The clinical diagnosis of nonanginal chest pain: The differentiation of angina from nonanginal chest pain by history

Constant, Jules

doi:10.1002/clc.4960060102

Cited by 25 publications

(8 citation statements)

References 30 publications

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“…This prevalence agrees with other studies in ambulatory settings [ 5 , 22 , 23 ]. Built exclusively on history and physical attributes, the diagnosis is a real challenge [ 24 - 26 ]. The presence of one or several points sensitive to gentle fingerprint palpation is an important sign, even if GPs sometimes diagnose CWS without it.…”

Section: Discussionmentioning

confidence: 99%

Chest wall syndrome among primary care patients: a cohort study

et al. 2007

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Section: Discussionmentioning

confidence: 99%

Chest wall syndrome among primary care patients: a cohort study

et al. 2007

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“…Therefore, an extended risk assessment is important in this population in order to identify those patients at particular risk of future cardiac events and outline goals for the long-term management strategy. It is generally accepted that the character of the symptoms in patients with suspected angina is central to clinical diagnosis and risk assessment [9–11]. A difficulty in the assessment of patients with DM is that symptoms of myocardial ischaemia are often absent or atypical (shortness of breath) [12].…”

Section: Introductionmentioning

confidence: 99%

Prognostic value of CT coronary angiography in diabetic and non-diabetic subjects with suspected CAD: importance of presenting symptoms

et al. 2010

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AimTo assess the prognostic relevance of 64-slice computed tomography coronary angiography (CT-CA) and symptoms in diabetics and non-diabetics referred for cardiac evaluation.MethodsWe followed 210 patients with diabetes type 2 (DM) and 203 non-diabetic patients referred for CT-CA for ruling out coronary artery disease (CAD). Patients were without known history of CAD and were divided into four categories on the basis of symptoms at presentation (none, atypical angina, typical angina and dyspnoea). Clinical end points were major cardiac events (MACE): cardiac-related death, non-fatal myocardial infarction, unstable angina and cardiac revascularizations. Cox proportional hazard models, with and without adjustment for risk factors and multiplicative interaction term (obstructive CAD × DM), were developed to predict outcome.ResultsDM patients with dyspnoea or who were asymptomatic showed a higher prevalence of obstructive CAD than non-diabetics (p ≤ 0.01). At mean follow-up of 20.4 months, DM patients had worse cardiac event-free survival in comparison with non-DM patients (90% vs. 81%, p = 0.02). In multivariate analysis, CT-CA evidence of obstructive CAD (in DM patients: HR: 6.4; 95% CI: 2.3–17.5; p < 0.001; in non-DM patients: HR: 7.4; 95% CI: 2.1–26.7; p = 0.002) and the presence of typical angina (in DM patients: HR: 2.9; 95% CI: 1.3–6.3; p = 0.007; in non-DM patients: HR: 2.7; 95% CI: 1.1–7.1; p = 0.03) were independent predictors of MACE in both groups. Furthermore, other independent outcome predictors included dyspnoea (HR: 3.8; 95% CI: 1.7–8.5; p = 0.001), the number of segments with any CAD (HR: 1.1; 95% CI: 1.001–1.2; p = 0.04) in DM patients and coronary calcium score >100 in non-DM patients (HR: 5.6; 95% CI: 1.4–21.5; p = 0.01). In Cox regression analysis of the overall population, interaction term obstructive CAD × DM resulted in non-significance.ConclusionsAmong DM patients, dyspnoea carried a high event risk with a MACE rate four times higher. CT-CA findings were strongly predictive of outcome and proved valuable for further risk stratification.

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“…It is generally accepted that the character of the symptoms in patients with suspected angina is central to clinical diagnosis and risk assessment 910 11 By convention a resting electrocardiogram (ECG) is recorded and often an exercise ECG, which is a routine investigation in 59% of the chest pain clinics in the United Kingdom12 and was part of the initial assessment in 76% of patients with angina in the recent Euro heart survey 13. Whether these investigations contribute incrementally to risk assessment in this group is unknown, as previous studies have focused on cost and feasibility rather than on prognostic value 14.…”

Section: Introductionmentioning

confidence: 99%

Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study

Feder

Junghans

Eldridge

et al. 2008

BMJ

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Objective To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics. Design Multicentre cohort study. Setting Rapid access chest pain clinics of six hospitals in England. Participants 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset. Main outcome measure Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years. Results Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk. Conclusion In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.

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The clinical diagnosis of nonanginal chest pain: The differentiation of angina from nonanginal chest pain by history

Cited by 25 publications

References 30 publications

Chest wall syndrome among primary care patients: a cohort study

Chest wall syndrome among primary care patients: a cohort study

Prognostic value of CT coronary angiography in diabetic and non-diabetic subjects with suspected CAD: importance of presenting symptoms

Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study

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