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EDITORIALS: Gurjinder Nijher, John Weinman, Christopher Bass, and John Chambers Chest pain in people with normal coronary anatomy BMJ 2001; 323: 1319-1320 [Full text]

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Chest pain problems: we need a new efficacious physical semeiotics.

Sergio Stagnaro   (8 December 2001)

Syndrome X: a spurious diagnosis?

A Chaudhuri   (8 December 2001)

The most undiagnosed cause of chest pain

Carlos A Selmonosky   (10 December 2001)

Rapid Access and deskilling of GPs

Graeme M Mackenzie   (12 December 2001)

Addressing patient concerns irrespective of the diagnosis

Faisal F Syed   (5 January 2002)

NON-CARDIAC CHEST PAIN: IS ADDRESSING PATIENT FEAR ENOUGH?

Guy D. Eslick, David S. Coulshed, Nicholas J. Talley   (14 January 2002)

A less thought of chest pain with normal coronary arteries

Munir E Nassar, M.D.   (19 February 2007)

Chest pain problems: we need a new efficacious physical semeiotics. 8 December 2001
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases Riva Trigoso (Genoa) Italy Send response to journal: Re: Chest pain problems: we need a new efficacious physical semeiotics.	Sirs, I consider G.N. Nijer’s, et al., article (1)as much interesting as worrying, at least from the physical semeiotics view-point. In fact, firstly, I am sorry to read that “coronary angiography is often necessary for patients with chest pain, but 20% to 30% of examinations show normal anatomy”, according to a lot of other authors. Consequently, I understand the real reason of the “mean waiting time from the general practitioner's referral to angiography (that) was 261 days in the United Kingdom in 1994 and about 60 days in Canada in 1993. Secondly, I disagree completely with authors when state that “providing a diagnosis may be less important than addressing a patient's concerns and fears”. In reality, in case of chest pain caused by other disorder than CAD, e.g. by GERD, the “correct” bed- side diagnosis, on the one hand, reassures the patient and, on the other hand, allows doctor to prescibe the proper treatment as well as to perform the unavoidable therapeutic monitoring: in my opinion, first is the "bed- side" diagnosis, and,if that is the case,laboratory tests, X-rays, and other sophysticated examinations, and then the therapy. Apart from the fact that the use of angiography itself can contribute to symptoms in these patients, and non-organic factors are often overlooked. Finally, I am sorry to find that “overlooked” is, in truth, all around the world, a new physical semeiotics, Biophysical Semeiotics, doctors were already told about by a lot of my e-letters to BMJ.com (e.g.: “A new physical semeiotics unavoidable in detecting disorders otherwise undiagnosed”, 30 March 2001). As a matter of fact,in my 45-years long "clinical" experience, half of the cases of retrosternal pain, for instance, really due to hiatal hernia, are attributed to coronary artery disorders and consequently patients undergo useless, numerous and expensive instrumental investigations, not to mention hospitalization. From the above remarks, we urgently need a new, efficacious physical semeiotics, I have previously described in 150 papers, partially on my web site : http://digilander.iol.it/semeioticabiofisica and in numerous other webb- sites (BMJ.com, Medscape, Staibene.it, Piazzetta, FIMG.it, a.s.o. As far as CAD diagnosis is concerned, it is well known around the world, that coronary heart disease is the commonest cause of death. However, in my opinion, there is nowadays an overlooked tool, really more practical, precious and efficacious in bed-side assessing, treating and monitoring both the real risk of coronary disease and this disorder itself, i.e. after its onset, beside all arteriosclerotic arteriopathies, than other sophysticated and expensive semeiotics (2, 3). Consequently, I suggest and claim in day to day praxis to look at these risk factors in all patients of both sexes, even asymptomatic, who present for clinical examination, apart from their clinical phenomenology (See above-cited site:”Early clinical Diagnosis of CAD”). After bed-side recognizing the real coronary heart risk or disease, physicians have to consider the “complete” treatment, including endothelial therapy, i.e. the “diet”, etymologically speaking, physical exercises and a lot of drugs, as Coenzyme Q10 (4, 5), carnitine (6), glutatione (7), sulodexide (8), very efficacious in improving endothelial function, essential factor in primary prevention and treatment of macro- and micro-vasculare disorders. Stagnaro Sergio MD, Member NYAS and AAAS 1)Nijher G. et al. Chest pain in people with normal coronary anatomy BMJ 2001;323:1319-1320 ( 8 December ) 2) Stagnaro S., Percussione Ascoltata degli Attacchi Ischemici Transitori. Ruolo dei Potenziali Cerebrali Evocati. Min. Med. 76, 1211, 1985 (Pub-Med indexed for Medline). 3) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos, Preconditioning and Myocardial Oxygenation evaluated clinically with the aid of Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease even silent. Acta Med. Medit. 13, 109, 1997. 4) Stagnaro-Neri M., Stagnaro S., Auscultatory Percussion Coenzyme Q deficiency Syndrome. VI Int. Symp., Biomedical and clinical aspects of Coenzyme Q. Rome, January 22.24, Chairmen K. Folkers, G.L. Littaru, T. Yamagani, Abs., pg. 105,1990. 5) Stagnaro S., Ipercolesterolemia e Coenzima Q10. The Pract. Ed. It. 133, 5-6, 1990. 6) Stagnaro-Neri M., Stagnaro S., La sindrome percusso- ascoltatoria da carenza di Carnitina. Clin. Ter. 145, 135,1994 (Pub-Med indexed for Medline) 6 Stagnaro-Neri M., Stagnaro S., Il Glutatione nella terapia microvascolare. Act Med. Medit. 7, 11, 1991 7) Stagnaro-Neri M., Stagnaro S., Sul meccanismo d’azione di Sulodexide a livello di correlazioni istangiche acrali patologicamente alterate: studio clinico percusso-ascoltatorio. Giornate Naz. di Angiologia. Milano, 23-29 Giugno 1991. Atti Min. Med., 40
Syndrome X: a spurious diagnosis? 8 December 2001
A Chaudhuri, Clinical Senior Lecturer in Neurology University of Glasgow Send response to journal: Re: Syndrome X: a spurious diagnosis?	In their editorial, the authors seem to suggest that a diagnosis of coronary artery spasm and microvascular angina in a patient with chest pain and normal coronary angiogram is "spurious". According to these authors, prescribing anti-anginal drugs to patients with chest pain due to a presumptive diagnosis of syndrome X or coronary artery spasm may be unhelpful. Not a single piece of research evidence has been cited to support this remarkable conclusion. One of the cited references is a BMJ paper of 1994; yet the authors seem to be unaware of some of the papers published more recently (for example, the study of myocardial NMR spectroscopy in women with chest pain but normal coronary angiogram)[1]. I was unable to see any reference to a large, randomised controlled trial of psychological intervention compared to standard medical care in syndrome X that might have strengthened their argument.They also do not mention gastro- oesophageal reflux disease that may present with chest pain, normal coronary angiogram and yet can be treated effectively with pharmacotherapy once diagnosed. Since more women than men present with anginal chest pain but normal coronary angiogram, the assumption of a psychosocial explanation for chest pain ("illness behaviour")in these patients has obvious implications. I would advise all medical students to read the paper that drew attention to the missed diagnosis of acute cardiac ischaemia in the emergency department[2] before jumping to any conclusions. References 1. Buchthal SD et al. Abnormal myocardial P31 nuclear magnetic resonance spectroscopy in women with chest pain but normal coronary angiogram. N Engl J Med 342: 829-35 (2000). 2. Pope JH et al. Missed diagnosis of cardiac ischaemia in emergency department. N Engl J Med 342: 1163-70(2000).
The most undiagnosed cause of chest pain 10 December 2001
Carlos A Selmonosky, Physician Gilmer Medical Center. 30539 Send response to journal: Re: The most undiagnosed cause of chest pain	Thoracic Outlet Syndrome is the most frequent cause of chest pains in those patients with normal angiograms and esophageal studies It is also associated with coronary and esophageal diseases in 30 to 40% of the cases. Thoracic outlet syndrome should be rule out in all cases of chest pains. A diagnostic triad:tenderness on palpation of the supraclavicular space,paresthesias and/or blanching on elevation of the hands and weakness of the abduction and adduction of the fifth finger,makes the diagnosis available at the bed side. Further information can be found at www.tos-syndrome.com
Rapid Access and deskilling of GPs 12 December 2001
Graeme M Mackenzie, GP Maryport Cumbria Send response to journal: Re: Rapid Access and deskilling of GPs	I enjoyed this review of non cardiac chest pain. In many ways it represents a increasing problem of overspecialising of health care. GPs are good at stopping the juggernaut of investigation at source but it takes nerve and sometimes is seen as not doing enough. Of course the GP who boldly states that chest pain is non cardiac at the first consultation does is not seen to be doing very much and the decision may be made on no more than a hunch and experience. However the potential savings in time, money and neuroses are huge. The trouble is that the system is very unforgiving if the hunch was wrong! Rapid access clinics be it chest pain, breast lumps, rectal bleeding deskill GPs in dealing with these symptoms because they give easy access to much decisions taken with much more information. However this article shows the negative side of this process. Our hospital colleagues with all due respect are less good at taking decisions with no tests as they have to be seen to be doing everything. I have always felt(and accept the provocative side of this statement) that the NHS GP system works well only because GPs half do things but the benefits to patients can be huge and the savings immense . It is a question of where to draw the line. Deciding that "probably" there is nothing wrong takes nerve and courage. Rapid access clinics deskill this process and the implications for the NHS are significant in terms of resources. It is not helped by "empire builders" who state in the public domain that patients with set symptoms always need extensive workup and referral. It leaves the "brave" GPs even more exposed.
Addressing patient concerns irrespective of the diagnosis 5 January 2002
Faisal F Syed, Medical Student University of Manchester, Oxford Road, Manchester M13 9PT Send response to journal: Re: Addressing patient concerns irrespective of the diagnosis	EDITOR Nijher and colleagues’ editorial suggests that chest pain heralds a downward spiral in a patients life regardless of the result of angiography, an intriguing prospect [1]. The concerns it raises about rapid access chest pain clinics are timely, drawing attention to problems which are easily overlooked and may well be affecting an increasing number of patients now that use of these clinics has reached proper establishment [2]. In addition, there is a dichotomy in recent years of increasing chest pain presentations in the face of decreasing ischaemic heart disease [3], indicating that patients are increasingly aware of the implications of pain in the chest and that more will consequently not have coronary artery disease. On the other hand are the responses above, which are very much in line with my education to date, stressing the importance of considering other, remediable organic causes before reaching the ultimate diagnosis of “stress” (a lesson personally reinforced by a consultant neurologist in a recent clinic!). However, stress too has defined management parameters and irrespective of other organic causes there is still the argument therefore that these worried patients need to be reassured, educated, as well as given the news that this most serious cause of chest pain is excluded. Faisal F. Syed Final Year Medical Student University of Manchester 1. Nijher G, Weinman J, Bass C, Chambers J. Chest pain in people with normal coronary anatomy. BMJ 2001;323:1319-1320. 2. Wood D, Timmis A, Halinen M. Rapid assessment of chest pain. BMJ 2001;323:586-587. 3. Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000;342(16):1187-95.
NON-CARDIAC CHEST PAIN: IS ADDRESSING PATIENT FEAR ENOUGH? 14 January 2002
Guy D. Eslick, Gastroenterological Society of Australia (GESA) Biomedical Scholar Department of Medicine, The University of Sydney, Nepean Hospital, P.O. Box 63, Penrith, NSW 2751, A, David S. Coulshed, Nicholas J. Talley Send response to journal: Re: NON-CARDIAC CHEST PAIN: IS ADDRESSING PATIENT FEAR ENOUGH?	We read with interest the editorial 1 on non-cardiac chest pain but are concerned about one of the sweeping conclusions. We disagree that “providing a diagnosis may be less important than addressing a patients concerns and fears”. In fact providing a diagnosis (label) is we believe the most important part of the care of such patients. There is good evidence that angiography fails to relieve the anxiety of patients2 but the psychological/psychiatric complications of chest pain which are described in the editorial may at least partially relate to the inability of Medical Practitioners to provide a definite diagnosis. Continued prescription of anti anginal drugs, and possibly failure to investigate further, undoubtedly contribute to continued anxiety. We suggest the problem is that patients with chest pain of non-cardiac origin need a label to hang onto rather than a label which says they have no diagnosis. Due to the frequent situation of there being more than one diagnosis, we suggest the use of a perhaps more appropriate label of “chest pain of unexplained origin.” A multidisciplinary approach could be useful with particular attention to psychological factors.3 Whilst “an alternative non -cardiac diagnosis can be difficult to make”, it is often possible. A definite diagnosis can be reached in up 85% of patients appropriately investigated.4 The impact of chest pain clinics is uncertain, and follow- up for patients with “non-cardiac chest pain” may be of value.5 Certainly “these clinics could worsen the situation” if adequate follow-up is not arranged. Adequate investigation for other physical causes of chest pain must be part of a comprehensive approach to this difficult problem. REFERENCES 1. Nijher G, Weinman J, Bass C, Chambers J. Chest pain in people with normal coronary anatomy: addressing patients’ fears is a priority. BMJ 2001;323:1319-1320. 2. Ockene IS, Shay MJ, Alpert JS, Weiner BH, Dalen JE. Unexplained chest pain in patients with normal coronary arteriograms: a follow-up study of functional status. New Engl J Med 1980;303:1249-1252. 3. Clouse RE, Lustman PJ. Psychiatric illness and contraction abnormalities of the esophagus. New Engl J Med 1983;309:1337-1342. 4. VanTrappen G, Janssens J. Angina and esophageal pain--a gastroenterologist's point of view. Eur Heart J 1986;7:828-834. 5. Eslick GD, Coulshed DS. Chest pain clinics: one step forward, two steps back? BMJ 2002 (in press).
A less thought of chest pain with normal coronary arteries 19 February 2007
Munir E Nassar, M.D., Physician witout portfolio or academic appointment USA 14534 Send response to journal: Re: A less thought of chest pain with normal coronary arteries	Dear Editor: Thanks go to the BMJ and its scholarly presentation of an important topic that of chest pain in an editorial by Drs Nijher and co -workers, BMJ2001:323, 1319-1320. May I draw to the attention of the authors and the responders an editorial to an intriguing condition first described in 1959 by Prinzmetal, known as Prinzmetal angina or in modern literature as vasospastic angina that may occur at rest (without effort or exertion), and with normal coronary arteries. So pschological stress, emotional trauma etc., may trigger the angina. Also, that atherosclerotic coronary artery plaques may be the culprit in producing the symptoms of angina at rest (unstable angina). Hence prior to attributing chest pain to non-cardiac origin conditions, the treating physician has to keep in mind Prinzmetal's angina. Ideally, demonstrating coronary vasospasm during coronary angiography and its relief with calcium channel blockers, if there are no contraindications to their use, would certainly alleviate the patient's anxiety and fear. Sincerely, Dr M E Nassar Competing interests: None declared