Noncardiac chest pain in patients with heart disease

This is a retrospective study of cardiac patients with noncardiac chest pain referred for evaluation of esophageal motility. Sixty-eight patients with heart disease were compared with 210 patients without heart disease according to findings from symptom questionnaires and a psychologic test (Brief Symptom Inventory). More than 70% of each group qualified for an anxiety or depressive diagnosis on the symptom questionnaire. These diagnoses were supported by significant elevations of scores on the anxiety and depression scales of the Brief Symptom Inventory. Male gender and a diagnosis of panic disorder occurred significantly more often in the patients with heart disease. "Stress" was cited as the cause of illness in about half the sample, but this led to less than satisfactory rates of psychiatric evaluation or pharmacotherapy. This is of particular concern for the cardiac patients because of the known adverse effect of anxiety and depression in those with heart disease.     

Ludwig's angina: an uncommon cause of chest pain

A 71-year-old male with coronary artery disease, hypertension, diabetes mellitus, tobacco and opioid dependence came to the emergency room complaining of one episode of retrosternal chest pain oppressive in nature of one day of evolution. He had acute respiratory distress and required mechanical ventilation. The initial impression was myocardial ischemia, but electrocardiography and cardiac enzymes ruled it out. During the following hours, neck and tongue edema developed. He was started on broad-spectrum antibiotics empirically. Neck computed tomography scan revealed a left parapharyngeal and submandibular abscess. The abscess was drained. The source of infection was found on the second molar of the left lower jaw. The patient improved and was successfully weaned from mechanical ventilation. Despite advances in therapy, Ludwig's angina remains a potentially lethal infection in which early recognition plays a crucial role.     

Diagnosing the cause of chest pain

Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. Risk of pulmonary embolism can be determined with a simple prediction rule, and a D-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses.     

Pediatric chest pain: case report of a malignant cause.

Pediatric chest pain is not an uncommon presenting complaint in the emergency department. Although the majority of cases are benign, the authors report on a patient with a fetal case of myocarditis. A discussion of myocarditis and its management as well as differential diagnosis is included.     

Rib fractures induced by coughing: an unusual cause of acute chest pain

We report three patients with stress fractures of the ribs induced by coughing. Standard radiographs of the chest and ribs did not reveal evidence of rib fractures in any of the patients. Bone scintigraphy, performed 1 to 2 weeks after initial onset of symptoms, showed a focal area of increased uptake along the chest wall in all cases. Thin section angulated helical CT directly visualized the subtle rib fractures. Initial diagnosis of a cough-induced fracture of the rib may be difficult because of the associated underlying disorder, and unnecessary examinations are commonly performed. Identification of a cough-induced fracture of the rib using helical CT may be clinically important to avoid unnecessary concern and additional examinations.     

Diaphragmatic cramp as a possible cause of noncardiac chest pain and referred mandibular pain.

The initial assumption that sudden acute chest pain may be of cardiac origin is justifiable, but when this proves not to be the case the patient is left with little explanation of the cause. It is suggested here that diaphragmatic cramp may be a cause of some undiagnosed noncardiac chest pains associated with mandibular referred pain. The phrenic nerve provides both motor and sensory innervation to the diaphragm, while the trigeminal nerve carries sensation from the mandibular teeth. Both nerves originate in separate nuclei close together in the lower medulla. Interconnections between these nuclei and others higher up in the brain may provide one explanation for this problem.     

Gastroesophageal reflux disease as a cause of chest pain

Patients with recurrent chest pain free of significant coronary artery disease account for 10% to 30% of patients undergoing coronary angiography. Recent studies suggest that gastroesophageal reflux disease may be very common in these patients. The cause of this chest pain seems to be related primarily to an acid-sensitive mucosa regardless of the presence of esophagitis. Unfortunately, a careful history will not distinguish chest pain arising from a cardiac versus an esophageal source. Therefore, all patients must undergo a thorough cardiac evaluation before assuming that acid reflux is the cause of their complaints. Initial gastroenterology evaluation will usually include upper GI endoscopy or barium studies, possibly with acid perfusion (Bernstein) testing, or both. However, the more sensitive and specific test for acid-related disease is prolonged esophageal pH monitoring. This study quantifies the amount of acid reflux but, more importantly, identifies the relationship between chest pain and acid reflux episodes. Patients should be studied in the outpatient setting with emphasis placed on performing activities that replicate their chest pain. Although we presume that acid-induced chest pain responds as well as heartburn to vigorous antireflux regimens, there are few studies to address this issue. Nevertheless, I have had great success in treating these patients with either high-dose H2 blockers or omeprazole therapy.     

The fetal thorax: Noncardiac chest anomalies

Fetal thoracic anomalies often lead to pulmonary hypoplasia with subsequent fetal or neonatal demise. Therefore, in utero sonographic identification of these anomalies is important. Unlike cardiac anomalies, most noncardiac thoracic abnormalities are easily detected with ultrasound. An unusually small thorax is usually obvious to the experienced sonographer, and thoracic masses are commonly observed on the routinely obtained four-chamber view of the heart. This article reviews the many causes of pulmonary hypoplasia with an emphasis placed on thoracic masses. Many examples of pathological fetal thoracic conditions are provided as well as a listing of differential considerations with regard to sonographic appearances of chest masses.     

Perforation of the oesophagus and aorta after eating fish: an unusual cause of chest pain

This report describes perforation of the oesophagus after eating fish complicated by perforation of the aorta six days later. The patient had not knowingly swallowed a fish bone. Aorto-oesophageal fistula is almost universally fatal. In the case described here, the fistula was demonstrated on contrast computed tomography before surgery, thus informing surgical management. The patient is the eighth reported survivor.     

Radionuclide esophageal transit test: Detection of esophageal dysmotility and reflux in noncardiac chest pain

Thirty-one patients with substernal chest pain but with normal coronary angiographic findings and 25 normal volunteers were included in our study. Esophageal motility—including esophageal mean transit time (MTT), residual fraction (RF), and retrograde index (RI) of the two groups—were evaluated by the radionuclide esophageal transit test. The results showed that among patients with noncardiac chest pain (NCP), 48% have a longer MTT, 39% have a higher RF, and 58% have a higher RI than normal volunteers. We found that esophageal disorders are a common source of noncardiac chest pain, and that radionuclide esophageal transit test is a simple noninvasive screening method to detect esophageal dysmotility or gastroesophageal reflux in such cases.     

CMR unveiling the cause of post CoVid-19 infection chest pain

The International Journal of Cardiovascular Imaging -