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 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Recurrent chest pain in patients with normal coronary arteries is a difficult clinical problem. Although long-term studies have shown that these patients have an excellent prognosis in terms of cardiac morbidity and mortality, many patients remain physically debilitated and continue to visit emergency departments. Recent information suggests that microvascular angina, esophageal disorders (including reflux disease and dysmotility), and panic disorder may be important causes of pain in such patients. It is particularly important to consider the diagnosis of gastroesophageal reflux disease, which is easier to diagnose and treat than most other causes of recurrent chest pain.
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PMID:Chest pain in patients with normal coronary arteries. A new look at potential causes. 157 28

Unstable angina is a broad clinical diagnosis that includes patients at different levels of risk for an unfavorable outcome. Although, as in other categories of coronary artery disease, the state of left ventricular function and the extent of coronary artery disease will determine long-term prognosis, recognition of clinical markers of an early unfavorable course may be of value in defining management strategies. This review focuses on the relevance of baseline clinical characteristics and noninvasive data in assessing the prognostic significance of unstable angina in light of its presenting features. Recurrence of chest pain within 48 h after admission carries a reduction in likelihood of survival of about 20% in patients with progressive or prolonged angina. Similarly, ECG changes on admission have a negative prognostic implication, particularly in rest angina, as they predict recurrence of ischemia, myocardial infarction or need for revascularization in 80% of the patients. In variant angina, determinants of prognosis are level of disease activity, as judged by recurrence of pain, ECG changes and use of calcium channel antagonists. Patients with angina after a myocardial infarction who have more than one episode of either angina or silent ischemia in 24 h have a 10% reduction in probability of survival during the 1st year compared with that of asymptomatic patients. An abrupt course, or the rapidity with which symptoms develop, is the main determinant of prognosis in new onset angina. Thus, recurrent angina and ECG changes appear to be relevant prognostic markers in the patient subsets considered; if these are present, early coronary angiography must be performed and revascularization procedures should be considered without delay.
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PMID:Unstable angina: outcome according to clinical presentation. 159 63

One hundred and eight consecutive patients admitted urgently for the first time with chest pain were interviewed to assess psychiatric symptoms prior to admission, at admission and three months later. Seventy-one patients had ischaemic heart disease, 19 had non-specific chest pain and 18 patients were excluded because of other organic causes for the pain. Compared to the ischaemic heart disease subjects, the non-specific chest pain patients tended to have more psychiatric disorder which increased over the three assessments; at follow up 33% of ischaemic heart disease patients and 59% of non-specific chest pain patients had psychiatric disorder. Chest pain was reported by 71% of the non-specific group at three months but this was not related to presence of psychiatric disorder. Unlike previous studies which 'have assessed out-patients with normal coronary angiograms', this study has shown that males predominate among patients admitted urgently with non-specific chest pain. In addition, these subjects use greater amounts of cigarettes and alcohol, and experience significantly more psychiatric disorder compared to patients admitted with ischaemic heart disease. The factors which lead to some of these patients developing chronic non-specific chest pain need to be investigated in further studies.
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PMID:The course of psychiatric disorder associated with non-specific chest pain. 159 8

Esophagomyotomy was performed in 42 patients with chest pain resulting from diffuse esophageal spasm and related disorders. The procedure used restricted the myotomy to the diseased portion of the esophagus, as demonstrated manometrically. More than half of the patients also required myotomy of the lower esophageal sphincter. Some patients required other surgical procedures. Overall results were excellent; the overall improvement rate was 70% at a median follow up of 5 years, 8 months. Postoperatively, 5 patients had recurrent or persistent pain. Esophagomyotomy is recommended for selected patients with clinically significant chest pain and/or dysphagia.
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PMID:Esophagomyotomy for noncardiac chest pain resulting from diffuse esophageal spasm and related disorders. 159 58

Patients with unexplained chest pain represent a major clinical dilemma for primary-care physicians, gastroenterologists, and cardiologists. References to this prevalent clinical problem date to more than 150 years ago; confusion about its pathophysiology has resulted in the use of a variety of descriptive terms such as "noncardiac," "atypical," and "angiographically negative" chest pain. Since none of these terms applies to all cases, the description "chest pain of undetermined origin" may be preferable. Because the esophagus has a similar location and innervation as the heart, an esophageal source for unexplained chest pain syndromes has been frequently suggested. Recent studies have emphasized the importance of gastroesophageal reflux as a likely component of esophageal pain. Moreover, "irritable esophagus" is an emerging concept that implies a generalized alteration in esophageal pain threshold, that is, abnormal nociception. The potential effects of stress or altered psychological states in this phenomenon must be considered, and the role of "panic attacks" in the production of pain in these patients needs to be clarified. In addition, stress may produce altered esophageal motility and lead to manometric abnormalities such as the "nutcracker esophagus" or a hypertensive lower esophageal sphincter. Finally, the precise contribution of the heart in producing pain in patients with normal coronary angiograms remains unclear because the precise role of microvascular angina has yet to be clarified.
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PMID:Chest pain of undetermined origin: overview of pathophysiology. 159 59

A minority of patients presenting with the common clinical challenge of unexplained chest pain can be diagnosed as having an esophageal etiology for their pain using conventional manometric and provocative (acid infusion and edrophonium) testing. Esophageal balloon distention may provide an important adjuvant to routine testing. Most pain from the esophagus is mediated by visceral sensory receptors located near the myenteric plexus; these receptors respond to movements of the organ wall in response to contractions or distention. Balloon distention can be used to simulate this wall movement. Early clinical studies have been expanded by recent investigations demonstrating a lowered pain threshold in response to balloon distention in patients with both unexplained chest pain and nonobstructive dysphagia. The physiologic basis for this increased sensitivity is not clear. Balloon distention has several effects on esophageal motility that may play a role in producing pain. The recording of cerebral evoked potentials is a technique newly developed to provide an objective measurement of the subjective sensation of pain. Electrical and mechanical stimulation of the esophagus has been shown to produce cerebral evoked potentials. Recent investigations of cerebral potentials evoked by balloon-induced esophageal stimulation have confirmed that this response depends on pain production, have clarified the appropriate stimulus parameters, and have localized the site of origin of the evoked potential to the balloon site. Balloon distention may prove to be an important addition to current esophageal provocative testing, although widespread applicability has been hampered by the lack of a commercially available standardized balloon. Recording evoked potentials produced by esophageal stimulation may provide additional clues in unraveling the mystery of unexplained chest pain.
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PMID:Esophageal balloon distention and cerebral evoked potential recording in the evaluation of unexplained chest pain. 159 60

An esophageal origin of noncardiac chest pain is generally accepted if prolonged pH and pressure recordings show that the pain episodes correlate in time with acid reflux, esophageal motor abnormalities, or a combination of both, or if provocative testing (acid perfusion, edrophonium, balloon distention) is positive. Many patients with noncardiac chest pain of esophageal origin are said to have an irritable esophagus. Irritable esophagus has been defined in two ways. Some researchers suggest it is actually a lowered esophageal pain threshold, based on the finding that such patients feel chest pain at lower balloon volumes than controls during intraesophageal balloon distention; they are said to be hypersensitive to balloon distention. Hypersensitivity to an esophageal stimulus is generally found in patients with noncardiac chest pain of esophageal origin, and hypersensitivity to a single stimulus is one criterion for a diagnosis. Our group defines irritable esophagus as a condition in which several different stimuli result in the same type of chest pain. Accordingly, we have grouped patients with esophageal chest pain into three categories: (a) patients with an acid-sensitive esophagus, in whom spontaneous pain episodes can be related to acid reflux (with or without accompanying motor disorders), and/or the acid perfusion test is positive; (b) patients with a mechano-sensitive esophagus, in whom the spontaneous pain episodes can be related to motility disturbances (without reflux), and/or the edrophonium test or balloon distention test is positive; (c) patients with an irritable esophagus, in whom some spontaneous pain episodes are related to reflux, while others are related to abnormal motility (without reflux). The last group includes patients whose spontaneous chest pain is related to reflux, with a positive motility tests; whose pain is related to abnormal motility, with a positive reflux test; and patients with positive tests for both reflux and abnormal motility. Seven studies examined a total of 281 noncardiac chest pain patients using prolonged pH and pressure recordings and provocative tests. An acid-sensitive, a mechano-sensitive, or an irritable esophagus was found in 20%, 14%, and 24% of patients, respectively.
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PMID:Irritable esophagus. 159 61

Identifying the cause of recurrent chest pain may be difficult. Significant coronary artery disease must be excluded before patients can be assured that their symptoms are truly "noncardiac." A normal coronary angiogram is the most definitive test but this may not preclude the presence of a new "fly in the ointment," i.e., microvascular angina. Musculoskeletal pain syndromes, psychological problems, and esophageal disorders, including both esophageal motility disorders and gastroesophageal reflux disease, are the most common causes of noncardiac chest pain. Nearly 30% of these patients will have an esophageal motility disorder, although its clinical relevance in the asymptomatic patient is controversial. Simple, inexpensive, provocation tests (most commonly edrophonium, bethanechol, and/or balloon distention) have been developed to recreate motility-related chest pain in the laboratory. These tests can identify the esophagus as the source of pain, but in most cases they do not direct therapy. Other disadvantages of provocation tests include the lack of a gold standard reference point, side effects, and the need for placebo because of a subjective end point. Recently, ambulatory esophageal pH and pressure monitoring have been used to define precisely the cause of esophageal chest pain. These systems can record multiple episodes of pain for up to 24 hours in an outpatient setting and have shown that gastroesophageal reflux (rather than motility disorders) is the most common esophageal cause of pain. However, these studies also suggest that many episodes of chest pain do not have an identifiable esophageal cause. Furthermore, this equipment is expensive, uncomfortable, may alter normal activity, and is not useful in patients having infrequent pain episodes. Psychological disturbances should be carefully sought in any patient with noncardiac chest pain: Many patients have anxiety, depression, or panic attacks that may complicate or contribute to their reported symptoms. It is questionable if these patients need additional testing. Rather, the challenge of the future is to prove that the multitude of tests aid in the overall treatment and outcome of patients with noncardiac chest pain.
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PMID:Overview of diagnostic testing for chest pain of unknown origin. 159 63

Angina pectoris is chest discomfort associated with myocardial ischemia. When coronary blood flow is inadequate to meet myocardial tissue demand, lactate accumulates, resulting in diastolic and systolic left ventricular dysfunction. This leads to ST-segment abnormalities and eventually to angina pectoris. Angina, most commonly a pressure-type sensation in the midanterior chest precipitated by exercise, stress, or cold, typically lasts 1-5 minutes and is alleviated by rest or nitroglycerin. Diagnostic studies to assess myocardial ischemia include treadmill exercise testing, Holter monitoring, and coronary angiography. Treadmill exercise testing has a relatively low accuracy for diagnosing coronary artery disease. This can be improved by combining exercise with thallium-201 imaging, two-dimensional echocardiography, or positron emission tomography (PET). Thallium-201 scintigraphy and exercise echocardiography have reported sensitivities of 70-85% and specificities of 50-60% when applied to low-risk, asymptomatic populations. PET scanning has a high predictive accuracy (sensitivity 90%, specificity 90-95%) and is more useful as a screening test; it can also assess the functional significance of coronary artery stenoses and differentiate viable myocardium from infarcted tissue. Holter monitoring is too insensitive and nonspecific to be used as a screening test for coronary artery disease; it can, however, assess the total ischemic burden in patients with known coronary artery disease and correlate symptoms and ST-segment abnormalities during episodes of pain at rest. Coronary angiography has been the gold standard for diagnosing coronary artery stenoses. Quantitative angiography has improved the assessment of coronary artery narrowing but is still limited in evaluating coronary blood flow. Doppler flow studies provide useful information regarding coronary flow reserve. Myocardial ischemia as a cause of chest pain is determined by evaluating the clinical characteristics consistent with angina, correlating electrocardiographic abnormalities with perfusion defects or wall motion abnormalities, and determining the extent and functional significance of coronary artery stenoses by coronary angiography.
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PMID:Excluding heart disease in the patient with chest pain. 159 64

Since 1768, when Heberden recognized a relationship of angina pectoris with eating, the close resemblance between angina-like pain of esophageal and cardiac origin has led to diagnostic confusion, with the role of the esophagus being, in turn, over- and underemphasized as a cause of symptoms. Although the classic features of angina do not distinguish the origin of the pain, certain other symptoms may identify esophageal pain. These include an inconsistent correlation of exercise with pain, periods of prolonged remission, provocation of pain by posture, association with other esophageal symptoms, relief by antacids, radiation of pain down the right arm and into the back, occurrence of pain at night, continuation of pain as a background ache, and relief from nitroglycerine delayed by 10 minutes or longer. However, while certain symptoms may alert the clinician to the possibility that angina-like pain is due to esophageal disease, no single symptom or combination of symptoms is infallible; there is no alternative to careful assessment. Esophageal disease accounts for the greatest number of patients with chest pain of unknown origin. The prevalence of angina-like esophageal pain in unselected emergency admissions with suspected myocardial infarction is 10-20%. Approximately one third or more of patients with angina and normal coronary arteries have esophageal problems. We have followed patients with angina-like esophageal pain for 9 years. Although prognosis remains good, confirming the original noncardiac diagnosis, greater than 80% of patients continue to have chest pain of undiminished intensity, and half are limited in their ability to work. Reassurance appeared to have one beneficial result: Patients were less likely to consult a physician after a positive diagnosis had been made.
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PMID:Anginal pain of esophageal origin: clinical presentation, prevalence, and prognosis. 159 65


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