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03Ma_Non

03Ma_Non

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05/22/2012

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7
CLINICAL VIGNETTE
Non-Cardiac Chest Pain
Julie Ma, M.D.
 Introduction
The evaluation of non-cardiac chest pain, defined aschest pain in patients with angiographically normalcoronary arteries, is estimated to carry an annualhealth care cost of $750 million.
1
Approximately10%-30% of patients undergoing cardiac catheteriza-tion in the investigation of chest pain are found tohave normal coronary arteries.
2
While non-cardiacchest pain carries a good prognosis, these patientshave frequent office visits, emergency room evalua-tions, hospital admissions and repeat catheterizationsfor their unexplained pain.Non-cardiac chest pain is especially difficult todiagnose in the diabetic patient who often presentswith atypical symptoms and are more likely to havesilent infarctions than are their non-diabetic counter-parts.
3
Thus, while it is important to consider non-cardiac etiologies of chest pain, it is especiallyprudent to suspect an acute coronary syndrome whenthis patient population presents with chest discomforteven if atypical.
Case Report
A 62-year-old female with a history of NIDDM,dilated cardiomyopathy and ventricular tachycardiastatus post AICD placement presented to the emer-gency room with dyspnea, intermittent substernalchest and midepigastric pain for five days. Shedescribed the pain as similar to her past "angina", withan intermittent "aching pressure" associated with lossof appetite, nausea, vomiting and diarrhea. An elec-trocardiogram showed right bundle branch block withleft axis deviation unchanged from an electrocardio-gram obtained at her last admission.One month earlier, the patient had been hospital-ized for similar symptoms. Myocardial infarction wasruled out and she was discharged with GERD treat-ment at that time. Review of the patient's historyrevealed that she had been admitted eleven times inthe previous year with similar symptoms. Endoscopyperformed one year ago revealed mild gastritis andcardiac catheterization was normal.The patient was taking captopril, furosemide,lansoprazole, sotalol and warfarin. Review of systemswas negative for fever, headache, cough, hemoptysis,hematemesis, melena and dysuria. The patient wastreated for unstable angina in the emergency roomwith aspirin and intravenous nitroglycerin withoutsignificant improvement in her pain. Her bloodpressure was 96/60 mm Hg, the pulse was 68, therespirations were 15, the temperature was 36.9 andthe oxygen saturation was 96 percent on 2 liters of oxygen by nasal cannula. The jugular venous pressurewas 8 cm; the lungs had bibasilar rales, and thecardiac exam showed a regular rate and rhythm witha displaced apical impulse. The abdominal examina-tion was unremarkable and rectal exam showedbrown stool with occult blood test negative.Laboratory data included a normal white cell countand differential, normal liver function tests, PT/INRof 54.3 and 5.1. Urinalysis showed a bland sedimentand chest radiograph was significant for cardiomegalyand pulmonary congestion.The patient was admitted to the CICU for atypicalchest pain. Treatment with intravenous morphine andfamotidine were initiated. The patient ruled out formyocardial infarction. The patient continued torequire large doses of intravenous morphine to controlher pain and her nausea persisted. A right upperquadrant ultrasound revealed a hypoechoic and thick-ened galbladder wall consistent with acute cholecys-titis. The patient was evaluated by General Surgeryand was felt to be a poor candidate for cholecystec-tomy due to her severe cardiac disease and coagu-lopathy. The patient was managed with intravenousmorphine and antibiotics with eventual resolution of her pain.
 Discussion
This case illustrates the importance of consideringnon-cardiac etiologies for recurrent chest pain and thedifficulty of making such a diagnosis especially in thediabetic patient. Due to the high mortality andmorbidity of myocardial infarction, patientspresenting with chest pain should always be consid-ered to have an acute coronary syndrome until provedotherwise. This is especially true in the diabetic popu-lation where symptoms tend to be more atypical andpatients present more often with silent ischemia.
3
The most common cause of non-cardiac chestpain is gastroesophageal reflux disease. In addition,musculoskeletal etiologies are frequently seen in theprimary care setting. However, acute cholecystitis andrelated hepatobiliary disorders should also be consid-ered as they can mimic an acute myocardial infarctionor ischemia in symptomatology, electrocardiographic
 
8changes, and even left ventricular segmental wallmotion abnormalities.
4
In this case, several unusual features of thispatient's history and presentation as well as the recur-rent nature of her symptoms after ischemia had beenruled out suggested an alternative diagnosis than acardiac etiology. With a five-day history of pain at rest,one would expect to have found electrocardiographicchanges consistent with ischemia or infarction. Inaddition, the nature of her pain, with radiation to theback is somewhat atypical for myocardial ischemia.
5
The patient's description of her pain as similar to thatwhich had brought her to the emergency room severaltimes prior to this admission suggest that the patient'ssymptoms at that time were most likely caused bycholecystitis rather than ongoing intermittentischemia. In addition, the patient was confirmed tohave had normal coronaries by catheterization lessthan five years prior to this admission with multipleadmissions in the recent past for similar symptoms.This should have signaled that there was a possiblenon-cardiac source of her pain. The associationbetween gastrointestinal symptoms, including nauseaand vomiting, and acute coronary syndromes is wellestablished.
6
This is particularly true for inferiormyocardial events and among diabetics and women.Thus, these presenting symptoms could not be used tosway the diagnosis towards a non-cardiac event.However, the persistence of the patient's symptomsdespite heparin and large quantities of nitroglycerinand morphine suggested as alternative diagnosis thancardiac ischemia.The normal liver function tests and white bloodcell count were surprising in light of the etiology of her symptoms and contributed to the delay in diag-nosis. It is also unclear whether her coagulopathy wassecondary to underlying infection and possible sepsisor from her medication. This laboratory data didpersuade the decision to continue with medicalmanagement rather than surgical intervention.The clinical approach to patient with chest pain of unclear origin includes the systematic exclusion of different diagnostic possibilities. These include painfrom the chest wall, pleura or mediastinum, as well asdiseases of the gastrointestinal tract. Musculoskeletaletiologies of chest pain are common accounting forapproximately 15% of all cases of non-cardiac chestpain.
5
After the exclusion of coronary syndromes,musculoskeletal etiologies can usually be diagnosedby history and physical examination, with pointtenderness the major physical finding and a history of pain of insidious onset related to unaccustomedphysical activity. Pulmonary etiologies of non-cardiacchest pain, including pneumonia, pneumothorax andpneumomediastinum, are less common and canusually be identified by exam and chest radiograph.
7
Gastroenterologic causes of chest pain are themost common causes of non-cardiac chest pain andcan be difficult to separate from a cardiac etiology.Peptic ulcer disease, incarcerated hiatal hernia, chole-cystitis and pancreatitis may all present with chestpain instead of classic epigastric and right upperquadrant discomfort. Esophageal disease has longbeen considered a common source of non-cardiacchest pain produced by motility disorders such asachalasia, diffuse esophageal spasm and nutcrackeresophagus or high amplitude esophageal contrac-tions.
1
Gastroesophageal reflux disease is the othermajor esophageal cause of non-cardiac chest pain. Astudy of patients with non-cardiac esophageal chestpain found GERD to be the cause in 40%, motilitydisorders in 20% and a combination of both, eithersimultaneously or separately, in 40%.
8
If there is astrong suspicion for peptic ulcer disease or refluxesophagitis, esophagogastroduodenoscopy may behelpful in the diagnosis. In addition, an abdominalultrasound to rule out hepatobiliary disease may alsobe warranted as seen in this case. Once these etiolo-gies have been excluded, prolonged ambulatoryesophageal pH monitoring has become a widely avail-able technique to rule out reflux.
1
Approximately 40%of patients with non cardiac chest pain have anabnormal degree of acid reflux on 24 hour pH moni-toring or a correlation between their symptoms andreflux events.
2
It should be noted that refluxconfirmed by pH monitoring does not necessarilymean that it is the etiology of the patient's symptoms.However, a normal study may help exclude reflux asa cause of non-cardiac chest pain while a positivestudy may be used to support reflux disease as theetiology of their pain.The management of chest pain of unclear etiologyis more complicated in patients with diabetes becauseof their higher incidence of heart disease, theirtendency to present with atypical symptoms, as wellas there predisposition to infection. As has beenemphasized earlier, acute coronary syndromes shouldbe ruled out in all diabetic patients presenting withchest pain and its associated symptoms. However,particularly in elderly patients with diabetes, non-cardiac causes of chest pain can also cause seriousmorbidity and often require early diagnosis and treat-

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