老年人非心源性胸痛13例报告

本回顾了我院自1973年至1995年60岁以上，源于良性食管病变而出现的心绞痛样胸痛的病人13倒，全组均住院曾诊为冠心病心绞痛，后均经心电图(ECG)，8例经心脏超声，2例经核素心血池显影检查确诊有冠心病5例，不支持冠心病8倒；全组13倒均有良性食管病变的形态学改变，经胃镜，确诊有返流性食管炎11例次，食管裂孔疝5例，痉挛性食管炎2例，     

老年人非心源性胸痛

<正>非心源性胸痛(non-cardiac chest pain,NCCP),是一类经过合理检查后排除心脏原因的非心源性、复发性、心绞痛样胸骨后胸痛。NCCP患者可表现为胸骨后挤压或烧灼痛,可放射至后背,颈部,肩部及下巴,与心源性胸痛类似。人群调查显示,NCCP的年平均患病率约为25%,不同国家和地区的患病率有所差异,男女之间无明显患病率差异^[1]。胃食管反流病(gastroesophageal reflux disease,GERD)被认为是NCCP最常见的病因,曾有报道,中国人群GERD患者胸痛的发病率为19%^[2],尚无确切社区人群NCCP患病率报道。老年人是GERD的高发人群,且老年GERD患者胸痛的发生率高于非老年患者^[3],同时,老年人也是冠心病等心源性胸痛的高发人群,因此,在临床上老年人胸痛的鉴别诊断和紧急处理极其重要^[4]。据估计在荷兰每年需花费2.3亿欧元用于确诊NCCP,如此高成本的花费主要是由于大量患者需排除心绞痛、心肌梗死和主动脉撕裂等危重病症,给医疗带来了沉重的...     

非心源性胸痛研究进展

非心源性胸痛(non-cardiac chest pain,NCCP)是指排除心脏因素所引起的复发性胸骨后疼痛,通常专指食管源性或推测为食管源性的胸痛[1]。NCCP为常见病,西方普通人群患     

非心源性胸痛的评估和处理

非心源性胸痛（NCCP）是指复发性心绞痛样胸痛,并除外心源性因素,是常见且具有挑战性的临床问题,需经过适当的评估,鉴别症状产生的原因。胃食管反流病（GERD）、食管动力异常和功能性胸痛是NCCP的三大主要病因,其中以GERD最为常见,应首先进行评估。质子泵抑制剂（PPI）试验、上消化道内镜检查、24 h食管pH-阻抗监测是评估GERD相关胸痛的常用方法,食管高分辨率测压是鉴别食管动力异常的主要工具,而诊断功能性胸痛需要心脏检查、PPI试验、上消化道内镜检查和活检病理、食管pH-阻抗监测和食管测压结果均阴性。NCCP的治疗应根据症状产生的机制选择个体化方案,PPI和平滑肌松弛剂分别是GERD和食管动力异常相关胸痛的常用药物,也可选择内镜和外科手术治疗,神经调节剂（主要为抗抑郁药）则是功能性胸痛的治疗基石。     

非心源性胸痛患者心理异常与症状间的关系

目的调查非心源性胸痛（NCCP）患者的心理精神因素异常状况，探讨它们与症状程度间的关系。方法对87例NCCP患者和健康对照组90人进行问卷调查，内容包括Zung焦虑自评量表（SAS）、Zung抑郁自评量表（SDS）、症状评分表，进行分析比较。结果1、NCCP患者焦虑、抑郁的发生率明显高于健康对照组（P〈0．005），平均焦虑、抑郁程度高于对照组（P〈0．001）。2、NCCP患者的症状积分与焦虑评分、抑郁评分呈正相关（P〈0．001）。结论焦虑和抑郁在NCCP发病机制中具有重要地位。     

小儿非心源性胸痛与胃食管反流的关系

目的了解小儿非心源性胸痛(NCCP)与胃食管反流(GER)的关系,探讨食管pH值监测在小儿NCCP诊断中的意义。方法对36例(病例组)诊断为NCCP并排除呼吸系统和胸部肌肉骨骼病变患儿进行24 h食管pH值监测,其中20例行胃镜检查。根据食管炎诊断标准,诊断为食管炎(食管炎组)11例,非食管炎(非食管炎组)9例。结果病例组24 h食管pH值<4、反流≥5 min、最长反流时间、酸性反流指数、Boix-Ochoa评分分别为(60±7)次、(2．44±0．74)次、(12．4±2．8)min、6．72±1．39、(24．6±3．9)分,对照组分别为(33±4)次、(0．35±0．11)次、(4．3±0．9) min、1．25±0．19、(7．7±0．9)分,两组比较差异有统计学意义(t分别=3．44、2．79、2．73、3．89、4．24, P均<0．01);以Boix-Ochoa评分>11．99为病理性GER诊断标准,病例组GER阳性为58．3％(21／36)。20例经胃镜检查的患者中诊断为食管炎为55．0％(11／20),其中GER阳性为81．8％(9／11);诊断为非食管炎为45．0％(9／20),其中GER阳性者为33．3％(3／9)。食管炎组反流≥5 min、酸性反流指数分别为(5．8±2．0)次、12．5±3．5,非食管炎组分别为(0．9±0．5)次、3．4±1．4,两组比较差异有统计学意义(Z分别=-2．400、-2．545,P均<0．05);食管炎组24 h食管pH值<4、最长反流时间、Boix-Ochoa评分分别为(73±11)次、(26±7)min、(41±10)分,非食管炎组分别为(34±11)次、(4±3)min、(14±5)分,两组比较差异有统计学意义(Z值分别为-2．926、-2．675、-2．584,P均<0．01)。结论GER是小儿NCCP的重要原因,食管pH值监测有助于小儿NCCP的病因诊断,并能指导治疗。     

抑酸试验在酸相关非心源性胸痛中的应用

目的 探讨质子泵抑制剂（PPI）诊断性治疗（抑酸试验）在酸相关非心源性胸痛（NCCP）中的应用价值.方法 收集因胸痛接受冠状动脉造影的69例NCCP症状人群,所有患者均填写中文版反流疾病调查问卷（RDQ）.胃镜检查和/或24 h食管pH监测阳性者即为酸相关NCCP,入选观察组,阴性者为对照组.观察组和对照组均予埃索美拉唑20 mg/次,2次/d,疗程1周.治疗前、后观察记录烧心程度和频率.结果 酸相关NCCP共39例,占NCCP的56.5％ （39/69）.以第1周无症状作为抑酸治疗阳性标准,酸相关NCCP抑酸试验的敏感度和特异度分别为79.5％和83.3％,阳性预测值86.1％,阴性预测值75.8％,Youden指数0.628.结论 酸相关性食管疾病是NCCP最常见病因.抑酸试验在酸相关NCCP中有较高的敏感度和特异度,是临床诊断酸相关NCCP简便而实用的方法.     

心源性胸痛的特征性改变对快速分诊的指导意义

【摘要】 目的：探讨心源性胸痛的特征性改变对快速分诊的指导意义。方法：回顾性研究我院心内科门急诊2013年6月至2014年6月以胸痛为主诉首诊的患者共386人次。其中因外伤所致的、不能确诊的、住院资料或随访资料不全的胸痛患者共67例予以剔除,剩余319例纳入本研究。根据出院诊断,将确诊为心源性胸痛患者定义为CCP组,其余非心源性胸痛患者定义为NCCP组。比较指标包括：可视化数字疼痛评分、劳力性胸痛、疼痛范围、放射痛、反复发作性胸痛、胸痛持续时间、低血压、心电活动是否稳定、血氧饱和度、诊疗时间等。结果：劳力性胸痛（70:115,χ2=8.70** ）,反复胸痛发作者（54:87,χ2=5.01* ）,低血压（28:25,χ2=12.71** ）,心电活动不稳定者（24:20,χ2=11.81** ）,是CCP患者的高危因素,也更常见于CCP组,且确诊时间更短（85.4: 131.6,t=2.34* ）,差异有统计学意义。结论：劳力性胸痛,反复胸痛发作以,低血压及心电活动不稳定者对快速分诊CCP患者有重要指导意义。     

急诊心源性胸痛患者临床特征分析

目的 总结心源性胸痛患者临床特征,加深临床对此类疾病的认识。方法 选取2021年1月至2021年12月经山东省济宁医学院附属医院急诊胸痛中心收治的心源性胸痛患者作为研究对象,对患者性别、年龄、来院方式、发病时间、既往史、合并症、临床表现、诊断及转归情况等进行归纳总结。结果共纳入心源性胸痛患者3107例,发病率男性多于女性,男女比为1.54:1,发病率最高的年龄段为65～74岁,84.84%的心源性胸痛患者自行来院就诊,发病时间好发于冬季,且凌晨、上午和晚上发病率最高。按照诊断进行分型包括：急性心肌梗死（AMI）1099例（35.37%）,不稳定型心绞痛（UA）1573例（50.63%）,非急性冠脉综合征（ACS）心源性胸痛435例（14.00%）。AMI患者多为持续性胸痛,UA和非ACS心源性胸痛患者多为间歇性胸痛,不同类型患者伴随症状、既往史/合并症各异,各型患者占比最高的既往史均为冠心病。心源性胸痛患者院内死亡率为1.71%(53/3107),死亡率最高为AMI患者,死亡原因均为心源性死亡。结论 心源性胸痛患者有一定的发病规律,各型患者临床特征不同,AMI患者死亡率最高。     

非心源性胸痛患者心理因素对其生活质量影响的研究

目的调查非心源性胸痛(NCCP)患者的心理精神因素异常状况,探讨它们与其生活质量间的关系。方法选择2008年1月～2010年6月在协和医院心内科因发作性胸痛为主要症状就诊,经冠脉造影/心脏动脉扫描检查排除心源性胸痛的203例NCCP患者,进行内容包括医院焦虑抑郁调查问卷(HADS),简明健康状况调查表SF-36,以健康人群为对照进行分析比较。结果 NCCP患者平均焦虑、抑郁得分高于对照组(6.92±4.50vs,4.05±2.78,6.16±4.57vs4.06±2.83,P值均0.01)。NCCP患者的焦虑、抑郁症发生率明显高于对照组(43.8%vs8.0%,35.0%vs10.0%,P值均0.01)。NCCP患者的生活质量在8个健康维度上均明显比健康人差(P值均0.01)。NCCP患者除生理功能与焦虑得分无相关性外(P=0.164),其它健康维度与焦虑、抑郁评分均呈明显负相关(P值均0.01)。结论焦虑和抑郁在NCCP发生机制中具有重要地位,并对患者生活质量有明显的影响。     

Cocaine-associated chest pain in a chest pain center

Chest pain is the most common cocaine-related complaint. The objective of this study was to describe an emergency department-based chest pain center for patients with cocaine-associated chest pain and to evaluate the safety of this protocol by assessing cardiac complications at 30 days.     

Noncardiac chest pain

Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.     

Esophageal chest pain

The unequivocal diagnosis of esophageal chest pain requires the demonstration of simultaneous manometric changes and chest pain. Numerous provocative agents have been used to enhance the diagnostic value of esophageal manometry. Our aims were to: evaluate consecutively a large group of patients with proven noncardiac chest pain and normal baseline manometric studies, using edrophonium chloride, 10 mg, and determine the value of provocative testing in clinical practice. One hundred twenty patients with normal standard baseline esophageal manometries were studied using blinded testing with edrophonium chloride and followed clinically by questionnaire. A positive response of both chest pain and manometric changes was observed in 34%, a negative response in 49%, and an indeterminate response in 17% of patients. Baseline manometric features, including high-amplitude contractions, did not predict the response to edrophonium chloride. Following edrophonium chloride administration, the change in amplitude, duration, and number of repetitive contractions from baseline was significantly greater in positive responders. Edrophonium decreased the velocity of propagated contractions in positive responders (P less than 0.05), but not in nonresponders. Response to edrophonium chloride could not be predicted by patient age, sex, or clinical symptomatology. Seventy percent of patients in both groups had symptoms indistinguishable from ischemic heart disease. After making a specific diagnosis of esophageal chest pain, patients showed a marked clinical improvement, with a significant decrease in physical limitation, emergency room visits, hospital and CCU admissions, and in further cardiac testing. We conclude that provocative testing with edrophonium chloride will make it possible to definitively implicate the esophagus in over 30% of patients with normal baseline manometric findings and noncardiac chest pain.     

Noncardiac chest pain

Opinion statement Noncardiac chest pain (NCCP) is a common condition with significant morbidity and economic implications. Psychological factors, gastroesophageal reflux disease (GERD), alteration in pain perception, and esophageal dysmotility play an important role in the pathogenesis of the disorder. Proton pump inhibitor (PPI) therapy is the most effective medical intervention for the treatment of GERD-related NCCP, as well as the most costeffective diagnostic strategy for this condition. Pain modulators such as tricyclic antidepressants, trazodone, and selective serotonin reuptake inhibitors infer a visceral analgesic effect and consequently are the treatment of choice for patients with non-GERD-related NCCP. Furthermore, cognitive behavioral therapy has also been shown to be useful in the management of subset of patients with non-GERD-related NCCP. Newer therapeutic modalities and interventions such as lower esophageal sphincter injection of botulinum toxin in NCCP patients with spastic esophageal motility disorders, theophylline, and 5-HT4 receptor agonists may supplement or replace current treatment for non-GERD-related NCCP. Future compounds may include new visceral analgesics or medications that interfere with the development of peripheral or central sensitization.     

Noncardiac chest pain

GOALS: Review of research directions in the etiology, evaluation, and treatment of patients with noncardiac chest pain. The author proposes a combined practical approach to noncardiac chest pain that incorporates these findings, which is useful in a clinical practice setting. BACKGROUND: Several major schools of thought have emerged in the etiology of noncardiac chest pain: acid reflux, motor disorder, altered pain threshold/hypersensitivity, and association with psychiatric dysfunction. There is significant overlap among these. Occult gastroesophageal reflux disease (GERD) is more common than motor disorders and is found in 30% to 40% of these patients; a subset has hypersensitivity, with a normal pH profile. Esophageal motility testing and endoscopy have a more limited role than 24-hour pH testing. Impedance planimetry and balloon sensory provocative testing remain research tools. Provocative testing with hydrochloric acid or edrophonium is less helpful than pH monitoring. Gastroesophageal reflux disease-induced chest pain requires high-dose long-term proton pump inhibitors (PPIs): at least 4 to 8 weeks. Psychotropics are superior to placebo, both in patients with and without psychiatric dysfunction. RESULTS: The author found combined PPIs and psychotropics helpful in patients with esophageal hypersensitivity and GERD, although supporting data is scant. CONCLUSIONS: A brief 1-week high-dose PPI challenge, i.e., omeprazole test, may be cost-effective in a primary care setting. However, this approach may not be useful in a referral setting, where pH data and diary assessment of associated symptoms provide useful management help. A behavioral model approach, with early emphasis on patient education, integrated with physiologic data helps the most.