Chest pain in people with normal coronary anatomy
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7325.1319 (Published 08 December 2001) Cite this as: BMJ 2001;323:1319
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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).
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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).
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests