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Query: UMLS:C0008031 (chest pain)
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The most common diagnoses of elderly patients in the emergency department (ED) were compared among three age subgroups: 65 to 74, 75 to 84, and 85 and older. The computerized billing records for patient visits to 10 northern New Jersey hospital EDs for the years 1985 to 1991 were retrospectively analyzed. The most frequently occurring ICD-9-CM codes for elderly patients were compared among the three age subgroups. Elderly persons comprised 174, 146 (14% of the total) patient visits. The 176,146 patient visits were assigned 259,440 ICD-9-CM codes. The most common ICD-9-CM codes for medical diagnoses included chest pain, cardiac dysrhythmias, congestive heart failure, syncope, abdominal pain, and dyspnea. Fractures, particularly of the lower limb and upper limb; contusions; open wounds, particularly of the head, neck, and trunk; and falls were among the most common trauma diagnoses. The proportions in the three age subgroups of each diagnosis were statistically significantly different, except for cardiac arrest and contusions of the trunk and of multiple sites. The diagnoses with clinically significant higher relative risks in older age subgroups were atrial fibrillation, congestive heart failure, syncope, hypovolemia/dehydration, gastrointestinal hemorrhage, dyspnea, pneumonia, pulmonary edema, cerebrovascular accident, septicemia, urinary tract infection, fractures, and open wounds of the head, neck, trunk, particularly the scalp, and falls. Clinically significant lower relative risks were found in older age subgroups for chest pain, acute myocardial infarction, hypertension, angina, chronic airway obstruction not elsewhere classified, epistaxis, contusions of the upper limb, and open wounds of the finger.
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PMID:Age-related differences in diagnoses within the elderly population. 945 12

Disorders of the cardiovascular system are common. Heart pain is one of the most frequent complaints leading patients to seek medical help. Although psychologically conspicuous behaviour in patients with functional cardiac complaints are well known, they are--if at all--diagnosed quite late. Descriptive diagnostics of functional cardiac complaints according to the International Classification of Diseases (ICD-10, Chapter 5) are discussed (Figure 1). Possible physical causes of the disease must first be excluded. In a second step it must be clarified whether the complaints even those non-verbally conveyed are due to psychic illness in a narrower sense. Anxiety and depressive disorders must be taken into consideration here. If the patient demonstrates an avoidance behavior in the case of anxiety, than an agoraphobia can be assumed; in episodic paroxysmal fear on can assume panic attacks in which vegetative anxiety equivalents such as shortness of breath, numbness, palpitation of the heart, tachycardia and chest pain are prominent often accompanied by trembling, perspiration, nausea and dizziness. The different depressive disorders are characterized by a dejected mood, loss of interest, loss of enthusiasm and drive reduction; the disorders are divided up according intensity and course. Within the scope of depressive physical symptoms, frequently unpleasant sensations and pain in the chest area are described along with concern, despair, and an increase in self-observation. If no psychic disturbance in a narrower sense can be diagnosed, then the diagnosis of a somatoform disorder allows for this behavior. It is characteristic for this category of illness that the repeated presentation of physical symptoms in connection with the persistent demand for medical treatment may be observed although no physical causes can be demonstrated. The patients insist that their complaints are of a physical origin despite the doctor's assertion that this is not the case. If the symptoms are related to vegetative innervated organs then one speaks of somatoform autonomous functional disorders (F45.3, Table 1). Cardiovascular disorders fall within this scope. Further diagnoses within the spectrum of somatoform disorders are hypochondric and somatization disorders which demonstrate a variety of symptoms and inconsistent and frequently changing complaints. If a descriptive diagnosis can correspondingly be made then further analysis of the disorder must be carried out in order to reach an indication for psychotherapeutic treatment. From a psychodynamic point of view, the personality- and conflict-related background of the disturbance is relevant. Quite often unconscious ambivalent separation conflicted--be they real are fantasized situations of being left or being left alone--may be observed to trigger cardiovascular symptoms. In the cognitive-behavioral therapeutic tradition an exact analysis of the patients symptomatology is carried out in which prior and actual cause factors of the symptoms are looked for. Irrespective of the different approaches, information on the context of the complaints both on a biological, intrapsychic and interpersonal level is necessary for psychosomatic diagnostics. The better the causal conditions are known on the basis of which functional cardiovascular complaints have arisen, the easier it is to recognize those factors that will influence a change and allow a therapeutic approach. This is best done in cooperation with practitioners and internists who still have a key position in the diagnosis and treatment of patients with functional cardiac disorders. The ways and means in which they conduct the anamnesis is decisive in leading their patients to regard psychosomatic diagnostics as being either stuck in the so-called "psycho corner" or as a helpful relationship which they can accept.
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PMID:[Diagnosis of functional heart complaints from the psychosomatic viewpoint]. 1037 96

A 36-year-old woman with a history of recurrent syncopal episodes presumably due to ventricular tachyarrhythmia in mitral valve prolapse underwent implantation of a transvenous ICD system. During a 23-month follow-up, she developed recurrent pericardial chest pain with pericardial friction rub. The first episode of chest pain occurred without any detectable change in pacing or sensing parameters. The second episode was associated with an increase in pacing threshold and drop in intracardiac signal amplitude. Right ventricular perforation was suspected fluoroscopically and confirmed by right ventriculography. This case report emphasizes the key steps in the diagnosis of this rare complication of an ICD implantation.
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PMID:Recurrent pericardial chest pain: a case of late right ventricular perforation after implantation of a transvenous active-fixation ICD lead. 1122 56

The study objectives, based on federal and state legislative language, were to objectively define symptoms and signs commonly agreed on by "prudent laypersons" as "emergency medical conditions." After comprehensive tabulation of symptom classifications from the International Classification of Diseases (ICD-9), we performed a survey of nonmedical laypersons. Data analysis included descriptive statistics, proportional calculations, and 95% confidence intervals. A minority of symptoms and signs (25/87, 29%) were considered emergency medical conditions by more than half of nonmedical survey respondents who were self-defined as prudent laypersons. The leading conditions deemed emergencies were loss of consciousness, seizure, no recognition of one side of the body, paralysis, shock, gangrene, coughing blood, trouble breathing, chest pain, and choking. Pain, except for renal colic or chest pain, was not considered an emergency. No symptoms or signs specifically related to gynecologic disorders were considered emergencies. Most symptoms and signs tabulated in the diagnostic coding manual, ICD-9, are not considered emergency medical conditions by self-designated prudent laypersons. These include many conditions that are commonly investigated and treated in the emergency department setting. Use of the prudent layperson standard for reimbursable emergency health services may not reflect the actual scope of symptoms necessitating emergency care.
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PMID:The "prudent layperson" definition of an emergency medical condition. 1178 4

In the management of psychogenic chest pain, the family doctor has a key role to play. His main task is to exclude physical or organic causes and identify the underlying psychogenesis--admittedly without wishing to establish a definitive (ICD-10) diagnosis. For this purpose, empathic reassurance of the patient is of major importance. Wherever possible, hospitalization of the patient for a diagnostic clarification should be avoided. Therapeutic options comprise suitable physiotherapy, psychohygienic measures, and appropriate pharmacotherapy. Major goals of such an approach are the establishment of a trusting relationship, and improving the patient's sleep patterns, physical fitness and emotional status. In the event of long-term persistence of the condition or a severe course, referral to a specialist is indicated.
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PMID:[Patient education, medication and physical therapy. Balm for "cardiac neurosis"]. 1204 46

African-Americans have far less access to treatment for heart disease than similar white Americans. In this article, we explore the sector difference theory hypothesis that treatment provided by a nonprofit Medicaid managed care plan can reduce or even eliminate the race gap. Specifically, we compare the treatment offered to patients in for-profit Medicaid managed care programs to the treatment offered to similar patients in nonprofit Medicaid managed care programs. Data are from the Maryland Health Services Cost Review Commission and cover all patients discharged from hospitals in Maryland during calendar year 1998 with principal diagnoses indicating diseases of the circulatory system (ICD-9-CM codes 390 through 459) or chest pain (ICD-9-CM codes 786.50 through 786.52 and code 786.59). African-Americans were significantly less likely to receive the three treatments of interest, even after controlling for principal diagnosis, blood pressure, co-morbidities, and age. In regard to African-American access to treatment, there were no significant differences between the sectors.
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PMID:Do nonprofit HMOs eliminate racial disparities in cardiac care? 1497 39

We studied the prevalence of anxiety and depressive disorders in patients with chest pain presenting to an emergency department. Majority of the patients had coronary artery disease (CAD). Twenty-three percent of patients with chest pain had a diagnosable psychiatric disorder according to ICD-10 research criteria. Anxiety and depressive disorders were equally distributed among patients with concomitant psychiatric syndrome. The level of psychological distress as measured on hospital anxiety and depression scale in patients of CAD with comorbid psychiatric syndrome was significantly more than patients with CAD alone and similar to non-CAD patients with psychiatric disorder. This finding is in agreement with an earlier study suggesting that the psychological distress seen in patients with CAD is related to the comorbid psychiatric condition and not to CAD.
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PMID:A study of lifetime prevalence of anxiety and depressive disorders in patients presenting with chest pain to emergency medicine. 1556 13

Functional heart symptoms, especially chest pain, are very widespread and, according to the International Classification of Diseases (ICD-10), are described as "somatoform autonomous functional disorders of the cardiovascular system". Although they are very often accompanied by considerable anxiety about having a heart attack, for example, they are initially not recognizable as such and have to be distinguished from somatic complaints. The most prevalent of these symptoms (Table 2) are chest pains, followed by feelings of weakness, a tendency to become easily fatigued and breathing difficulties. The perception of changes in cardiac activity, such as tachycardia, heart palpitations, irregular heartbeat or arrhythmias, is also extremely unsettling and thus anxiety-provoking. Therefore, although a responsible cardiac diagnosis is the basis for every further step taken, it is advisable to carry out a brief anamnesis immediately, if possible, to determine the prior history (Table 1). For example, previously conducted clarification of somatic causes, consultations with more than one physician in parallel or repeated medical emergency calls can be helpful for orientation. Moreover, in the interview during the diagnostic measures, the possibility of functional causes should always be pointed out in order to counteract a somatic fixation early on. The health-care policy role that lies in early diagnosis of functional cardiac complaints has to be regarded as highly relevant. Following exclusionary diagnosis, the patients should not be discharged as "healthy" from the cardiological practice without a more in-depth anamnesis of their complaints, because differentiated questioning of the patient not only about typical physical and psychic symptoms, but also about behavior patterns (Table 3) that can accompany functional cardiac complaints, works in favor of a doctor-patient relationship that is based on trust. Since, in addition to anxiety disorders, above all depressive states accompany functional heart complaints, and can also cause them in the sense of a comorbidity, a knowledge of characteristics related to depression (Table 4), such as a depressed mood, loss of interest or low motivation, is very helpful for a better understanding of the patients. The "vicious circle" that rapidly develops precisely in the case of this group of patients, consisting of physical symptoms, avoidance behavior and psychological as well as interpersonal difficulties, is described and possible solutions are pointed up. In summary, the following recommendations can be formulated for day-to-day clinical practice: 1. From the very beginning, a holistic approach should be conveyed in the interview by addressing psychological and social aspects as well, and taking them into account as possible causes. 2. The somatic diagnosis should, if possible, not go beyond that which is urgently necessary from a cardiological standpoint and presented in guidelines. One should, above all, not give in to pressure from the patients if it is a matter of repeated examinations within a short period of time. 3. A differentiated and focused anamnesis helps the patients to feel understood and taken seriously. 4. A relationship based on trust enhances the chances for a successful transfer to psychosomatic examination and treatment.
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PMID:[Functional heart pain]. 1591 33

This was a study of 157,028 emergency department (ED)-diagnosed visits for chest pain (International Classification of Diseases, Ninth Revision [ICD-9]: 786) in 6 cities in Canada. The generalized linear mixed methods technique was applied to analyze the relations between daily counts of ED visits for chest pain on the levels of ambient air pollutants after adjusting for meteorological variables. The daily counts of visits were analyzed separately for the whole period (January-December), warm (April-September), and cold (October-March). The results are presented in the form of the excess risks associated with an increase in the mean values of the pollutant concentrations. The highest increase was obtained for nitrogen dioxide (NO2) exposure in the warm period as follows: 5.9% (95% confidence interval, 3.3-5.8) for mean value equals to 20.1 ppb. The associations of ED visits for chest pain with air pollution are very similar to the associations of ED visits related to cardiac problems.
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PMID:Air pollution and ED visits for chest pain. 1937 23

We report a case of a young woman who presented with atypical angina. During an episode of chest pain she had a documented run of sustained polymorphic ventricular tachycardia (VT). In addition to medical therapy, she received an ICD to prevent future episodes of sudden cardiac death.
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PMID:Implantable cardioverter defibrillator (ICD) for polymorphic ventricular tachycardia (VT) due to coronary vasospasm. 1967 Mar 86


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