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Differentiation of “esophageal” and “cardiac” chest pain
nostic tests, and less on the softer and less costly subjective evidence contained in the clinical history. The data also suggest that the more information physicians have to interpret, the more likely that information will be discordant, and the less accurate the interpretations will be. Such information overload would have alarming consequences on the efficiency of clinical testing strategies. 1. Diamond GA, Forrester JS. Analyns dmgnosis
of coronary artery 2. Diamond GA A clinically 1983;1.574-575
disease. relevant
of probability as an aid to the clinical N Engl J Med 1978.300:1350-1358. classijkatlon of chest dtscomfort. JACC
3. Diamond GA, Stamloff HM, Forrester JS, Pollock BH, Swan HJC. Computer assisted coronary
diagnosis m the non rnvasioe eoaluation artery disease. JACC 1983;1.444-455.
of patients
with suspected
4. Wong DF, Tibblts P, O’Donnell J, Collision H, LaFrance N, Han S, Otto A. Karam P, Camargo EE, Wagner HN Jr. Computer-assated Bay&an analysis in
Differentiation
of *‘Esophageal”
the drngnosts
of coronary
5. Greenberg
PS, Ellestad MH,
artery
dtsease
(abstr).
J Nucl
Med 1982;23:P83. of the multiuariate of the probability of coronar.v
Clover RC. Comparison
analysis and CADENZA system for detection artery disease Am J Cardiol 1984;53:493-496. 6. Hlatky M, Botvmick E, Brundage B. Diagnosttc accuracy compared wtth probability calcuktions using Bay&s rule. 1982:49:1927-1931.
of cardiologzsts Am J Cardiol
7. Melin JA, Wijns W, Vanbutsele RJ, Robert A, De Coster P, Brasseur LA, Beckers C, Detry JMR. Alternative diagnostic strategtes for coronary artery disease in woment demonstration of the usefulness analysis. Circulation 1985:71.535-542.
and efficiency
of probability
8. Detry JMR, Robert A, Luwaert RJ, Rousseau MF, Brasseur LA, M&n JA, Brohet CR. Diagnostic ualue of computerized exerctse testing in men without previous myocardial infarction. A multruariate, compartmentalandprobabllistic approach. Eur Heart J 1985,6:227-238 9. Winkler RL. Scoring rules and evaluation ofprobability assessors. J Am Stat Assoc 1969:64:1073-1078. IO. Shapiro AR. The eualuatron of clinical predictions. A method and initial applications. N Engl J Med 1977;296:1509-1514. Il. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science 1974;185.1124&1131.
and “Cardiac”
Chest Pain
Peter M. Schofield, MD, Peter J. Whorwell. MD, Philip E. Jones, MD, Nicholas H. Brooks, MD, and David H. Bennett, MD
etween 10 and 20% of patients referred for coronary B angiography because of chest pain are found to have normal coronary arteries.’ Some of them have esophageal
Group 1 comprised36 patients with esophagealdysfunction (19 had both dysmotility and gastroesophageal rejlux, 12 had esophagealdysmotility alone and 5 had dysfunction2 while others have been shown to have abnor- gastroesophagealreflux alone). Of the 27 patients in mal left ventricular function.3 This study determines group 2,22 had left ventricular dysfunction asdefined by whether patients with esophageal dysfunction could be abnormal regional wall motion and 5 had normal left distinguished from those without an esophageal abnor- ventricular and esophagealfunction. Four patients had mality on the basis of their clinical history. both esophagealdysfunction and abnormal left ventricuWe studied 63 patients (40 women and 23 men, ages lar regional wail motion in group 2. The only difference 30 to 68 years) with chestpain typical of angina pectoris in chestpain characteristics betweengroup 1 and 2 was and normal coronary angiograms. A questionnaire, the frequency of radiation through to the back, which modified from that usedby Master,4 was usedto record wassignificantly more commonin patients with esophadetails of the patients’ chestpain beforefurther investi- geal dysfunction [27 of 36 (75%) us 6 of 27 (22%), gations were undertaken. The questionnaireincluded 28 respectively, p
cation with intravenous edrophonium during esophageal manometry and treadmill exercise testing at the time of esophageal pH monitoring helped to confirm the association between symptoms and the esophageal abnormality.5 Esophageal pain, therefore, may mimic “cardiac” chest pain. Our patients were a selected group of patients withTHE AMERICAN
JOURNAL
OF CARDIOLOGY
AUGUST
1, 1988
315
BRIEF
REPORTS
in the spectrum of esophageal disease who presented with chest pain rather than symptoms more suggestive of an esophageal disorder. The present study has found that the only feature of the chest pain differentiating patients with an esophageal abnormality from those with presumed myocardial ischemia associated with either left ventricular dysfunction or coronary artery disease was radiation through to the back. In patients with angina pectoris and normal coronary angiograms, therefore, radiation of pain through to the back implies an esophageal abnormality and suggests the search for an esophageal disorder. This characteristic of the chest pain had a sensitivity of 75% and a specificity of 78%. It was not possible to differentiate patients with normal esophageal function (the majority of whom had
Physiologic Differences Bundle &anch Block
left ventricular abnormalities) from those with coronary artery disease on the basis of the clinical history. 1. Kemp HG, Vokonas PS, Cohn PF, Gorlin R. The anginalsyndrome associated wrth normal coronary arteriograms: report of a six-year experience. Am J Med 1973;54:735-742. 2. Alban Davies H, Jones DB, Rhodes J. “Esophageal angina” as the cause of chest pan JAMA 1982:248:2274-2278. 3. Schofield PM, Brooks NH, Bennett DH. Lzft uentricular dysfunction in patrents with angina pectms and normal coronary angiograms. Br Heart J 1986;56:327-333. 4. Master AM The soectrum of an&o and non-cardiac chest min. JAMA 1964;187:894-899 ’ z v 5. Schofield PM, Brooks NH, Colgan S, Bennett DH, Whorwell PJ, Bray CL, Ward C, Jones PE. Left oentncularfunctron and esophagealfunction inpatients with angina pectoris and normal coronary a@ograms. Br Heart J 1987;S8.218224 6. Leighton RF, Wilt SM, Lewis RP. Detectron of hypokinesis by a quantitative analysis of left uentricular nneangiograms. Cwculation 1974;50:121-127.
in Rate-Related
Versus
Exercise-Induced
Left
Hitoshi Koito, MD, and David H. Spodick, MD, DSc eft bundle branch block (BBB) due to increased L heart rate (Figure 1) and exercise-induced left BBB (Figure 2) are well known. Numerous authorities refer to both as “rate related,” implying that exercise-induced left BBB is a variant of left BBB due to increased heart rate.1-5 Investigation of our patients indicates that this is not strictly correct. Because none of our patients had indications for atria1 pacing, we could not compare such a “pure” rate stimulus. Yet our results indicate that exercise-induced left BBB and left BBB due to “spontaneous” rate increases behave so differently that, while increased heart rate might be 1 determinant of exercise-induced left BBB, the 2 cannot be equated. We prospectively investigated consecutivepatients: IO with left BBB appearing during exercise testing and 10 with left BBB with spontaneousheart rate increases during routine electrocardiography. The patients were otherwise unselected. Exercise-induced left BBB occurred during Bruce tests to evaluate chest pain; each was aborted when left BBB appeared. Cycle length was measuredto the nearest 10 ms at onsetand offset of left BBB. For exercise-induced left BBB, onset and offset pressure-rate products were calculated. Statistical signifkances were estimated by analysis of variance and t tests. All patients had coronary disease.No patient had chest pain before or when exercise-induced left BBB appeared. Onset of exercise-induced left BBB occurred at a meancycle length of 490 f 120 (standard deviation) ms (mean heart rate 122 beatslmin); this was signt$cantly different from resting control cycle length of 780 f 210 ms, p
316
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
62
heart rate 91 beatslmin); this was significantly different (p
TABLE Branch
I Exercise-Induced Versus Block (Mean Measurements
Pt Exercise
Raterelated
Rate vs exercise
1 2 3 4 5 6 7 8 9 10 Mean 1 2 3 4 5 6 7 8 9 10 Mean
Age (yrs), Sex
Cycle Onset
63, 58, 63, 61, 51, 65, 58, 65, 68. 77,
F M M M F M F M F F
41. F 60, M 61, M 40,M 56, F 63, F 70. F 60, F 83, F 69, M
f SD
f SD
Rate-Related to Nearest Length
Left Bundle 10 ms) Difference
(ms) Offset
(ms)
420 540 480 490 420 400 390 790 530 440 490f120
620 880 620 650 520 600 470 1,050 690 550 660f180
200 340 140 160 100 200 80 260 160 110 175f79
740 710 760 760 860 780 590 1,140 800 710 790f140
770 780 840 800 920 840 610 1,200 840 760 84Of150
30 70 80 40 60 60 20 60 40 50 51f19
p
p
p
of coronary artery 2. Diamond GA A clinically 1983;1.574-575
disease. relevant
of probability as an aid to the clinical N Engl J Med 1978.300:1350-1358. classijkatlon of chest dtscomfort. JACC
3. Diamond GA, Stamloff HM, Forrester JS, Pollock BH, Swan HJC. Computer assisted coronary
diagnosis m the non rnvasioe eoaluation artery disease. JACC 1983;1.444-455.
of patients
with suspected
4. Wong DF, Tibblts P, O’Donnell J, Collision H, LaFrance N, Han S, Otto A. Karam P, Camargo EE, Wagner HN Jr. Computer-assated Bay&an analysis in
Differentiation
of *‘Esophageal”
the drngnosts
of coronary
5. Greenberg
PS, Ellestad MH,
artery
dtsease
(abstr).
J Nucl
Med 1982;23:P83. of the multiuariate of the probability of coronar.v
Clover RC. Comparison
analysis and CADENZA system for detection artery disease Am J Cardiol 1984;53:493-496. 6. Hlatky M, Botvmick E, Brundage B. Diagnosttc accuracy compared wtth probability calcuktions using Bay&s rule. 1982:49:1927-1931.
of cardiologzsts Am J Cardiol
7. Melin JA, Wijns W, Vanbutsele RJ, Robert A, De Coster P, Brasseur LA, Beckers C, Detry JMR. Alternative diagnostic strategtes for coronary artery disease in woment demonstration of the usefulness analysis. Circulation 1985:71.535-542.
and efficiency
of probability
8. Detry JMR, Robert A, Luwaert RJ, Rousseau MF, Brasseur LA, M&n JA, Brohet CR. Diagnostic ualue of computerized exerctse testing in men without previous myocardial infarction. A multruariate, compartmentalandprobabllistic approach. Eur Heart J 1985,6:227-238 9. Winkler RL. Scoring rules and evaluation ofprobability assessors. J Am Stat Assoc 1969:64:1073-1078. IO. Shapiro AR. The eualuatron of clinical predictions. A method and initial applications. N Engl J Med 1977;296:1509-1514. Il. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science 1974;185.1124&1131.
and “Cardiac”
Chest Pain
Peter M. Schofield, MD, Peter J. Whorwell. MD, Philip E. Jones, MD, Nicholas H. Brooks, MD, and David H. Bennett, MD
etween 10 and 20% of patients referred for coronary B angiography because of chest pain are found to have normal coronary arteries.’ Some of them have esophageal
Group 1 comprised36 patients with esophagealdysfunction (19 had both dysmotility and gastroesophageal rejlux, 12 had esophagealdysmotility alone and 5 had dysfunction2 while others have been shown to have abnor- gastroesophagealreflux alone). Of the 27 patients in mal left ventricular function.3 This study determines group 2,22 had left ventricular dysfunction asdefined by whether patients with esophageal dysfunction could be abnormal regional wall motion and 5 had normal left distinguished from those without an esophageal abnor- ventricular and esophagealfunction. Four patients had mality on the basis of their clinical history. both esophagealdysfunction and abnormal left ventricuWe studied 63 patients (40 women and 23 men, ages lar regional wail motion in group 2. The only difference 30 to 68 years) with chestpain typical of angina pectoris in chestpain characteristics betweengroup 1 and 2 was and normal coronary angiograms. A questionnaire, the frequency of radiation through to the back, which modified from that usedby Master,4 was usedto record wassignificantly more commonin patients with esophadetails of the patients’ chestpain beforefurther investi- geal dysfunction [27 of 36 (75%) us 6 of 27 (22%), gations were undertaken. The questionnaireincluded 28 respectively, p
cation with intravenous edrophonium during esophageal manometry and treadmill exercise testing at the time of esophageal pH monitoring helped to confirm the association between symptoms and the esophageal abnormality.5 Esophageal pain, therefore, may mimic “cardiac” chest pain. Our patients were a selected group of patients withTHE AMERICAN
JOURNAL
OF CARDIOLOGY
AUGUST
1, 1988
315
BRIEF
REPORTS
in the spectrum of esophageal disease who presented with chest pain rather than symptoms more suggestive of an esophageal disorder. The present study has found that the only feature of the chest pain differentiating patients with an esophageal abnormality from those with presumed myocardial ischemia associated with either left ventricular dysfunction or coronary artery disease was radiation through to the back. In patients with angina pectoris and normal coronary angiograms, therefore, radiation of pain through to the back implies an esophageal abnormality and suggests the search for an esophageal disorder. This characteristic of the chest pain had a sensitivity of 75% and a specificity of 78%. It was not possible to differentiate patients with normal esophageal function (the majority of whom had
Physiologic Differences Bundle &anch Block
left ventricular abnormalities) from those with coronary artery disease on the basis of the clinical history. 1. Kemp HG, Vokonas PS, Cohn PF, Gorlin R. The anginalsyndrome associated wrth normal coronary arteriograms: report of a six-year experience. Am J Med 1973;54:735-742. 2. Alban Davies H, Jones DB, Rhodes J. “Esophageal angina” as the cause of chest pan JAMA 1982:248:2274-2278. 3. Schofield PM, Brooks NH, Bennett DH. Lzft uentricular dysfunction in patrents with angina pectms and normal coronary angiograms. Br Heart J 1986;56:327-333. 4. Master AM The soectrum of an&o and non-cardiac chest min. JAMA 1964;187:894-899 ’ z v 5. Schofield PM, Brooks NH, Colgan S, Bennett DH, Whorwell PJ, Bray CL, Ward C, Jones PE. Left oentncularfunctron and esophagealfunction inpatients with angina pectoris and normal coronary a@ograms. Br Heart J 1987;S8.218224 6. Leighton RF, Wilt SM, Lewis RP. Detectron of hypokinesis by a quantitative analysis of left uentricular nneangiograms. Cwculation 1974;50:121-127.
in Rate-Related
Versus
Exercise-Induced
Left
Hitoshi Koito, MD, and David H. Spodick, MD, DSc eft bundle branch block (BBB) due to increased L heart rate (Figure 1) and exercise-induced left BBB (Figure 2) are well known. Numerous authorities refer to both as “rate related,” implying that exercise-induced left BBB is a variant of left BBB due to increased heart rate.1-5 Investigation of our patients indicates that this is not strictly correct. Because none of our patients had indications for atria1 pacing, we could not compare such a “pure” rate stimulus. Yet our results indicate that exercise-induced left BBB and left BBB due to “spontaneous” rate increases behave so differently that, while increased heart rate might be 1 determinant of exercise-induced left BBB, the 2 cannot be equated. We prospectively investigated consecutivepatients: IO with left BBB appearing during exercise testing and 10 with left BBB with spontaneousheart rate increases during routine electrocardiography. The patients were otherwise unselected. Exercise-induced left BBB occurred during Bruce tests to evaluate chest pain; each was aborted when left BBB appeared. Cycle length was measuredto the nearest 10 ms at onsetand offset of left BBB. For exercise-induced left BBB, onset and offset pressure-rate products were calculated. Statistical signifkances were estimated by analysis of variance and t tests. All patients had coronary disease.No patient had chest pain before or when exercise-induced left BBB appeared. Onset of exercise-induced left BBB occurred at a meancycle length of 490 f 120 (standard deviation) ms (mean heart rate 122 beatslmin); this was signt$cantly different from resting control cycle length of 780 f 210 ms, p
316
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
62
heart rate 91 beatslmin); this was significantly different (p
TABLE Branch
I Exercise-Induced Versus Block (Mean Measurements
Pt Exercise
Raterelated
Rate vs exercise
1 2 3 4 5 6 7 8 9 10 Mean 1 2 3 4 5 6 7 8 9 10 Mean
Age (yrs), Sex
Cycle Onset
63, 58, 63, 61, 51, 65, 58, 65, 68. 77,
F M M M F M F M F F
41. F 60, M 61, M 40,M 56, F 63, F 70. F 60, F 83, F 69, M
f SD
f SD
Rate-Related to Nearest Length
Left Bundle 10 ms) Difference
(ms) Offset
(ms)
420 540 480 490 420 400 390 790 530 440 490f120
620 880 620 650 520 600 470 1,050 690 550 660f180
200 340 140 160 100 200 80 260 160 110 175f79
740 710 760 760 860 780 590 1,140 800 710 790f140
770 780 840 800 920 840 610 1,200 840 760 84Of150
30 70 80 40 60 60 20 60 40 50 51f19
p
p
p