophageal dysmotility and air in two or three oesophageal segments (P < 0.05; sensitivity 48%, specificity 82%). However, the prevalence of an air oesophagogram showed no significant difference between patients with connective tissue diseases and the control group (10/47; 21%). CONCLUSION: The radiological sign of an air oesophagogram is neither sensitive nor specific enough to omit oesophageal motility studies in patients with connective tissue diseases.     

Increased occurrence of esophageal hypermotility disorders in patients with arterial hypertension

BACKGROUND AND OBJECTIVE: It has been noted in previous manometric examinations of the oesophagus in patients with chest pain that abnormal motility was often associated with arterial hypertension. A systematic study of this relationship was therefore undertaken. PATIENTS AND METHODS: In 40 patients with chest pain (18 women and 22 men, mean age 54.7 [24-70] years) and in 20 healthy volunteers (12 men, 8 women, mean age 50.8 [22-63] years) standardized oesophageal manometry and arterial blood pressure monitoring were performed over 24 hours. Coronary heart disease and gastrointestinal lesions had been excluded by angiography and endoscopy, respectively. RESULTS: 20 patients (group H) had hypertension (median 24-hour blood pressure > 135/85 mmHg), while 20 patients (group N) and the normal controls (group K) were normotensive. Oesophageal manometry data differed significantly between the three groups regarding distal pressure amplitude (in hPa [hectopascals]; group H: 62 hPa*,**, group N 44 hPa* and group K 36 hPa**; [*P < 0.0005]) and the proportion of simultaneous contractions (group H 23%, group N 22%**, group K 10%***; ***P < 0.001). The hypertensive patients had significantly more frequent motility abnormalities than normal controls (13/20 vs 4/20, P < 0.001); while normotensive patients had more frequent episodes of abnormal propulsion in the oesophagus (proportion of propulsive contractions in group H: 53%, in N: 44%, in K: 59%; P < 0.01). CONCLUSION: Oesophageal motility differed significantly in patients with chest pain from that in healthy controls. Patients with chest pain and hypertension more frequently had oesophageal hypermotility. This suggests a generalized abnormality of smooth muscle.     

Impact of a public campaign on pre-hospital delay in patients reporting chest pain

OBJECTIVE: To decrease pre-hospital delay in patients with chest pain. DESIGN: Population based, prospective observational study. SETTING: A province of Switzerland with 380000 inhabitants. SUBJECTS: All 1337 patients who presented with chest pain to the emergency department of the H?pital Cantonal Universitaire of Geneva during the 12 months of a multimedia public campaign, and the 1140 patients who came with similar symptoms during the 12 months before the campaign started. MAIN OUTCOME MEASURES: Pre-hospital time delay and number of patients admitted to the hospital for acute myocardial infarction (AMI) and unstable angina. RESULTS: Mean pre-hospital delay decreased from 7h 50 min before the campaign to 4 h 54 min during it, and median delay from 180 min to 155 min (P < 0.001). For patients with a final diagnosis of AMI, mean delay decreased from 9 h 10 min to 5 h 10 min and median delay from 195 min to 155 min (P < 0.002). Emergency department visits per week for AMI and unstable angina increased from 11.2 before the campaign to 13.2 during it (P < 0.02), with an increase to 27 (P < 0.01) during the first week of the campaign; visits per week for non-cardiac chest pain increased from 7.6 to 8.1 (P = NS) during the campaign, with an increase to 17 (P < 0.05) during its first week. CONCLUSIONS: Public campaigns may significantly reduce pre-hospital delay in patients with chest pain. Despite transient increases in emergency department visits for non-cardiac chest pain, such campaigns may significantly increase hospital visits for AMI and unstable angina and thus be cost effective.     

Letter from Reykjavik

BACKGROUND AND OBJECTIVES: In previous manometric investigations, we observed that patients with chest pain and arterial hypertension frequently tend to display oesophageal motility abnormalities. Therefore, we set out to study this systematically. METHODS: Patients with chest pain and normal coronary angiogram (n=40) and healthy controls (n=20) were studied prospectively in a standardized fashion using a portable oesophageal manometry and blood pressure registration system over 24 hours. RESULTS: Twenty patients exhibited increased arterial blood pressure (24 h median > 135/85 mmHg), while in the other 20 patients and all controls the 24 h blood pressure patterns were normal. Median pressure amplitudes in the distal oesophagus were 46.5, 33 and 27 mmHg in patients with or without arterial hypertension and controls, respectively, and 30, 27 and 27 mmHg in the proximal oesophagus, respectively. The durations of distal contractions were 3.9, 3.4 and 3.4 s, respectively, and those of proximal contractions were 3.2, 3.0 and 3.2 s, respectively. Percentages of propulsive contractions were 53%, 44% and 59%, respectively, and those of simultaneous contractions were 23%, 25% and 10%, respectively. CONCLUSIONS: Patients and controls differ significantly regarding their oesophageal motility patterns. Patients without arterial hypertension exhibit impaired propulsion of oesophageal contractions, whereas patients with arterial hypertension tend to produce oesophageal hypermotility. This suggests that, depending on the presence or absence of arterial hypertension, different pathomechanisms of oesophageal motility disturbances come into play.     

Silicone versus polymethylmethacrylate intraocular lenses with regard to capsular opacification

Between May 1996 and May 1997, a total of 398 patients (321 males, 77 females) were registered at our institute for trans-telephonic electro-cardiographic monitoring (TTEM). Their age ranged from one month to 95 years. Almost two-third (67%) of patients were from Delhi and one-third (33%) from other places in India and neighbouring countries. Clinical profile of these patients was post-bypass surgery, post-myocardial infarction, chest pain for evaluation, post-percutaneous transluminal coronary angioplasty, chronic stable angina, evaluation of palpitations, arrhythmias, and pace-maker follow-up. Out of 664 symptomatic transmissions, 568 (86%) were received for cardiac symptoms and 96 (14%) for non-cardiac symptoms. Seventy-nine percent patients had chest pain or palpitations at the time of transmission, whereas 21 percent had other symptoms like chest discomfort, breathlessness or dizziness. The electro-cardiograms were transmitted within one hour of the onset of chest pain in 84 percent, palpitations in 78 percent and dizziness in 75 percent. Of patients with symptomatic transmissions, 628 (95%) required either reassurance or drug-dose adjustment and outpatient department review. Only 36 (5%) patients were hospitalised as an emergency, and out of these only 19 (3%) needed acute management. In conclusion, trans-telephonic electro-cardiographic monitoring is a very convenient and an 'all-time-available' monitoring facility for establishing patient-physician contact in the shortest time. It is useful in rendering instant advice for hospitalisation in emergency situations while avoiding unnecessary visits to the hospital.     

Intraesophageal balloon distension test in Chagas' disease patients with noncardiac chest pain

Patients with Chagas' disease often have chest pain as a prominent symptom. The objective of this study was to compare the results of intraesophageal balloon distension in chagasic and nonchagasic patients with chest pain not caused by coronary obstruction. We studied 40 patients with chest pain and angiographically normal coronary arteries, 25 with a positive serologic test for Chagas' disease (Chagas group, 16 women, mean age 53+/-10 years), and 15 with a negative serologic test (control group, 11 women, mean age 46+/-10 years). All patients had radiologic and endoscopic examinations of esophagus, stomach, and duodenum, esophageal manometry with the acid infusion test in the distal esophagus, and intraesophageal balloon distension. None of them had esophageal dilation or any signs of cardiovascular disease. A 25-mm-long latex balloon located 10 cm above the lower esophageal sphincter was inflated and deflated over a period of 10 sec at 1-ml increments of air until the subjects reported chest pain or to a maximum volume of 20 mi. The test caused chest pain in 14 subjects in the control group (93%) and in 12 in the Chagas' disease group (48%, P < 0.05). The mean volume of air that caused chest pain was 10+/-3 ml in the control group and 15+/-4 ml in the Chagas' disease group (mean+/-SD, P < 0.05). The maximum intraesophageal pressure during the examination was higher in Chagas' disease patients with chest pain during balloon distension (60 +/- 21 mm Hg) than in patients who did not have chest pain (37 +/-18 mm Hg, P < 0.05) and did not differ from the control group (48+/-16 mm Hg, P > 0.05). With the other examinations there was no difference between groups or between patients with or without chest pain during the balloon distension test. Although esophagitis was observed in 47% of patients in the control group and in 40% of the Chagas' disease group, the acid infusion test was positive in 27% of patients in the control group and in 4% of patients in the Chagas' disease group. We conclude that, as compared to a group of patients with similar chest pain, chagasic patients are less sensitive to esophageal distension. Thus, it is unlikely that their chest pain is related to esophageal mechanisms.     

Is functional dyspepsia largely explained by gastro-oesophageal reflux disease?

Functional dyspepsia is a chronic disorder of unknown aetiology. The lack of endoscopic abnormalities in patients with this disorder has led many physicians to believe that gastro-oesophageal reflux disease may be responsible for most symptoms. Our group has addressed this issue, by pathophysiological studies in a large cohort of Dundee patients with persistent dyspeptic symptoms. Peptic ulcer and gallstones were excluded in all patients by appropriate tests. Ambulatory pH monitoring showed oesophageal acid reflux that lay above the conventional diagnostic threshold in approximately 20% of patients. This subset was diagnosed as having gastro-oesophageal reflux disease. In the remainder, moderate or severe reflux-like symptoms were reported by approximately 44% patients, who were categorized as reflux-like functional dyspepsia. Reflux symptoms were mild or absent in 36% patients, who were categorized as non-reflux-like dyspepsia. While oesophageal pH profiles lay within the conventional normal range in both of these functional dyspepsia subgroups, patients with reflux-like functional dyspepsia had significantly greater acid exposure values, including total oesophageal acid exposure time, percentage time at a pH of less than 4.0, DeMeester scores and pain reflux event correlation. Hence patients with reflux-like functional dyspepsia have oesophageal acid exposure that lies below the diagnostic threshold for gastro-oesophageal reflux disease but exceeds that of patients with non-reflux dyspepsia. The high pain/reflux event correlation in reflux-like functional dyspepsia suggests that subthreshold oesophageal acid exposure may be associated with troublesome reflux symptoms.     

Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder?

Severe nonexertional (resting) chest pain may be due to myocardial ischemia, esophageal dysfunction, psychiatric disorder, or any combination thereof and frequently poses a difficult diagnostic challenge. Our aim was to investigate causes of chest pain in patients with coronary artery disease. Forty-five patients with angiographically proven obstructive coronary lesions and recurrent chest pain at rest were studied; 18 had refractory pain despite cardiac therapy (problem group), and 27 had documented myocardial ischemia (control group). Esophageal manometry, edrophonium provocation, 24-hr pH studies, and psychiatric interview were performed in all patients. The clinical evolution and the outcome of specific treatment during follow-up was used to establish the etiology of chest pain. Esophageal dysfunction was identified in all problem patients and in 52% of controls, and the esophagus was incriminated as the source of pain in 8 (44%) and 5 (18.5%), respectively. After a mean follow-up of 49 months (range 24-76 months), the cause of chest pain in the problem group was identified as panic disorder in 9 patients (50%), gastroesophageal reflux in 6 (33%), esophageal dysmotility in 2 (11%), and gallstone disease in 1 (6%). Of the control patients, 18 (67%) had ischemic pain alone, while 9 had concurrent causes: panic disorder in 5 (19%) and esophageal dysfunction in 4 (15%). Esophageal dysfunction and psychiatric disturbances are common in patients with coronary artery disease presenting with resting chest pain, and may contribute to patients' symptoms.     

A long-term follow-up study of patients with ischaemic heart disease versus patients with nonspecific chest pain

Ninety consecutive patients who were admitted to hospital with acute chest pain were followed-up five years later. At the time of the original admission, all of the patients received a detailed physical and psychiatric evaluation. Seventy-one patients were diagnosed as having ischaemic heart disease, and 19 were diagnosed as having nonspecific chest pain. Patients with nonspecific pain were younger, consumed greater amounts of alcohol, smoked more than their organic counterparts, and were more likely to suffer from psychiatric disorder. The five-year assessment was carried out using a self-report questionnaire. Of the original 71 patients with ischaemic heart disease, 14 had died; 43 questionnaires were returned, 80.2% of the original sample. Sixteen (84.9%) of the patients with nonspecific pain were followed up; none had died. Both groups were predominantly male. The patients with nonspecific pain still smoked more than the patients with ischaemic heart disease, and they had significantly more symptoms of anxiety. The overall prevalence of psychiatric morbidity remained high, however, in both groups. Patients who had psychiatric illness at the time of the original assessment were more anxious at follow-up and more likely to complain of chest pain than those who had been well. Patients with nonspecific chest pain continued to seek treatment on a regular basis from their general practitioners either for chest pain or for other symptoms, but few were in frequent contact with hospital services. The possible preventive effects of psychiatric intervention at an earlier stage in both groups of patients needs to be investigated.     

Quantum chemical studies of methadone

To clarify the association between chest pain and significant coronary artery disease in patients who have aortic valve disease, 76 consecutive candidates for aortic valve replacement were evaluated prospectively with use of a historical questionnaire and coronary arteriography. Of the 76 patients, 19 (25 percent) had no chest pain, 21 (28 percent) had chest pain that was not typical of angina pectoris and 36 (47 percent) had chest pain typical of anigina pectoris. In 18 of 19 patients the absence of chest pain correlated with the absence of coronary artery disease. The single patient without chest pain who had coronary artery disease had evidence of an inferior myocardial infarction in the electrocardiogram. Thus, absence of chest pain and the absence of electrocardiographic evidence of infarction predicted the absence of coronary disease in all cases. The presence of chest pain did not predict the presence of coronary artery disease, but the more typical the pain of angina pectoris the more likely were patients to have significant coronary artery disease. Of the 21 patients with atypical chest pain, 6 (29 percent) had coronary artery disease, but of the 36 patients with typical angina pectoris 23 (64 percent) had significant coronary artery disease. In addition, when patients with chest pain not typical of angina pectoris also had coronary artery disease, the diseased vessels usually supplied smaller areas of the left ventricle than when the pain was typical of angina pectoris. In 21 of 23 patients (91 percent) with typical angina pectoris and significant coronary artery disease, lesions were present in the left coronary artery. There was no systolic pressure gradient across the aortic valve that excluded the presence of coronary artery disease, although all patients with a calculated aortic valve area of less than 0.4 cm2 were free of coronary artery disease. Patients with severe left ventricular dysfunction were more likely to have normal coronary arteries.     

Involvement of the frontal ventrolateral orbital cortex in descending inhibition of nociception mediated by the periaqueductal gray in rats

OBJECTIVE: To improve the characterisation of chest pain by comparing symptoms in patients with normal and abnormal coronary angiograms. STUDY DESIGN: Prospective case-control study. SETTING: Single tertiary cardiac referral centre. PATIENTS: 65 consecutive patients with chest pain and completely normal coronary angiograms recruited over a period of one year, and 65 sex matched patients with significant stenoses at angiography. MAIN OUTCOME MEASURES: Standardised chest pain questionnaires. RESULTS: 61 of 65 patients (94%) and every control reported chest pain on exertion. There were no important differences in the site, quality, and radiation of pain but three symptoms had discriminatory value expressed in binary fashion ("typical" v "atypical"): the consistency with which pain was reproduced by exercise (typical, score index 10/10), the duration of pain episodes (typical, five minutes), and the frequency of pain at rest (typical, 10% all pain episodes). All three symptoms were atypical in 21 (32%) patients with normal coronary angiograms, but only one patient with an abnormal coronary angiogram. Patients with no typical features had a 2% chance of an abnormal coronary angiogram if aged under 55 years or 12% if aged 55 years or more. The additional impact of exercise stress testing was low. CONCLUSIONS: Chest pain characteristics which separate patients with normal coronary angiograms from patients with obstructive coronary heart disease can be defined objectively. This may allow improvements in referral patterns for specialist opinion or angiography, and in characterisation of patients in research studies.     

"Nonspecific" chest pain associated with high long-term mortality: results from the primary prevention study in G?teborg, Sweden

BACKGROUND: The syndrome angina pectoris with effort-related chest pain or discomfort is usually easy to recognize. However, vague and nonspecific symptoms may cause little reason for extensive evaluation. The prognosis of such patients in the general population has so far not been well described. HYPOTHESIS: The study was undertaken to investigate long-term prognosis in men with chest pain considered to be nonspecific in comparison with men with typical angina pectoris (AP) or prior myocardial infarction (MI), and men without chest pain. METHODS: At the second screening of the G?teborg Primary Prevention Study in 1974-1977, 6,488 men aged 51 to 59 years at baseline were available for the present analysis. Men who had responded positively to a postal questionnaire about chest pain during exercise or at rest were interviewed by a physician according to a Rose questionnaire at the screening examination. Those with typical or probable AP were further examined by single experienced physician. The following four groups were formed: Group 1: men who did not complain of chest pain (n = 5,545). Group 2: men who had not consulted any doctor because of chest pain, but who had chest pain according to a questionnaire (n = 441); these men were not considered to have AP according to a three-step examination by experienced physicians. Group 3: typical AP (n = 232). Group 4: men who had suffered an MI (n = 134). RESULTS: During 16 years of follow-up, coronary heart disease (CHD) mortality for Groups 1-4 was 8.0, 19.5, 24.8, and 48.5%, respectively. Mortality from all cardiovascular diseases was 11.5, 24.5, 31.2, and 59.0%, respectively. Noncardiovascular disease mortality was 14.1, 17.7, 14.3, and 8.7%, respectively. Thus, the relative risk (RR) for CHD mortality among men with nonspecific chest pain (Group 2) was 2.77 [95% confidence interval (CI) 2.20, 3.50], for all cardiovascular disease mortality 2.46 (95% CI 2.00, 3.02), and for noncardiovascular disease mortality 1.60 (95% CI 1.28, 2.00). Total mortality in this group was as high (44%) as among those with typical AP (45%), but the highest mortality was found among men with a previous MI (68%). In men without chest pain it was 26%. Patients of Groups 2-4 had higher levels of cardiovascular risk factors than those in Group 1. Neither any specific questions in the Rose questionnaire, nor electrocardiographic changes at rest (uncommon) were of prognostic significance. Serum cholesterol, systolic blood pressure, diabetes, and smoking were significant predictors of outcome, both with respect to fatal CHD and to total mortality during the 16-year follow-up. CONCLUSION: We found a high cardiovascular as well as noncardiovascular mortality among patients with chest pain who had not been considered to have AP at a three-step examination procedure. It is important to be suspicious of early CHD symptoms in men (and women?) with "nonspecific" chest symptoms and to analyze their cardiovascular risk factor pattern further because they are at considerably higher risk for future events than those in whom CHD is not suspected.     

Prevalence of aspirin use among patients calling 9-1-1 for chest pain

OBJECTIVE: Early aspirin administration during an acute myocardial infarction (AMI) decreases morbidity and mortality. This investigation examined the extent to which patients with a complaint of chest pain, the symptom most identified with AMI by the general population, self-administer aspirin before the arrival of emergency medical services (EMS) personnel. METHODS: In this prospective, cross-sectional prevalence study, data were derived through the analysis of EMS incident reports for patients with a complaint of chest pain from June 1, 1997, to August 31, 1997. RESULTS: The study included 694 subjects. One hundred two (15%) took aspirin for their chest pain before the arrival of EMS personnel. Of the 322 subjects who reported taking aspirin on a regular basis, 82 (26%) took additional aspirin for their acute chest pain. Only 20 (5%) of the 370 patients who were not using regular aspirin therapy self-administered aspirin acutely (p<0.001). In addition, patients with lower intensity of chest pain (p = 0.03) were more likely to take aspirin for their chest pain. CONCLUSION: Only a relatively small fraction of individuals calling 9-1-1 with acute chest pain take aspirin prior to the arrival of EMS personnel. These individuals are more likely to self-administer aspirin if they are already taking it on a regular basis. It is also possible that they are less likely to take aspirin if their chest pain is more severe.     

Prognostic value of pharmacological stress echocardiography in women with chest pain and unknown coronary artery disease

OBJECTIVES: In this study we sought to investigate the prognostic value of pharmacological stress echocardiography in women referred for chest pain, having unknown coronary artery disease. BACKGROUND: The noninvasive identification of a high-risk subgroup among women with chest pain and unknown coronary artery disease is an unresolved task to date. METHODS: A total of 456 women (mean [+/-SD] age 63+/-10 years) underwent pharmacological stress echocardiography with either dipyridamole (n = 305) or dobutamine (n = 151) for evaluation of chest pain and were followed-up for 32+/-19 months. None of them had a previous diagnosis of coronary artery disease. RESULTS: No major complication occurred during stress testing. Five tests (1.1%) were prematurely interrupted because of the appearance of side effects. Echocardiographic positivity was identified in 51 patients. During the follow-up, 23 cardiac events occurred: 3 deaths, 10 infarctions and 10 cases of unstable angina; an additional 21 patients underwent coronary revascularization. At Cox analysis, the echocardiographic evidence of ischemia was found as the only independent predictor of hard cardiac events (death, infarction) (odds ratio [OR] = 27.5; 95% confidence interval [CI] = (6.5 to 115.5; p = 0.0000). When spontaneous cardiac events (death, infarction and unstable angina) were considered as endpoints, the positive echocardiographic result (OR = 23.9; 95% CI = 8.6 to 66.8; p = 0.0000) and family history of coronary artery disease (OR = 3.7; 95% CI = 1.5 to 9.1; p = 0.0037) were independently correlated with prognosis. By using an interactive stepwise procedure, the prognostic value of stress echocardiography was found to be incremental to that provided by clinical variables, both considering hard and spontaneous cardiac events as endpoints. The 3-year survival rate for the negative and the positive population was respectively, 99.5% and 69.5% (p = 0.0000) considering hard cardiac events, 99.2% and 50.6% (p = 0.0000) considering spontaneous cardiac events. CONCLUSIONS: Pharmacological stress echocardiography is safe, highly feasible and effective in risk stratification of women with chest pain and unknown coronary artery disease, also when hard endpoints are considered. Its use can have relevant implications in daily clinical practice for selection of patients needing further investigations.     

Clinical and echocardiographic findings in patients with suspected acute aortic dissection

OBJECTIVES: The objective of this study was to define the range of clinical presentations, echocardiographic findings, and underlying final diagnoses in patients with clinically suspected acute aortic dissection. METHODS AND RESULTS: This study was designed as a retrospective review of clinical and echocardiographic data in consecutive patients evaluated for clinically suspected acute aortic dissection. The study population consisted of 75 studies in 74 consecutive patients referred for urgent or emergency evaluation because of signs and symptoms suggesting acute aortic dissection. A history and physical examination designed to elicit the cause of chest pain, evidence of congestive heart failure, and other cardiovascular abnormalities was performed in each patient. All patients underwent transesophageal echocardiography by experienced operators. Routine 12-lead electrocardiograms and chest radiographs were available for review in the majority of patients. Magnetic resonance imaging or computed tomography was performed in only 5 (6%) and 34 (44%) patients, respectively. Contrast aortography was performed in 21 (27%) patients. For the entire patient cohort, the most prevalent symptom was chest pain alone (n = 31; 41%) or chest pain in conjunction with back pain (n = 23; 31%). Classic "tearing" pain was an infrequent symptom. Syncope or other neurologic findings were present in 15 (20%) patients. Acute aortic dissection was responsible for 34 (45%) of the 75 presentations, with 31 (41% of total evaluations, 92% of dissections) involving the ascending aorta (Stanford type A, DeBakey type 1 or 2). Alternate major cardiovascular diagnoses, including acute myocardial infarction, primary valvular disease, or pericardial disease, were established in 12 (16%) cases. Aortic pathology, other than dissection, was found in 15 (20%) cases. Transesophageal echocardiography established the diagnosis responsible for the symptoms in 61 (81%) cases. CONCLUSIONS: Symptoms in patients with acute aortic dissection are more variable than commonly recognized. Transesophageal echocardiography is an accurate primary diagnostic tool in patients with clinically suspected acute aortic dissection. It allows rapid diagnosis of dissection and can identify alternate cardiovascular pathology responsible for the symptoms in a significant number of patients without acute dissection.     

Indications and results of pleuropulmonary decortications in the university hospital of Kinshasa

BACKGROUND: A significant number of patients with chest pains who undergo coronary angiography (20-30%) have normal coronary arteries. Up to 50% of this group are eventually diagnosed as Panic Disorder and most continue to complain of their symptoms, in spite of the normal coronary angiogram. We hypothesized that the cognitions of panic disorder subjects on presentation with chest pain would differ from those of patients suffering from true angina pectoris. METHODS: We investigated the cognitions associated with chest pain of three patient groups: proven symptomatic coronary artery disease (CAD+), subjects with chest pain and a normal coronary angiogram (CAD-), and patients with panic disorder (PD). All patients were classified according to whether the symptomatology was, firstly, associated with frightening cognitions (during the episode), and, secondly, whether either these cognitions (cognitive predominance), or the physical symptom (physical predominance), dominated the clinical picture. RESULTS: We observed that in the CAD+ group, 18% experienced frightening cognitions but in only 4% (2 of 66 patients) were the cognitions the dominant experience during the chest pain. In contrast, all the PD patients experienced frightening cognitions and in 83% of this group, the cognitions were the predominant experience. In the CAD- group, 48% were found to be PD compatible. CONCLUSIONS: This study indicates that the cognitions of patients during episodes of chest pain, evaluated by three questions, help to differentiate between PD and true coronary symptoms. Consequently, the presence of frightening cognitions in the presence of chest pain, particularly at the onset of the clinical problem, makes necessary the need for psychiatric evaluation with the objective of excluding PD.