No abstract

Ten per cent of patients with angina pectoris have normal coronary arteries and cardiac function and, despite this reassurance, continue to have chest pain. Since pain of cardiac or esophageal origin is clinically difficult to differentiate, 50 patients with severe chest pain, normal cardiac function, and normal coronary arteriography with ergotamine provocation were evaluated with a symptomatic questionnaire and esophageal function test. On 24-hour esophageal pH monitoring, 23 patients had abnormal reflux, and 27 were normal. There was no difference in the incidence and severity of chest pain, esophageal symptoms, or medication taken between refluxers and nonrefluxers. Ten refluxers and ten nonrefluxers had chest pain on exercise electrocardiography. Thirteen refluxers documented chest pain during the pH monitoring period, and in 12 it coincided with a reflux episode. Fifteen nonrefluxers documented chest pain during the monitoring period, and in only one did it coincide with a reflux episode. Of the 23 refluxers, 12 were treated with medical therapy and 11 by a surgical antireflux procedure, and all followed for two to three years. Ten (91%) of the 11 surgically treated patients are totally free of chest pain compared with five (42%) of the 12 medically treated patients. All 12 patients who had chest pain coincide with a documented reflux episode responded positively to antireflux therapy, eight surgical and four medical. It is concluded that 46% of patients complaining of angina pectoris with normal cardiac function and coronary arteriography have gastroesophageal reflux as a possible etiology. Seventy-three per cent of these patients have total abolition of chest pain by either surgical or medical antireflux therapy. Patients whose experience of chest pain coincided with a documented reflux episode on 24-hour esophageal pH monitoring had a 100% response to medical or surgical therapy. Overall, surgical therapy gave better results (91%) but was associated with an 18% temporary morbidity. Objective evaluation of reflux status and its correlation to the symptom of chest pain by 24-hour pH monitoring allows for selective therapy in these difficult to manage patients.

A double-blind study of the effects of isosorbide dinitrate, 10 mg given orally four times a day, propranolol, 40 mg four times a day, and the combination of these two drugs was performed on 21 patients with angina pectoris. Each patient received placebo, isosorbide, propranolol, and the combination of the two drugs for 1 month each in a random sequence over 4 months. The number of anginal pains and nitroglycerin tablets used were recorded, and a multistage treadmill ECG exercise test was performed after each treatment period. Frequency of anginal pains was reduced significantly with propranolol (7.0±2.5 pains/week) and the combination of propranolol and isosorbide dinitrate (9.9±2.9) as compared with placebo (21.0±6.4). Similarly, the number of nitroglycerin tablets was reduced with propranolol-containing regimens. Isosorbide was not significantly better than the placebo. Symptomatic improvement with propranolol could be related to a reduction in heart rate, and the product of heart rate and systolic blood pressure during exercise ( P <0.001). The capacity of these patients to perform a multistage exercise test, however, was not improved significantly, and the ischemic ST-segment changes were not altered by the treatments. Thus, propranolol appeared to be effective on the symptoms of angina pectoris, but it did not significantly improve exercise performance, and it did not prevent the ischemic patterns in the exercise ECG in this group of patients. Isosorbide dinitrate, alone or in combination with propranolol, was ineffective in this study.

In our report, the presence or absence of angina pectoris did not predict the presence of coronary artery disease. A significant number of patients with aortic stenosis and angina pectoris have coronary artery disease but coronary artery disease also exists in asymptomatic form in a significant number of patients with severe aortic stenosis that could not be detected clinically and therefore suggests that the routine use of selective coronary arteriography is indicated in patients over 40 years undergoing cardiac catheterization because of aortic stenosis. This is very important in the preoperative evaluation and in planning the technique of operation to employ during extracorporeal circulation and in determining the necessity of combining aortic valve replacement and myocardial revascularization.

No abstract