Prevalence of coronary blood flow reserve abnormalities among patients with nonobstructive coronary artery disease and chest pain

BACKGROUND: Very little is known about the mechanisms underlying adverse reactions to radiocontrast medium. On the basis of the clinical features of the adverse reactions, it has generally been considered that an IgE-dependent mechanism is not involved in these adverse reactions, and only a few studies have demonstrated the presence of IgE antibody to radiocontrast medium in patient sera. METHODS: We assayed for IgE antibody to ioxaglic acid (Hexabrix), a representative radiocontrast medium, in the sera of patients who had developed adverse reactions to ioxaglic acid. A conjugate was prepared by coupling succinyl ioxaglic acid to human serum albumin. Enzyme immunoassay and radioimmunoassay for the detection of IgE antibody to ioxaglic acid in patient sera were constructed by physical adsorption or by covalent coupling of the conjugate on solid supports. RESULTS: When the radioactivity or the absorbance exceeding the mean plus 3 SD for normal healthy subjects was regarded as positive, IgE antibody was detected in the sera of 47.1% of the patients who had a past history of adverse reactions to ioxaglic acid and 16.2% of those who had experienced adverse reactions to ioxaglic acid within 24 h before the blood collection, although the IgE antibody levels were low. On the other hand, IgE antibody to ioxaglic acid was not detected in the sera of patients with no history of adverse reactions to ioxaglic acid. Inhibition experiments revealed the presence of IgE antibody specific to ioxaglic acid in the serum defined as positive for IgE antibody to ioxaglic acid. The presence of IgE antibody to ioxaglic acid did not always correlate with the activation of mast cells due to the occurrence of adverse reactions to ioxaglic acid. CONCLUSIONS: A small amount of IgE antibody to ioxaglic acid was detected in the sera of some patients with a history of adverse reactions to ioxaglic acid, and these adverse reactions may be partly explained by the presence of IgE antibody in the serum of at least some patients.     

Comparison of aspirin with a thromboxane antagonist for patients with prolonged chest pain and ST segment depression

AIM: To compare a thromboxane antagonist (GR3219) with aspirin in patients with prolonged chest pain and ST segment depression to see if the frequency of attacks of chest pain was reduced. METHODS: The trial was part of a study comparing GR3219 with aspirin, and streptokinase with placebo and comprised the GR3219/aspirin leg. Thirty one patients were randomly assigned to GR3219 80 mg twice daily and 28 to aspirin 300 mg daily. The patients were under the age of 76 and admitted to a coronary care unit within 6 hours of continuous chest pain. The ECG showed at least 1 mm of flat or down-going ST segment. The patients kept diaries of their pain over the subsequent 31 days. RESULTS: Seventy percent of patients developed further chest pain. There was no difference between the pattern of recurrent chest pain according to which drug was used. CONCLUSIONS: The hypothesis that specific thromboxane A blockade with GR3219 would be more efficacious than aspirin was not supported by these results.     

Communication problems for patients hospitalized with chest pain

In many settings, primary care physicians have begun to delegate inpatient care to hospitalists, but the impact of this change on patients' hospital experience is unknown. To determine the effect on physician-patient communication of having the regular outpatient physician (continuity physician) continue involvement in hospital care, we surveyed 1,059 consecutive patients hospitalized with chest pain. Patients whose continuity physicians remained involved in their hospital care were less likely to report communication problems regarding tests (20% vs 31%, p =.03), activity after discharge (42% vs 51%, p =.02), and health habits (31% vs 38%, p =. 07). In a setting without a designated hospitalist system, communication problems were less frequent among patients whose continuity physicians were involved in their hospital care. New models of inpatient care delivery can maintain patient satisfaction but to do so must focus attention on improving physician-patient communication.     

Psychosocial correlates of chest pain among African-American women

While 10-30% of individuals with chest pain who undergo cardiac arteriography are found to have no demonstrable pathology, women are far more likely than men to have normal coronary arteries in the presence of angina. Black women, in particular, frequently seek medical attention for persistent episodes of chest pain. This cross-sectional study was designed to examine the potential role of psychological and social factors in relation to chest pain among black women. Among our population-based sample of 188 women, 48% reported experiencing chest pain. Seventeen of these cases met the Rose criteria for classification as cardiac pain while 74 of them reported pain not consistent with cardiac origin. A statistically significant difference was observed in the stress scores among the women; the highest stress scores occurred among those with Rose angina and the lowest scores were obtained from those women reporting no chest pain experiences (p < 0.001). There was no association detected between the presence and type of chest pain and psychosocial measures of depression and coping abilities. These results confirm the high rates of chest pain experienced among black women, and provide insight into the role of psychological factors that should be considered in the identification of treatment options.     

Computer-generated correspondence for patients attending an open-access chest pain clinic

AIM: To determine whether general practitioners (GPs) prefer structured computer-generated or standard dictated outpatient clinic letters. DESIGN: Questionnaire survey of all GPs referring patients to an open-access chest pain clinic at a district general hospital in London. The GPs were asked to compare three twinned examples of structured computer-generated and unstructured dictated letters. RESULTS: Of 93 respondents (response rate 77.5%), 75 (80.6%) preferred the computer-generated letter and 16 (17.2%) preferred the dictated letter (p < 0.0005). The preferred features of the computer-generated letter were its clear presentation, subheadings, and concise information. The computer-generated letter scored significantly higher than the dictated letter: for clarity, mean 8.2 vs 6.5 (p < 0.0005); content, mean 8.5 vs 6.9 (p < 0.0005); and readability, mean 8.2 vs 6.8 (p < 0.0005). The GPs in the survey considered a mean delay of 3.4 days to be acceptable for receiving the letter from the chest pain clinic. CONCLUSION: GPs prefer structured computer-generated letters to unstructured dictated letters for patients referred to an open-access chest pain clinic. Computer-generated correspondence allows rapid feedback of information to the referring GP, one of the key requirements of open-access clinics.     

Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain

STUDY OBJECTIVES: To determine the test performance characteristics of serum cardiac troponin T (cTnT) measurement for diagnosis of acute myocardial infarction (AMI), and to determine the ability of cTnT to stratify emergency department patients with chest pain into high- and low-risk groups for cardiac complications. METHODS: We conducted a prospective observational cohort study with convenience sampling in a tertiary care, urban ED. The study sample comprised 667 patients presenting to the ED with a complaint of chest pain or other symptoms suggesting acute ischemic coronary syndrome (AICS). Patients were assigned to different blood sampling protocols for cTnT therapy on the basis of their ECG at presentation: nondiagnostic for AMI at 0, 3, 6, 9, 12, and 24 hours after ED presentation; or ECG diagnostic for AMI at 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 18, and 24 hours after ED presentation. RESULTS: Of 667 patients, 34 had AMI diagnosed within 24 hours of ED arrival. Using a .2 microgram/L discrimination level for cTnT, sensitivity for AMI within 24 hours of ED arrival was 97% (95% confidence interval, 91.4% to 99.9%), and specificity was 92% (89.8%-94.1%). When the effects of age, race, sex, and creatine kinase-MB isoenzyme subunit test results were controlled, a patient with cTnT of .2 microgram/L or greater was 3.5 (1.4 to 9.1) times more likely to have a cardiac complication within 60 days of ED arrival than a patient with a cTnT value below .2 microgram/L. CONCLUSION: Measurement of cTnT will accurately identify myocardial necrosis in patients presenting to the ED with possible AICS. Elevated cTnT values identify patients at increased risk of cardiac complications.     

Dipyridamole stress echocardiography for risk stratification in hypertensive patients with chest pain

BACKGROUND: The noninvasive prognostic assessment of coronary artery disease (CAD) in hypertensive patients represents an unresolved task to date. In this study, we investigated the value of dipyridamole stress echocardiography in risk stratification of hypertensive patients with chest pain and unknown CAD. METHODS AND RESULTS: Dipyridamole stress echocardiography was performed in 257 hypertensives (110 men; age, 63+/-9 years) complaining of chest pain and without a history of CAD. No major complications occurred. Four tests were interrupted prematurely because of side effects, with 98. 4% feasibility of test. A positive echocardiographic response was found in 72 patients (27 during the low-dose [0.56 mg/kg]). During the follow-up (32+/-18 months), 27 cardiac events occurred: 3 deaths, 8 infarctions, and 16 cases of unstable angina. Moreover, 27 patients underwent coronary revascularization. At multivariate analysis, the positive echocardiographic result (OR, 5.5; 95% CI, 1.4 to 16.6) was the only predictor of hard cardiac events (death, infarction). Considering spontaneous cardiac events (death, infarction, and unstable angina) as end points, the positive echocardiographic result (OR, 4.2; 95% CI, 1.8 to 9.6) and family history of CAD (OR, 4.2; 95% CI, 1.5 to 6. 9) were independently associated with prognosis. The 3-year survival rates for the negative and the positive populations were, respectively, 97% and 87% (P=0.0019) considering hard cardiac events and 96% and 74% (P=0.0000) considering spontaneous cardiac events. CONCLUSIONS: Dipyridamole stress echocardiography is safe, highly feasible, and effective in risk stratification of hypertensives with chest pain and unknown CAD. At present, it represents an attractive option for prognostic assessment of this clinically defined population.     

Echocardiography with dobutamine in hypertensive patients with chest pain

INTRODUCTION: The exercise stress test shows limited diagnostic accuracy for the detection of coronary artery disease in hypertensive patients. Echocardiography with dobutamine is a useful tool in the assessment of coronary artery disease. PURPOSE: Our purpose has been to compare dobutamine stress echocardiography and exercise stress test for diagnosing coronary disease in hypertensive patients. MATERIAL AND METHODS: Dobutamine stress echocardiography (administered up to 40 micrograms/kg/min, and atropine when necessary), exercise stress test and coronary arteriography were performed on 74 hypertensive patients with chest pain and no previous history of coronary artery disease. RESULTS: Forty-eight (65%) patients underwent a diagnostic exercise stress test and 66 (89%) a diagnostic dobutamine stress echocardiography. Coronary artery disease (> or = 70% stenosis in, at least, one major vessel) was demonstrated in 28 (58%) patients who underwent a diagnostic exercise stress test, and in 39 (59%) patients who completed a dobutamine stress echocardiography. Sensitivity for exercise stress test was 82%, and 79% for dobutamine stress echocardiography (p = NS). Specificity was higher for dobutamine stress echocardiography (100% vs 60%; p < 0.005). CONCLUSIONS: Dobutamine stress echocardiography has high sensitivity and specificity for the detection of coronary artery disease in hypertensive patients. Dobutamine stress echocardiography has higher feasibility and specificity than exercise stress test in this group of patients.     

Psychological comorbidity in patients with alarming chest pain symptoms]

About 1/3 of patients with chest pain undergoing coronary arteriography (CA) have no coronary artery disease (CAD). Individuals with non-CAD chest pain may be younger and more likely to be female; they may express higher degrees of neuroticism. Are those features stable enough to justifi; exclusion from CA if present? To investigate this issue, data on psychodiagnostic parameters (depression, anxiety, somatic complaints) were obtained in patients before this were referred to CA. Inclusion criteria were a chief complaint of chest pain with episodes of angina-like pain at rest, suspicious enough to warrant cardiac catherisation; and no prior history of CAD or other organic heart disease. The sample consisted of 77 patients, recruited from 89 eligible patients. 12 patients were excluded because CA findings were missing for multiple reasons. CA was conducted by Judkins technique. Patients were labeled as CAD (-) if no stenosis were detectable. In 50 (65%) of cases CA findings were positive and in 27 (35%) findings were negative. CAD+ were significantly older (p < 0.05); the superiority in both groups were male. Prevalence of emotional disorders was markedly more pronounced in both groups in comparison to the normal population and to a group of male myocardial infarction survivors. However, those features did not discriminate between the groups. Long acting chest pain was predictive for high degrees of emotional disability (relative risk 5.33; 95% Kl 1.6-61.6; p < 0.012). Chest pain at rest is a major source of anxiety, depression and subsequent somatic preoccupation despite its ischaemic or functional origin. It leads to clinically relevant adjustment disorders in a significant proportion of chest pain patients and triggers emotional disstress. These factors may thus have less impact on risk stratification than expected.     

Comparative analysis of emergency department treatment of patients with chest pain

A vital function of the emergency physician is separating patients with chest pain who require intensive immediate treatment from those who require minimal care. The care of 701 patients presenting with chest pain in two Baltimore hospitals was evaluated using medical record data and follow-up questionnaires to discharged patients. Twenty per cent were admitted. There was a significant difference between the two hospitals in admission rates. Thirty-five per cent of the discharged patients felt no better two weeks after emergency department discharge. Plans for further research include a study to clarify the difference in admission rates and the characteristics of individuals who remained symptomatic at two weeks.     

Management of chronic pain among elderly patients

OBJECTIVE: To identify the Staphylococcus aureus capsular serotypes that are not typable, using capsular serotypes 5 and 8, which are currently used to type S aureus isolated from cows with mastitis. SAMPLE POPULATION: Milk samples (n = 273) from cows with mastitis in 178 dairy herds in California, Wisconsin, Michigan, Texas, and New York that were collected by state diagnostic laboratories and S aureus-positive milk samples collected by Veterinary Health Services in the United Kingdom (15), France (22), The Netherlands (36), and Germany (21). PROCEDURE: Capsular serotyping of coded isolates was performed by use of direct cell agglutination and immunoprecipitation of cell extracts with antisera specific for capsular types 5 and 8 and a newly developed S aureus serotyping antiserum 336. RESULTS: In the United States, S aureus capsular types 5 and 8 accounted for 18 and 23% of the isolates, respectively, and type 336 accounted for 59%. Percentage of capsular serotypes in European samples were as follows: type 5 = 34%, type 8 = 34%, type 336 = 30%, and nontypable = 2%. CONCLUSIONS: Serotypes 5 and 8 accounted for only 41% of S aureus isolates from US milk samples, but accounted for 70% of isolates from European milk samples. Addition of the newly developed serotyping antiserum 336 to the typing scheme accounted for 100% of US samples and 98% of European samples and will enable development of a more comprehensive S aureus vaccine.     

Coping in chest pain patients with and without psychiatric disorders.

We first examined relations between psychiatric disorder and coronary heart disease (CHD) in 77 patients presenting with chest pain. The coping profiles of chest pain patients with and without psychiatric disorder and CHD were then compared. Psychiatric patients with no medical illness (n?=?129) were also studied. On the basis of previous research we hypothesized specific coping differences across the groups. As expected, chest pain patients without psychiatric disorder scored significantly higher on a problem-focused coping scale than chest pain patients with psychiatric disorder, who in turn scored higher on this scale than psychiatric patients with no medical illness. The opposite pattern occurred for a measure of wishful thinking. Scores of chest pain patients with psychiatric disorder were higher on a measure of avoidance and lower on a measure of seeking of social supports than those without psychiatric disorder. Scores on a self-blame measure were not different across the groups. The results are discussed in the context of illness behavior and somatization. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How to manage chest pain in patients with normal coronary angiograms

Sympathetic nerve activity is maintained after high spinal injury through circuits that remain in question. We evaluated patterns of c-fos gene induction as a monitor of spinal neurons responding to high spinal cord transection in the rat. Rats were anesthetized with isofluorane. Lower cervical or upper thoracic spinal segments were exposed, immersed in warm mineral oil and transected. Spinal cords were exposed but not transected in anesthetized controls. After 2.5 h, spinalized and control rats were perfused for immunocytochemistry. Cervical and thoracolumbar spinal segments and dorsal root ganglia were sectioned coronally. Tissues were incubated in primary, polyclonal antisera raised in rabbit or sheep against a peptide sequence unique to the N-terminal domain of Fos, and processed immunocytochemically. Neurons were induced to express Fos-like immunoreactivity (FLI), bilaterally, in the spinal gray, but not in primary sensory ganglia. Spinal cord transection induced neurons to express FLI in thoracic laminae I, IIo (outer substantia gelatinosa), Vre (lateral reticulated division), VII (lamina intermedia) and X, and the intermediolateral cell column. Lamina VIII was also labeled in spinal-injured but not in control animals. Immunolabeled nuclei were prominent in lumbar segments and were concentrated in the medial third of laminae I and IIo, and in laminae VII and X. Few cells were labeled in upper cervical or sacral segments. FLI was sparse in the spinal gray of controls and expressed mainly within the dorsal root entry zone of upper thoracic segments. Patterns of c-fos gene expression were site-specific and correlated with laminae that respond predominantly to noxious stimulation and that contain sympathetic interneurons. Laminae that are responsive to non-noxious stimuli and activated by walking, IIi, nucleus proprius, medial V and layer VI were not induced to express FLI. We conclude that neurons in specific spinal laminae that process high threshold afferents and that harbor neurons with sympathetic nerve-related activity are activated selectively by spinal cord transections. We hypothesize that peripheral afferents processed by spinal-sympathetic circuit neurons may regulate sympathetic discharge in the absence of supraspinal drive.     

Prevalence of personality disorders among patients with anxiety disorders

Outpatients with a principal diagnosis of an anxiety disorder (n = 347) were administered the Structured Clinical Interview for DSM-III-R/Axis II Disorders (SCID-II) during their intake evaluation. At least one personality disorder was found in 35% of these patients. Patients with social phobia (61%) and generalized anxiety disorder (49%) were most often diagnosed with a personality disorder. Patients with simple phobia were rarely diagnosed with a personality disorder (12%). The most commonly diagnosed personality disorders were from the "anxious/fearful" cluster (27% received at least one diagnosis from cluster C), most notably avoidant and obsessive-compulsive personality. Our findings suggest that personality disorders, in general, are less prevalent among anxious patients than among depressive patients.