title: Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder?
abstract: Severe nonexertional (resting) chest pain may be due to myocardial ischemia, esophageal dysfunction, psychiatric disorder, or any combination thereof and frequently poses a difficult diagnostic challenge. Our aim was to investigate causes of chest pain in patients with coronary artery disease. Forty-five patients with angiographically proven obstructive coronary lesions and recurrent chest pain at rest were studied; 18 had refractory pain despite cardiac therapy (problem group), and 27 had documented myocardial ischemia (control group). Esophageal manometry, edrophonium provocation, 24-hr pH studies, and psychiatric interview were performed in all patients. The clinical evolution and the outcome of specific treatment during follow-up was used to establish the etiology of chest pain. Esophageal dysfunction was identified in all problem patients and in 52% of controls, and the esophagus was incriminated as the source of pain in 8 (44%) and 5 (18.5%), respectively. After a mean follow-up of 49 months (range 24-76 months), the cause of chest pain in the problem group was identified as panic disorder in 9 patients (50%), gastroesophageal reflux in 6 (33%), esophageal dysmotility in 2 (11%), and gallstone disease in 1 (6%). Of the control patients, 18 (67%) had ischemic pain alone, while 9 had concurrent causes: panic disorder in 5 (19%) and esophageal dysfunction in 4 (15%). Esophageal dysfunction and psychiatric disturbances are common in patients with coronary artery disease presenting with resting chest pain, and may contribute to patients' symptoms.
authors.affiliation: Service of Gastroenterology, Hospital Clinic i Provincial, University of Barcelona, Spain.
authors.forename: E
authors.initials: E
authors.lastname: Ros
authors.forename: X
authors.initials: X
authors.lastname: Armengol
authors.forename: L
authors.initials: L
authors.lastname: Grande
authors.forename: V
authors.initials: V
authors.lastname: Toledo-Pimentel
authors.forename: G
authors.initials: G
authors.lastname: Lacima
authors.forename: G
authors.initials: G
authors.lastname: Sanz
mesh_terms: D016022:Case-Control Studies; D002637:Chest Pain / Q000209:etiology*; D003327:Coronary Disease / Q000150:complications* / Q000628:therapy; D015154:Esophageal Motility Disorders / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D005764:Gastroesophageal Reflux / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D016584:Panic Disorder / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D015995:Prevalence; D013997:Time Factors; D016896:Treatment Outcome