Societies release recommendations for diagnosing chest pain in the emergency department

New recommendations from the American College of Cardiology and American College of Radiology have established appropriate use of diagnostic imaging for patients with chest pain, one of the most common reasons for emergency department visits.

22 jan 2016--The document addresses 20 fundamental clinical scenarios for emergency imaging for chest pain and assesses when imaging is useful in each case, and if so, what information is provided by the specified imaging procedure. The clinical scenarios are broken down into leading critical diagnoses: acute coronary syndrome, pulmonary embolism and acute aortic syndrome. There is a fourth category, triple rule out computerized tomography (CT), for the minority of patients for whom a leading diagnosis is not possible.
Using the well-established modified Rand methodology, an expert panel rated each of the diagnostic procedures for the 20 clinical scenarios on a scale from 1 to 9. Each procedure has a corresponding rating of "rarely appropriate," "may be appropriate" or "appropriate."
"This document captures a wide scope of those patients who come to the emergency department with chest pain, although there will always be patients who present unique situations and no document can be a substitute for clinical judgment," said Frank J. Rybicki, MD, PhD, professor and chair of the department of radiology at the University of Ottawa, head of medical imaging at The Ottawa Hospital and co-chair of the writing committee.
The authors explain that the concept of appropriateness assesses the risks and benefits of a treatment, test or procedure and that these criteria provide imaging guidance to inform the clinician's judgment.


Provided by American College of Cardiology

A useful method to diagnose chest pain with foregut symptoms

22 feb 2009--Recent reports have indicated that recurrent chest pain is often a result of esophageal motility disorders or gastroesophageal reflux diseases (GERD), which is known as esophageal chest pain. However, very few studies have been performed about esophageal manometric studies, 24-h intra-esophageal pH monitoring and a Holter electrocardiography for the differential diagnosis of chest pain caused by esophageal dysfunctional and/or myocardial ischemia.

A research team led by Prof. Ru Wen Wang from China addressed this question. Their study will be published on February 14, 2009 in the World Journal of Gastroenterology.

In their study, 61 patients with chest pain and foregut symptoms were included. Thirty-nine patients were diagnosed with non-specific esophageal motility disorders (29 patients with abnormal gastroesophageal reflux and eight patients with myocardial ischemia). Five patients had diffuse spasm of the esophagus plus abnormal gastroesophageal reflux (two patients had concomitant myocardial ischemia), and one patient was diagnosed with nutcracker esophagus.

The study indicated that spasm of the esophageal smooth muscle might cross talk with the heart-coronary smooth muscle, leading to myocardial ischemia. And the combination of esophageal manometric studies, 24-hour intraesophageal pH monitoring and Holter electrocardiography are significant for the differential diagnosis of chest pain, particularly with foregut symptoms. As an added incentive, combined monitoring is very cost-effective to the patients from developing country.

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Reference: Deng B, Wang RW, Jiang YG, Tan QY, Liao XL, Zhou JH, Zhao YP, Gong TQ, Ma Z. Diagnosis of chest pain with foregut symptoms in Chinese patients. World J Gastroenterol 2009;15(6): 742-747

http://www.wjgnet.com/1007-9327/15/742.asp

Correspondence to: Ru-Wen Wang, MD, Thoracic Surgery Department, Institute of Surgery Research, Daping Hospital, The Third Military Medical University, Chongqing 400042, China. superdb@163.com

High Blood Pressure Can Mask Dangerous Chest Pain

MONTREAL, July 11 -- Patients with high blood pressure may be at risk for silent ischemia because they have a decreased perception of the pain that would otherwise signal heart disease, researchers here said.
In a prospective study of 907 men and women suspected of having myocardial ischemia, those with high blood pressure tended to have significantly lower pain scores during exercise (P=0.003) than those with normal pressure, according to Bianca D'Antono, Ph.D., of the Montreal Heart Institute, and colleagues.
The relationship was present whether or not imaging showed an actual deficit in perfusion, the researchers reported in the July issue of Psychophysiology.
Previous studies - using experimental models of pain - have suggested that people with high blood pressure feel less discomfort, but this is one of the first to look at pain in a more natural setting, the researchers said.
From 2000 through 2003, men and women referred to the Montreal Heart Institute for diagnosis of possible myocardial ischemia were asked to take part in the study, which measured their pain both at rest and during exercise stress testing.
Patients' cardiac perfusion was measured using single positron emission tomography (SPECT) at baseline, at rest, and after a stress test. The participants also filled out the short form of the McGill Pain Questionnaire on the rest day and after exercise.
The exercise test itself was conducted on a treadmill using the Bruce protocol and was stopped when a patient reported considerable pain, was out of breath, showed anomalies on an electrocardiogram, or reached 90% of the maximal heart rate expected for the patient's age.
The cohort was divided in two on the basis of median post-exercise systolic blood pressure, with the cut-off for high blood pressure being 170 millimeters of mercury.
In a general linear model of total score on the pain questionnaire, ischemia, post-exercise systolic blood pressure, and exercise duration were significant predictors of pain.
Specifically:
Patients who had ischemia, as determined by SPECT, felt significantly more pain during exercise, at P=0.025.
Patients who exercised longer had significantly less pain, at P<0.001.
Patients with high post-exercise systolic blood pressure had significantly less pain, at P=0.003, regardless of whether they had a perfusion deficit or EEG anomalies.
The patients also evaluated their pain as being more or less widespread. Analysis of those evaluations showed that exercise duration was significantly associated (at P<0.001) with the perception of widespread pain, but blood pressure was not, the researchers said.
They noted that the inverse relationship between blood pressure and pain remained significant after adjustment for a range of possible confounding variables.
The researchers also evaluated exertional chest pain during daily living, using the Canadian Cardiovascular Society grading scale. Again, higher blood pressure was significantly associated at P=0.001 with lower angina, they found.
The latter findings are important, the researchers concluded, because "the clinical problems associated with silent ischemia, such as failure to take medication or seek medical care, are related to the experience of angina in the daily life rather than in the hospital."
The study was supported by the Canadian Institutes for Health Research and the Heart and Stroke Foundation of Quebec. The authors did not report any potential conflicts. Primary source: PsychophysiologySource reference: Ditto B et al. "Chest pain is inversely associated with blood pressure during exercise among individuals being assessed for coronary heart disease." Psychophysiology, 44 (2007), 183-188.