Heart-focused anxiety and chest pain in postangiography medical patients

The present cross-sectional study sought to examine the extent to which heart-focused anxiety is associated with the co-occurrence of coronary artery disease (CAD) and a history of regular smoking in a sample of 148 postangiography patients from a cardiology unit. Individuals with CAD who regularly smoked demonstrated significantly greater heart-focused attention, but no greater degree of avoidance and fear of heart-focused sensations, than did nonsmoking persons with CAD and smokers without CAD. We also found evidence that heart-focused attention and fear incrementally predicted (above and beyond demographic variables and body mass index) intensity of average chest pain. Overall, this study provides some of the first empirical evidence that the co-occurrence of regular smoking and CAD is associated with specific dimensions of health anxiety. We discuss these findings in relation to models of panic pathology and anxious responding to bodily sensations.     

Heart-Focused Anxiety and Chest Pain: A Conceptual and Clinical Review

This article reviews the concept of heart-focused anxiety that may occur in response to cardiac-related stimuli and sensations. Our aim was to examine the relation between chest pain, panic, and heart-focused anxiety in persons with and without heart disease. We identify a preoccupation with the heart and its functioning based on the belief that it will lead to negative consequences (e.g., death, pain) as an important psychological variable in the production of anxious and fearful responding. We then discuss heart-focused anxiety in relation to other clinically relevant variables in anxiety-related problems such as hypochondriacal concerns, including physical symptoms, disease fear, disease conviction, and safety-seeking behavior. Finally, we briefly discuss the clinical importance of heart-focused anxiety in the assessment and treatment of certain anxiety and cardiac-related problems.     

Heart-focused anxiety,illness beliefs,and behavioral impairment: Comparing healthy heart-anxious patients with cardiac and surgical inpatients

Psychological features and complaints of persons presenting to medical settings with heart-focused anxiety and noncardiac chest pain are poorly understood. Comparing 20 healthy heart-anxious patients to cardiac and surgical inpatients and nonpatient controls, we found that healthy heart-anxious patients (a) were as afraid of chest pain and heart palpitations as inpatients with heart disease, (b) were as incapacitated by symptoms and using medical services as much as both inpatient groups; and (c) reported higher levels of cardiac disease conviction, heart awareness, and behaviors designed to protect their heart than surgical patients and nonpatients. Compared to all other groups, healthy heart-anxious patients reported more panic and other anxiety disorders, hypochondriacal beliefs, physical symptoms, obsessive-compulsive concerns, and negative affect. Following a hyperventilation test, heart-anxious patients also indicated more distressing symptoms and thoughts, and felt less safe and in control than surgical patients and nonpatients. Results support efforts for a timely recognition, diagnosis, and behavioral treatment of persons with heart-focused anxiety.     

中国男性的冠状动脉钙化检测及其意义

目的 :因冠状动脉钙化是冠状动脉粥样硬化的标志之一。故深入研究中国男性冠状动脉钙化的检出率。方法 :共调查 73 8例男性 ,按年龄分成 6组 :<2 9岁、 3 0～ 3 9岁、 40～ 49岁、 5 0～ 5 9岁、 6 0～6 9岁、 >70岁。另按症状分成三个亚组 :冠心病组、无冠心病组、混合组。有不典型胸痛 ,但无证据表明其为典型心绞痛。结果 :男性患者随着年龄增加 ,其冠状动脉钙化检出率显著增加 ;无症状男性 ,随着年龄的增加 ,其冠状动脉钙化的积分增加 ;男女性别间钙化发生率有显著差异。结论 :电子束 CT是有价值的检测冠脉钙化的有用方法 ,中国人男女性别间冠状动脉钙化检出率有显著差异。     

Apolipoprotein(a) phenotypes are reliable biomarkers for familial aggregation of coronary heart disease

Lipoprotein(a) [Lp(a)] is an atherogenic and prothrombotic molecule formed by the covalent binding of the highly polymorphic apolipoprotein(a) [apo(a)] to apoprotein B-100 of LDL. High Lp(a) concentrations are a recognized genetic risk factor for coronary heart disease (CHD) and have been shown to be related with a familial clustering of ischemic cardiac events. Nevertheless, the association between apolipoprotein(a) isoforms and a positive familial history of CHD has received far less attention. In this report, we explored the distribution of apo(a) phenotypes in 127 CHD subjects with a family history of coronary events and in 92 CHD patients without such a history. Twenty-two apo(a) isoforms were detected by a high-resolution immunoblotting method. In univariate analysis, the percentage of subjects with at least one small sized apo(a) isoform was significantly higher in CHD patients with a positive family history than in those without (P<0.01). Multivariate analysis showed that apo(a) isoforms of low molecular weight were the best predictors of familial aggregation of cardiac ischemia. We conclude that apo(a) size polymorphism is strongly associated with a familial history of CHD and is more efficient than Lp(a) plasma concentrations in predicting the familial clustering of coronary disease. When detected by high-resolution techniques, apo(a) phenotypes are objective laboratory markers that can substitute for a knowledge of a positive family history of CHD and should be used, together with Lp(a) levels, to better assess the familial predisposition to coronary events.     

A behavioral analysis of chest pain in patients suspected of having coronary artery disease

A group of 83 men and women who had been referred to Johns Hopkins Hospital for cardiac catheterization for evaluation of chest pain and possible coronary artery bypass surgery were assessed behaviorally for their chest pains. During the approximately 2-week period between clinical evaluation and catheterization, the patients completed self-report forms about their chest pains. Patients completed one form for each episode of chest pain. Referring physicians also completed a form about the patients "typical" chest pain. The data were analyzed in terms of the antecedents, concomitants, and consequences of the chest pain, and patients' reports were compared to physicians' judgments. Major findings were as follows: 1) Antecedents--most episodes occurred while the patient was at home at times when his mood was one of contentment. 2) Concomitants--the average patient reported fewer than one episode per day which persisted for about 4 min and was rated as 36 on a scale of 0 to 100. The most common physical symptoms accompanying the episode were breathlessness and weakness, and the most common pain sensations were reported to be pressing or aching. There was no consistency among patients either in primary location or path of radiation of the pain. Duration of pain did not correlate significantly either with sensation or symptoms; however, severity rating did correlate with symptoms and sensations. 3) Consequences--most episodes were self-treated with nitroglycerin or rest. Patients typically returned to their ongoing activities; however, there were a number of interactions between the likelihood of returning to ones ongoing activity and the antecedents of the episodes. 4) The referring physicians significantly overestimated the frequency and severity of their patients' episodes; furthermore, they were selective in their abilities to identify correctly the antecedents or concomitants associated with their patients' pain--e.g., they were reliable in their judgments about subjects who had sleep-related episodes; however, they were inaccurate in characterizing the typical sensations or symptoms reported by their patients. It is suggested that a behavioral analysis may enable a physician to characterize his patient's chest complaints better, and perhaps also may facilitate the differentiation between chest complaints indicative of coronary artery disease and chest complaints of a noncoronary origin.     

Anxiety and depressive symptoms and anxiety sensitivity in youngsters with noncardiac chest pain and benign heart murmurs

OBJECTIVE: Chest pain in children and adolescents is rarely associated with cardiac disease. We sought to examine psychological symptoms in youngsters with medically unexplained chest pain. We hypothesized that children and adolescents with medically unexplained chest pain would have high rates of anxiety and depressive symptoms. METHODS: We assessed 65 youngsters with noncardiac chest pain (NCCP) and 45 comparison youngsters with benign heart murmurs using self-report measures of anxiety and depressive symptoms and anxiety sensitivity. RESULTS: Compared with the asymptomatic benign-murmur group, youngsters with NCCP had higher levels of some anxiety symptoms and anxiety sensitivity. Differences on depressive symptoms were not significant. CONCLUSIONS: Though preliminary, results suggest that youngsters with chest pain may experience increased levels of some psychological symptoms. Future studies of noncardiac chest pain in youngsters should include larger samples and comprehensive diagnostic assessments as well as long-term follow-up evaluations.     

对难以解释的胸痛病人的心理评估与心理干预

目的 :分别对心内科冠心病心绞痛患者和难以解释的胸痛患者进行心理评估、心理干预 ,观察不同组患者的患病行为、对支持性心理治疗的反应。方法 :在心内科连续收集因胸闷、胸痛疑为冠心病而住院行心导管检查的患者 ,心导管检查阳性者为冠心病心绞痛组 ,阴性者为难以解释组。在心内科诊断明确前进行精神检查并对有精神障碍者做出诊断 (ICD -10标准 )。使用《患病行为问卷》评定患者的患病行为。以汉密尔顿焦虑量表和抑郁量表在入院和心导管手术前分别评定患者情绪状态 ,用以评估支持性心理治疗的效果。住院期间对难以解释胸痛的患者进行针对疾病观念的短期认知干预 ,并在一年后随访 ,与上一年住院而未加干预的难以解释胸痛的患者进行了疾病观念和就医行为方面的比较。结果 :在心内科共收集 46例 ,难以解释组 2 8例 ,其中存在明显心理健康问题的有 60 % (17/2 8) ,而冠心病组 (18例 )中这一比例只有11% (2 /18)。在患病行为上 ,难以解释组不良情绪较心绞痛组明显 ,同时 ,他们也更多地意识到自己的问题与心理有关。在疾病观念上 ,难以解释组中的心理障碍患者比没有心理障碍者病感强 ,疑病倾向重。而 1年后随访发现 ,短期认知干预对改善疾病观念和就医行为效果不显著。结论 :心内科患者中有相当部分其主诉难     

Coping in chest pain patients with and without psychiatric disorders

We first examined relations between psychiatric disorder and coronary heart disease (CHD) in 77 patients presenting with chest pain. The coping profiles of chest pain patients with and without psychiatric disorder and CHD were then compared. Psychiatric patients with no medical illness (n = 129) were also studied. On the basis of previous research we hypothesized specific coping differences across the groups. As expected, chest pain patients without psychiatric disorder scored significantly higher on a problem-focused coping scale than chest pain patients with psychiatric disorder, who in scored higher on this scale than psychiatric patients with no medical illness. The opposite pattern occurred for a measure of wishful thinking. Scores of chest pain patients with psychiatric disorder were higher on a measure of avoidance and lower on a measure of seeking of social supports than those without psychiatric disorder. Scores on a self-blame measure were not different across the groups. The results are discussed in the context of illness behavior and somatization.     

血清尿酸在冠心病患者中的变化及意义

目的 探讨血清尿酸水平与冠心病的关系.方法 经冠状动脉造影确诊的冠心病患者(冠心病组)95例和非冠心病患者(对照组)72例,冠心病组又分为单支病变亚组(40例)、双支病变亚组(32例)和三支病变亚组(23例),均测定血清尿酸水平.结果 冠心病组血清尿酸水平显著高于对照组(P＜0.01),双支病变亚组和三支病变亚组血清尿酸水平均显著高于单支病变亚组(P＜0.05;P＜0.01).结论 血清尿酸水平与冠心病密切相关,且随冠心病病情严重程度而增加,高尿酸血症是冠心病的一个危险因素.     

The relation of chest pain symptoms to angiographic findings of coronary artery stenosis and neuroticism

The present article examines the relations among self-reported and physician-estimated chest pain variables to angiographically determined coronary stenosis (CAD) and neuroticism scores. Six of the 48 chest pain variables were significantly related to coronary stenosis, but only one variable, chest pain elicited by walking, was positively related to stenosis. Chest pain during sleep, sighing and dizziness accompanying chest pain, right lower chest pain radiation, and infrequent rest to cope with the chest pain were significantly negatively related to stenosis. Neuroticism scores (N) were not significantly related to CAD but were significantly correlated with 13 of the 48 chest pain variables. In addition to correlating positively with the chest pain variables that were negatively correlated with CAD, N scores were significantly related to higher pain severity ratings, being angry, annoyed, tense, afraid, worried, and upset before the chest pain, breathlessness during the pain episode, and pain sensations described as stabbing. The six chest pain variables significantly correlated with CAD yielded a multiple correlation of 0.58, accounting for 34% of the variance, whereas N scores accounted for only 5% of the variance; however, N contributed less than 1% unique variation to stenosis in combination with the six chest-pain variables. That N influences chest pain reports more than actual stenosis is further confirmed by the results of physicians' ratings of their patients' typical chest pain episodes. Recognition of patients' characteristic levels of distress or neuroticism may aid physicians in evaluating symptoms more accurately and in treating their chest pains more appropriately.     

Chest pain and subsequent consultation for coronary heart disease: a prospective cohort study

BACKGROUND: Chest pain may not be reported to general practice but could be an important first sign of coronary heart disease (CHD). AIMS: To determine whether self-reported chest pain predicts future consultation for CHD in those with no history of consultation for CHD. DESIGN OF STUDY: Population-based study, with 7 year's follow up by GP record linkage. SETTING: General practice in North Staffordshire. METHOD: A survey, including the Rose angina questionnaire, was mailed to 4002 adults. Linked GP records used to identify responders with no record of CHD (G3 Read code or British National Formulary code for nitrate use) in the 32 months before the survey to form the sample for a 7-year prospective study. 'Survival' was compared in those with and without self-reported chest pain up to the earliest date of GP diagnosis of CHD, death, or end of the study period. RESULTS: The survey response was 65% and 2348 participants gave permission to access their GP records. Of these, 2229 had no prior consultation for CHD. From the questionnaire, 558 reported chest pain of which 186 reported exertional pain and 103 met the criteria for angina. When followed prospectively, incidence of CHD consultations was higher in those with any chest pain definition, compared with no pain, and continued to be so for 7 years subsequently. Although these associations were strongly age related, self-reported symptoms were found to be an independent risk factor for future consultation for CHD. CONCLUSION: This study highlighted that self-reported chest pain is a marker of future CHD. The usefulness of early identification of people with this symptom remains to be established.     

Evidence of a selective increase in cardiac sympathetic activity in patients with sustained ventricular arrhythmias

BACKGROUND. Although enhanced efferent cardiac sympathetic nervous activity has been proposed as an important factor in the genesis of ventricular arrhythmias and sudden cardiac death, direct clinical evidence has been lacking. METHODS. We measured the rates of total and cardiac norepinephrine spillover into the plasma, which reflect respectively overall and cardiac sympathetic nervous activity, in 12 patients who had recovered from a spontaneous, sustained episode of ventricular tachycardia or ventricular fibrillation outside the hospital 4 to 48 days earlier. The results were compared with those from three age-matched reference groups without a history of ventricular arrhythmias: 12 patients with coronary artery disease, 6 patients with chest pain but normal coronary arteries, and 12 healthy, normal subjects. RESULTS. The patients who had had ventricular arrhythmias had reduced left ventricular ejection fractions, as compared with the patients with coronary artery disease or chest pain (mean [+/- SE], 46 +/- 3 percent vs. 58 +/- 4 percent and 69 +/- 5 percent, respectively; P less than 0.003). The rates of total norepinephrine spillover into the plasma were similar in the three reference groups, but 80 percent higher in the patients with ventricular arrhythmias (P less than 0.005). The rate of cardiac norepinephrine spillover was 450 percent higher in these patients (176 +/- 39 pmol per minute, as compared with 32 +/- 8 pmol per minute in the normal subjects; P less than 0.001), a disproportionate increase relative to the increase in total spillover, which indicated selective activation of the cardiac sympathetic outflow. This increase in cardiac norepinephrine spillover was probably caused by a reduction in left ventricular function. CONCLUSIONS. These results suggest that in some patients major ventricular arrhythmias are associated with and perhaps caused by sustained and selective cardiac sympathetic activation. We speculate that depressed ventricular function was present before the ventricular arrhythmia occurred, and that this resulted in reflex cardiac sympathetic activation, which in turn contributed to the genesis of the arrhythmia.     

Chest pain admissions: characteristics of black, Latino, and white patients in low- and mid-socioeconomic strata.

To assess the potential impact of socioeconomic status (SES) factors on health-care seeking behavior for suspected acute coronary artery disease symptoms, equal numbers of black, Latino, and white patients seeking care for chest pain at two large hospital emergency rooms were studied. Differences between low and middle SES groups with respect to pre-attack health, health history, ethnicity, gender, and modes of transportation to the hospital were explored. Highly significant self-reported differences between low SES and middle SES patients were found as follows: low SES subjects were more likely to describe themselves as being in fair to poor general health (68% versus 18%), had more frequent chest pain, reported other types of heart disease, were more often current smokers, more likely to be black or Latino, and to be younger. Members of the low SES group also were less [corrected] likely to have known cholesterol levels, to have used estrogen, to have had a prior ECG or cardiac surgery, to be nonsmokers, to have had a stress test, and to have typical angina. Middle SES subjects more often described typical angina, prior use of estrogen (females), congenital, rheumatic, or family history of heart disease, prior knowledge of high cholesterol, were more likely to be of the male gender, and to be older than the low SES cohort. The data reveal that low SES subjects, with markedly less health-care resources compared with middle SES subjects, have a worse general health and cardiac risk profile despite the fact that they were significantly younger (mean age 53.4 versus 60.7, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Cognitive change following cognitive behavioural therapy for non-cardiac chest pain.

BACKGROUND: Seventeen to 43% of patients with non-cardiac chest pain suffer from anxiety/panic disorders. Cognitive behavioural therapy (CBT) is effective in reducing non-cardiac chest pain. However, no data are available indicating that pain reduction following CBT may be cognitively mediated or whether success of CBT is dependent on the presence of panic. The aim of the study was threefold: (1) does CBT have a differential effect on cognitive measures; (2) does a relationship exist between improvement in non-cardiac chest pain and changes in cognitive measures, and (3) can panic be established as a moderator of the effect of treatment? METHODS: Sixty-five patients with non-cardiac chest pain completed a randomised trial comparing study CBT with 'care as usual'. Dependent measures were: frequency of chest pain, anxiety, the fear of bodily sensations, attributions and catastrophic cognitions. RESULTS: CBT had a differential effect on most of the cognitive measures. Pain reduction was associated with the development of more adequate cognitions with respect to chest pain, independent of anxiety reduction. Although panic patients reported higher baseline scores on the cognitive measures, no differences in treatment results were found between panic and no-panic patients. CONCLUSIONS: Pain reduction following CBT may be cognitively mediated. The presence of panic did not affect the outcome of treatment, implying a broad applicability of the cognitive model for treatment of patients with non-cardiac chest pain.     

Chest pain with normal coronary arteries: a comparative study of psychiatric and social morbidity

Ninety-nine patients with chest pain and a presumptive diagnosis of coronary heart disease were assessed blindly within 24 hours of angiography, using standardized psychiatric and social interviews and a personality inventory. Thirty-one patients had normal coronary arteries (NCA), 15 had slight disease and 53 had significant coronary obstruction. Twenty-eight (61%) of the 46 patients with insignificant disease and 12 (23%) of the 53 with significant obstruction had psychiatric morbidity. Associations between the overall severity of psychiatric morbidity and measures of social maladjustment were strongest in the patients with normal coronary arteries. The 26 men with insignificant coronary artery disease had higher scores of neuroticism and extraversion than the 41 with important coronary occlusions. No differences were observed when the same comparisons were made for the women. The findings indicate that approximately two thirds of patients with normal and near-normal coronary arteries have predominantly psychiatric rather than cardiac disorders: the symptoms in these patients are more likely to represent the somatic manifestations of anxiety and overbreathing than the consequences of underlying cardiac disease. Physicians should be aware of the ways in which neurotic illness may present with symptoms mimicking cardiac disease, especially when cardiovascular symptoms are accompanied by phobic symptoms and unexplained shortness of breath.     

Abnormal myocardial phosphorus-31 nuclear magnetic resonance spectroscopy in women with chest pain but normal coronary angiograms

BACKGROUND: After hospitalization for chest pain, women are more likely than men to have normal coronary-artery angiograms. In such women, myocardial ischemia in the absence of clinically significant coronary-artery obstruction has long been suspected. Most methods for the detection of the metabolic effects of myocardial ischemia are highly invasive. Phosphorus-31 nuclear magnetic resonance (31P-NMR) spectroscopy is a noninvasive technique that can directly measure high-energy phosphates in the myocardium and identify metabolic evidence of ischemia. METHODS: We enrolled 35 women who were hospitalized for chest pain but who had no angiographically significant coronary-artery obstructions and 12 age- and weight-matched control women with no evidence of heart disease. Myocardial high-energy phosphates were measured with 31P-NMR spectroscopy at 1.5 tesla before, during, and after isometric handgrip exercise at a level that was 30 percent of the maximal voluntary grip strength. We measured the change in the ratio of phosphocreatine to ATP during exercise. RESULTS: Seven (20 percent) of the 35 women with chest pain and no angiographically significant stenosis had decreases in the phosphocreatine:ATP ratio during exercise that were more than 2 SD below the mean value in the control subjects without chest pain. There were no significant differences between the two groups with respect to hemodynamic variables at rest and during exercise, risk factors for ischemic heart disease, findings on magnetic resonance imaging and radionuclide perfusion studies of the heart, or changes in brachial flow during the infusion of acetylcholine. CONCLUSIONS: Our results provide direct evidence of an abnormal metabolic response to handgrip exercise in at least some women with chest pain consistent with the occurrence of myocardial ischemia but no angiographically significant coronary stenoses. The most likely cause is microvascular coronary artery disease.     

Association of coronary calcification with prognosis of Covid-19 patients without known heart disease

Risk factors that determine the severity of Covid-19 have not been fully elucidated. The aim of this study was to evaluate the role of coronary artery calcification (CAC) as a risk factor for death or mechanical ventilation (MV) of patients without known heart disease infected with Covid-19. We analyzed 283 consecutive in-patients with acute respiratory symptoms with chest computed tomography (chest-CT), without previous heart disease, and criteria for Covid-19 (RT-PCR positive and/or typical clinical and chest-CT findings). CAC was classified by the number of coronary segments affected as absent (0), mild (1-3), and severe calcification (more than 3). The association between CAC, CAC severity, and death or MV due to severe respiratory failure was assessed by logistic regression. The mean age was 58.7±15.7 years and 54.1% were men. Patients with CAC were older, more likely to have hypertension, and less likely to be obese. CAC was present in 75 patients (26.5%), of which 42 had a mild calcification and 33 had severe calcification, and was associated with death (OR=2.35, 95%CI: 1.01-5.48) or MV (OR=2.72, 95%CI: 1.20-6.20) adjusted for multiple confounders, with significant and increased odds ratio for the severe form of CAC (death: OR=3.70, 95%CI: 1.20-11.42; MV: OR=3.30, 95%CI: 1.09-9.95). We concluded that CAC was an independent risk factor for death or MV in Covid-19 patients without previous heart disease, particularly for those with severe calcification. CAC can be easily visualized on common chest-CT, widely used in evaluation of moderate to severe Covid-19.     

Low plasma levels of FGF-2 and PDGF-BB are associated with cardiovascular events in type II diabetes mellitus (diabetes heart study)

Objective: We tested associations of the growth factors VEGF, FGF-2, HGF and PDGF-BB with coronary artery calcium scores and cardiovascular events (CVD) in type 2 diabetes mellitus (T2DM). Methods: A cross-sectional study selected 40 frequency matched (by age, gender and race) subjects with T2DM from the first (0–111) and the third (> 1400) coronary artery calcium (CAC) score tertiles in the Diabetes Heart Study (DHS), in which 36 were with and 41 were without history of CVD events. Plasma levels of VEGF, FGF-2, HGF and PDGF-BB were measured in all subjects. Results: None of the growth factors was significantly different between the first and third CAC score tertiles. Mean plasma FGF-2 and PDGF-BB levels were significantly higher in the group without prior CVD events compared with the group with prior CVD events [mean(95%CI): 219.20 (194.42–247.15) vs. 152.93 (135.64–172.43) pg/ml, p = 0.03] and [mean(95%CI): 106.70 (89.12–127.74) vs. 61.56 (50.91–74.44) pg/ml, p = 0.03], respectively. Subgroup analysis in the first CAC tertile showed a significantly higher PDGF-BB levels in those without compared with those with CVD events [mean (95%CI): 208.36 (190.57–228.15) vs. 102.93 (80.64–125.21) pg/ml, p = 0.004]. Conclusion: Plasma growth factor levels were not significantly different between the extremes of CAC scores in T2DM. However, low plasma levels of PDGF-BB and FGF-2 are associated with prior cardiovascular events in T2DM. Studies are needed to confirm our results and also to establish temporality of this association.