Medline ® Abstracts for References 1-9

OBJECTIVE: To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain.

DESIGN: Prospective observational study.

SETTING: General medical outpatient clinic in a university teaching hospital.

PARTICIPANTS: One hundred ninety new, consecutive patients with a mean age of 44 years (SD = 14 years, range 30-58 years) with a main complaint of abdominal or chest pain.

MEASUREMENTS AND MAIN RESULTS: The preliminary diagnosis, established on the basis of patient history and physical examination, was compared with a final diagnosis, obtained after workup at completion of the chart. A nonorganic cause was established in 66 (59%) of 112 patients with abdominal pain and in 65 (83%) of 78 with chest pain. The preliminary diagnosis of "nonorganic"versus "organic" causes was correct in 79% of patients with abdominal pain and in 88% of patients with chest pain. An "undoubted" preliminary diagnosis predicted a correct assessment in all patients with abdominal pain and in all but one patient with chest pain. Overall, only 4 patients (3%) were initially incorrectly diagnosed as having a nonorganic cause of pain rather than an organic cause. In addition, final nonorganic diagnosis (n = 131) was compared with long-term follow-up by obtaining information from patients and, if necessary, from treating physicians. Follow-up information, obtained for 71% of these patients after a mean of 29 months (range 18-56 months) identified three other patients that had been misdiagnosed as having abdominal pain of nonorganic causes. Compared with follow-up, the diagnostic accuracy for nonorganic abdominal and chest pain at chart completion was 93% and 98%, respectively.

CONCLUSIONS: A preliminary diagnosis of nonorganic versus organic abdominal or chest pain based on patient history and physical examination proved remarkably reliable. Accuracy was almost complete in patients with an "undoubted" preliminary diagnosis, suggesting that watchful waiting can be recommended in such cases.

OBJECTIVE: To describe diagnostic distribution and outcome of chest pain among patients attending an urban family practice.

DESIGN: Retrospective, descriptive chart review.

SETTING: Primary care practice.

PARTICIPANTS: All patients contacts for chest pain at Fossvogur Health Centre in the years 1989 and 1990 (193 contacts with 189 patients) were examined. One patient died before follow up and two could not be reached for follow up; they were excluded from the study. Of the 190 contacts and 186 patients studied, one patient who had two contacts with the clinic died during the study.

MAIN OUTCOME MEASURES: Age and sex distribution, physical examination, investigations, diagnosis, and treatment; well-being of every patient was checked 3 to 4 years after initial contact. We asked about evolution of symptoms and looked for possible misdiagnosis.

RESULTS: Musculoskeletal pain was diagnosed in 48.9% of contacts, heart diseases in 17.9% and 9.5% had undiagnosed chest pain. The history was the main diagnostic tool for patients with musculoskeletal diseases, while patients with heart diseases were examined more carefully and underwent more diagnostic procedures. Follow up showed that no serious disease had been missed in spite of restrictive use of laboratory investigations.

CONCLUSIONS: The working methods of family doctors who examined patients with chest pain in this health centre can differentiate between patients with serious diseases and those with benign conditions.

Chest pain is important to patients and clinicians because it can signal a threat to life as well as present diagnostic and therapeutic challenges. Because prior clinical research has not provided clear guidance to primary care clinicians, the Ambulatory Sentinel Practice Network was interested in investigating chest pain as it presents and is managed in primary care. A contemporary exploratory study was required to characterize chest pain from a clinical perspective, to test the feasibility of investigating chest pain in a network of primary care practices, and to generate promising areas for investigation. This article provides a detailed distribution of demographic, diagnostic, and therapeutic variables associated with a convenience sample of 832 patients with chest pain. Most of the patients in this study were seen only by primary care clinicians in office settings. There were promising areas identified for further investigation, including an unexpected frequency of costochondritis in black women, clinician uncertainty in the management of patients with chest pain thought to be of gastrointestinal origin, constant vigilance for infrequent myocardial infarctions, perceived discordance between clinician and patient concerning the patient's chest pain, and the methodological requirement of improved delineation of episodes of chest pain.

Among 23 clinical characteristics examined in 3,627 consecutive, symptomatic patients referred for cardiac catheterization between 1969 and 1979, nine were found to be important for estimating the likelihood a patient had significant coronary artery disease. A model using these characteristics accurately estimated the likelihood of disease when applied prospectively to 1,811 patients referred since 1979 and when used to estimate the prevalence of disease in subgroups reported in the literature. Since accurate estimates of the likelihood of significant disease that are based on clinical characteristics are reproducible, they should be used in interpreting the results of additional noninvasive tests and in quantitating the added diagnostic value.

When faced with a patient with acute chest pain, clinicians must distinguish myocardial infarction (MI) from all other causes of acute chest pain. If MI is suspected, current therapeutic practice includes deciding whether to administer thrombolysis or primary percutaneous transluminal coronary angioplasty and whether to admit patients to a coronary care unit. The former decision is based on electrocardiographic (ECG) changes, including ST-segment elevation or left bundle-branch block, the latter on the likelihood of the patient's having unstable high-risk ischemia or MI without ECG changes. Despite advances in investigative modalities, a focused history and physical examination followed by an ECG remain the key tools for the diagnosis of MI. The most powerful features that increase the probability of MI, and their associated likelihood ratios (LRs), are new ST-segment elevation (LR range, 5.7-53.9); new Q wave (LR range, 5.3-24.8); chest pain radiating to both the left and right arm simultaneously (LR, 7.1); presence of a third heart sound (LR, 3.2); and hypotension (LR, 3.1). The most powerful features that decrease the probability of MI are a normal ECG result (LR range, 0.1-0.3), pleuritic chest pain (LR, 0.2), chest pain reproduced by palpation (LR range, 0.2-0.4), sharp or stabbing chest pain (LR, 0.3), and positional chest pain (LR, 0.3). Computer-derived algorithms that depend on clinical examination and ECG findings might improve the classification of patients according to the probability that an MI is causing their chest pain.

OBJECTIVE: To examine the association among panic disorder, atypical chest pain and coronary artery disease (CAD). This article's purpose is to inform cardiologists of the prevalence of psychiatric disorders, primarily panic disorder, among patients consulting for chest pain. Panic disorder is described. Treatment modalities are summarized, and social, financial and medical consequences of nondetection are underlined.

DATA SOURCES: PSYCHLIT and MEDLINE searches under panic disorder and chest pain-related headings were conducted.

DATA EXTRACTION: The search covered January 1973 to June 1993. Thirty-eight articles were studied.

DATA SYNTHESIS: Panic disorder is present in 30% or more of chest pain patients with no or minimal CAD and may coexist with CAD. Panic disorder may often be unrecognized by physicians. Left untreated, risk for disease progression may be augmented, and social vocational disability as well as medical costs may increase.

CONCLUSION: Physicians should attend to the panic symptomatology and, when in doubt, refer possible panic patients with or without CAD to a mental health professional for assessment and treatment. Future panic prevalence studies in cardiology patients should be prospective, attempt to increase sample size and use randomized protocols where experimenters are blind to chest pain and medical diagnoses. Studies should also focus on CAD patients with atypical chest pain refractory to optimal cardiac therapy.

In the United States each year,>5.3 million patients present to emergency departments with chest discomfort and related symptoms. Ultimately,>1.4 million individuals are hospitalized for unstable angina and non-ST-segment elevation myocardial infarction. For emergency physicians and cardiologists alike, these patients represent an enormous challenge to accurately diagnose and appropriately treat. This update of the 2002 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction (UA/NSTEMI) provides an evidence-based approach to the diagnosis and treatment of these patients in the emergency department, in-hospital, and after hospital discharge. Despite publication of the guidelines several years ago, many patients with UA/NSTEMI still do not receive guidelines-indicated therapy.

BACKGROUND: Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States.

METHODS: Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White).

FINDINGS: Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice.

CONCLUSIONS: Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.