Dissecting intramural haematoma of the oesophagus.
(1/1212)
The largest series of patients (n = 10) with dissecting intramural haematoma of the oesophagus is described. The typical features, chest pain with odynophagia or dysphagia and minor haematemesis are usually present but not always elicited at presentation. If elicited, these symptoms should suggest the diagnosis and avoid mistaken attribution to a cardiac origin for the pain. Precipitating factors such as a forced Valsalva manoeuvre cannot be identified in at least half the cases. Early endoscopy is safe, and confirms the diagnosis when an haematoma within the oesophageal wall or the later appearances of a longitudinal ulcer are seen. Dissecting intramural haematoma of the oesophagus has an excellent prognosis when managed conservatively. (+info)
The effect of race and sex on physicians' recommendations for cardiac catheterization.
(2/1212)
BACKGROUND: Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain. METHODS: We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test. RESULTS: The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004). CONCLUSIONS: Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain. (+info)
Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques.
(3/1212)
BACKGROUND: The modern imaging techniques of transesophageal echocardiography, CT, and MRI are reported to have up to 100% sensitivity in detecting the classic class of aortic dissection; however, anecdotal reports of patient deaths from a missed diagnosis of subtle classes of variants are increasingly being noted. METHODS AND RESULTS: In a series of 181 consecutive patients who had ascending or aortic arch repairs, 9 patients (5%) had subtle aortic dissection not diagnosed preoperatively. All preoperative studies in patients with missed aortic dissection were reviewed in detail. All 9 patients (2 with Marfan syndrome, 1 with Takayasu's disease) with undiagnosed aortic dissection had undergone >/=3 imaging techniques, with the finding of ascending aortic dilatation (4.7 to 9 cm) in all 9 and significant aortic valve regurgitation in 7. In 6 patients, an eccentric ascending aortic bulge was present but not diagnostic of aortic dissection on aortography. At operation, aortic dissection tears were limited in extent and involved the intima without extensive undermining of the intima or an intimal "flap." Eight had composite valve grafts inserted, and all survived. Of the larger series of 181 patients, 98% (179 of 181) were 30-day survivors. CONCLUSIONS: In patients with suspected aortic dissection not proven by modern noninvasive imaging techniques, further study should be performed, including multiple views of the ascending aorta by aortography. If patients have an ascending aneurysm, particularly if eccentric on aortography and associated with aortic valve regurgitation, an urgent surgical repair should be considered, with excellent results expected. (+info)
Quality of life four years after acute myocardial infarction: short form 36 scores compared with a normal population.
(4/1212)
OBJECTIVES: To assess the impact of myocardial infarction on quality of life in four year survivors compared to data from "community norms", and to determine factors associated with a poor quality of life. DESIGN: Cohort study based on the Nottingham heart attack register. SETTING: Two district general hospitals serving a defined urban/rural population. SUBJECTS: All patients admitted with acute myocardial infarction during 1992 and alive at a median of four years. MAIN OUTCOME MEASURES: Short form 36 (SF 36) domain and overall scores. RESULTS: Of 900 patients with an acute myocardial infarction in 1992, there were 476 patients alive and capable of responding to a questionnaire in 1997. The response rate was 424 (89. 1%). Compared to age and sex adjusted normative data, patients aged under 65 years exhibited impairment in all eight domains, the largest differences being in physical functioning (mean difference 20 points), role physical (mean difference 23 points), and general health (mean difference 19 points). In patients over 65 years mean domain scores were similar to community norms. Multiple regression analysis revealed that impaired quality of life was closely associated with inability to return to work through ill health, a need for coronary revascularisation, the use of anxiolytics, hypnotics or inhalers, the need for two or more angina drugs, a frequency of chest pain one or more times per week, and a Rose dyspnoea score of >/= 2. CONCLUSIONS: The SF 36 provides valuable additional information for the practising clinician. Compared to community norms the greatest impact on quality of life is seen in patients of working age. Impaired quality of life was reported by patients unfit for work, those with angina and dyspnoea, patients with coexistent lung disease, and those with anxiety and sleep disturbances. Improving quality of life after myocardial infarction remains a challenge for physicians. (+info)
Management of non-cardiac chest pain: from research to clinical practice.
(5/1212)
BACKGROUND: Non-cardiac chest pain assessed by cardiologists in their outpatient clinics or by coronary angiography usually has a poor symptomatic functional and psychological outcome. Randomised trials have shown the effectiveness of specialist psychological treatment with those who have persistent symptoms, but such treatment is not always acceptable to patients and may not be feasible in routine clinical settings. OBJECTIVES: To describe a sample of patients referred to cardiac outpatient clinics from primary care in a single health district who were consecutively reassured by cardiologists that there was not a cardiac cause for their presenting symptom of chest pain. DESIGN: Systematic recording of referral and medical information of patients consecutively reassured by cardiologists. Reassessment in research clinic six weeks later (with a view to inclusion in a randomised trial of psychological treatment, which has been separately reported) and followed up at six months. SETTING: A cardiac clinic in a teaching hospital providing a district service to patients referred from primary care. PATIENTS: 133 patients from the Oxfordshire district presenting with chest pain and consecutively reassured that there was no cardiac cause during the recruitment period; 69 had normal coronary angiograms and 64 were reassured without angiography. INTERVENTION: A subgroup (n = 56) with persistent disabling chest pain at six weeks were invited to take part in a randomised controlled trial of cognitive behavioural treatment. MAIN OUTCOME MEASURES: Standardised interview and self report measures of chest pain, other physical symptoms, mood and anxiety, everyday activities, and beliefs about the cause of symptoms at six week assessment; repeat of self report measures at six months. RESULTS: Patients had a good outcome at six weeks, but most had persistent, clinically significant symptoms and distress. Some found the six week assessment and discussion useful. The psychological treatment was helpful to most of those recruited to the treatment trial, but a minority (15%) of those treated appeared to need more intensive and individual collaborative management. Patients reassured following angiography were compared with those reassured without invasive investigation. They had longer histories of chest pain, more often reported breathlessness on exertion, and were more likely to have previously been diagnosed as having angina, treated with antianginal medication, and admitted to hospital as emergencies. CONCLUSION: These findings suggest a need for "stepped" aftercare, with management tailored according to clinical need. This may range from simple reassurance and explanation in the cardiac clinic to more intensive individual psychological treatment of associated underlying and often enduring psychological problems. Simple ways in which the cardiologist might improve care to patients with non-cardiac chest pain are suggested, and the need for access to specialist psychological treatment discussed. (+info)
Group psychological treatment for chest pain with normal coronary arteries.
(6/1212)
We used a psychological treatment package (education, relaxation, breathing training, graded exposure to activity and exercise, and challenging automatic thoughts about heart disease) to treat 60 patients who had continuing chest pain despite cardiological reassurance following haemodynamically normal angiography. The treatment was delivered in six sessions over eight weeks to groups of up to six patients. The patients kept daily records of chest pain episode frequency and nitrate use. Questionnaires were used to assess anxiety, depression and disability. Exercise tolerance was tested by treadmill electrocardiography, with capnographic assessment of hyperventilation. The results were compared with waiting-list controls. Treatment significantly reduced chest pain episodes (p < 0.01) from median 6.5 to 2.5 per week. There were significant improvements in anxiety and depression scores (p < 0.05), disability rating (p < 0.0001) and exercise tolerance (p < 0.05), and these were maintained at six month follow-up. Treatment reduced the prevalence of hyperventilation from 54% to 34% (p < 0.01) but not the prevalence of ECG-positive exercise tests. Patients continuing to attribute their pain to heart disease had poorer outcomes. Group psychological treatment for non-cardiac chest pain is feasible, reduces pain, psychological morbidity and disability, and improves exercise tolerance. (+info)
Direct evidence of endothelial injury in acute myocardial infarction and unstable angina by demonstration of circulating endothelial cells.
(7/1212)
Circulating endothelial cells (CECs) have been detected in association with endothelial injury and therefore represent proof of serious damage to the vascular tree. Our aim was to investigate, using the technique of immunomagnetic separation, whether the pathological events in unstable angina (UA) or acute myocardial infarction (AMI) could cause desquamation of endothelial cells in circulating blood compared with effort angina (EA) and noncoronary chest pain. A high CEC count was found in AMI (median, 7.5 cells/mL; interquartile range, 4.1 to 43.5, P <.01 analysis of variance [ANOVA]) and UA (4.5; 0.75 to 13.25 cells/mL, P <.01) within 12 hours after chest pain as compared with controls (0; 0 to 0 cells/mL) and stable angina (0; 0 to 0 cells/mL). CEC levels in serial samples peaked at 15.5 (2.7 to 39) cells/mL 18 to 24 hours after AMI (P <.05 repeated measures ANOVA), but fell steadily after UA. Regardless of acute coronary events, the isolated cells displayed morphologic and immunologic features of vascular endothelium. The CECs were predominantly of macrovascular origin. They did not express the activation markers intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1, and E-selectin, although some were positive for tissue factor. CECs failed to exhibit characteristics of apoptosis (TUNEL assay) excluding this event as a possible mechanism of cell detachment. The presence of CECs provides direct evidence of endothelial injury in AMI and UA, but not in stable angina, confirming that these diseases have different etiopathogenic mechanisms. (+info)
Comparison of myocardial perfusion imaging and cardiac troponin I in patients admitted to the emergency department with chest pain.
(8/1212)
BACKGROUND: Identification of patients with acute coronary syndromes (ACS) among those who present to emergency departments with possible myocardial ischemia is difficult. Myocardial perfusion imaging with 99mTc sestamibi and measurement of serum cardiac troponin I (cTnI) both can identify patients with ACS. METHODS AND RESULTS: Patients considered at low to moderate risk for ACS underwent gated single-photon emission CT sestamibi imaging and serial myocardial marker measurements of creatine kinase-MB, total creatine kinase activity, and cTnI over 8 hours. Positive perfusion imaging was defined as a perfusion defect with associated abnormalities in wall motion or thickening. cTnI >/=2.0 ng/mL was considered abnormal. Among the 620 patients studied, 59 (9%) had myocardial infarction and 81 (13%) had significant coronary disease; of these patients, 58 underwent revascularization. Perfusion imaging was positive in 241 patients (39%), initial cTnI was positive in 37 (6%), and cTnI was >/=2.0 ng/mL in 74 (12%). Sensitivity for detecting myocardial infarction was not significantly different between perfusion imaging (92%) and cTnI (90%), and both were significantly higher than the initial cTnI (39%). Sensitivity for predicting revascularization or significant coronary disease was significantly higher for perfusion imaging than for serial cTnI, although specificity for all end points was significantly lower. Lowering the cutoff value of cTnI to 1.0 ng/mL did not significantly change the results. CONCLUSIONS: Early perfusion imaging and serial cTnI have comparable sensitivities for identifying myocardial infarction. Perfusion imaging identified more patients who underwent revascularization or who had significant coronary disease, but it had lower specificity. The 2 tests can provide complementary information for identifying patients at risk for ACS. (+info)