Search

Background: Although the prognostic role of stress SPECT MPI is generally well established, its value in predicting non-fatal cardiac events in patients with acute, non-specific chest pain (NSCP) remains unclear. The aims of this study are 1) to describe the baseline clinical characteristics and prevalence of myocardial perfusion (MP) deficits, by use of an adenosine stress SPECT MPI, in NSCP patients without known CAD discharged after hospitalization for suspected ACS; and 2) to prospectively describe the 4-year clinical outcome in terms of all-cause and cardiac mortality; hospitalization and coronary revascularization procedures; and cardio-vascular events in patients with and without MP deficits., Methods and Results: We evaluated a series of 272 consecutive patients with acute NSCP and aged 18-75years. ICD10-based registries were used to determine the primary outcome (a composite measure of incident CAD death, ACS, or revascularization) and two secondary outcomes (1. all-cause death; 2. a composite measure of cardiovascular death, ACS, revascularization, or stroke). Forty two (15%) participants had a MP deficit. During follow-up (median 1361days), 7 participants had a primary event, 4 died, and 20 had a secondary composite event. Annual event rates were 0.70, 0.39 and 2.07, respectively. MP deficits predicted both subsequent primary and composite secondary events (HR: 7.54; 95% CI=[1.69; 33.69] and 2.93 (95% CI=[1.10; 7.81], respectively). Usual clinical cardiac risk classification could not meaningfully differentiate between patients with and without MP deficits., Conclusion: SPECT MPI substantially improved prediction of incident CAD beyond usual clinical procedures and risk classification systems among NSCP patients., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: We have previously reported short-term follow-up from a pragmatic randomized clinical trial comparing 2 treatments for acute musculoskeletal chest pain: (1) chiropractic treatment and (2) self-management. Results indicated a positive effect in favor of the chiropractic treatment after 4 and 12 weeks. The current article investigates the hypothesis that the advantage observed at 4 and 12 weeks would be sustained after 1 year. In addition, we describe self-reported consequences of acute musculoskeletal chest pain at 1-year follow-up., Methods: In a nonblinded, randomized controlled trial undertaken at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain of musculoskeletal origin were included. After the baseline evaluation, patients were randomized to 4 weeks of either chiropractic treatment or self-management, with posttreatment questionnaire follow-up 52 weeks later. The primary outcome measures were change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale)., Results: Both groups experienced decreases in pain, positive global, self-perceived treatment effect, and increases in the 36-Item Short Form Health Survey scores. No statistically significant differences were observed between groups at the 1-year follow-up, and we could not deduce a common trend in favor of either intervention., Conclusions: At the 1-year follow-up, we found no difference between groups in terms of pain intensity and self-perceived change in chest pain in the first randomized clinical trial assessing chiropractic treatment vs minimal intervention for patients with acute musculoskeletal chest pain. Further research into health care utilization and use of prescriptive medication is warranted., (Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Objective: The purposes of this study were to identify the most important determinants from the patient history and clinical examination in diagnosing musculoskeletal chest pain (MSCP) in patients with acute noncardiac chest pain when supported by a structured protocol and to construct a decision tree for identification of MSCP in acute noncardiac chest pain., Methods: Consecutive patients with noncardiac chest pain (n = 302) recruited from an emergency cardiology department were assessed. Using data from self-report questionnaires, interviews, and clinical assessment, patient characteristics were associated with the MSCP diagnosis, and the decision-making process of the clinician was reconstructed using recursive procedures in the tradition of constructing Classification and Regression Trees., Results: Thirty-eight percent of patients had MSCP. There was no single determinant that predicted the condition completely. However, many items with high associations could be identified, mainly with high negative predictive value. The decision-making process was reconstructed giving rise to a 5-step, linear decision tree without branches., Conclusions: Clinicians use a combination of indicators including systematic palpation of the spine and chest wall and items from the case history to diagnose MSCP. However, the high negative predictive values of the main determinants suggest that the MSCP diagnosis may be a diagnosis by exclusion., (Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Objective: The musculoskeletal system is a common but often overlooked cause of chest pain. The purpose of the present study is to evaluate the relative effectiveness of 2 treatment approaches for acute musculoskeletal chest pain: (1) chiropractic treatment that included spinal manipulation and (2) self-management as an example of minimal intervention., Methods: In a nonblinded, randomized, controlled trial set at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain and no clear medical diagnosis at initial presentation were included. After a baseline evaluation, patients with musculoskeletal chest pain were randomized to 4 weeks of chiropractic treatment or self-management, with posttreatment questionnaire follow-up 4 and 12 weeks later. Primary outcome measures were numeric change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale)., Results: Both groups experienced decreases in pain, self-perceived positive changes, and increases in Medical Outcomes Study Short Form 36-Item Health Survey scores. Observed between-group significant differences were in favor of chiropractic treatment at 4 weeks regarding the primary outcome of self-perceived change in chest pain and at 12 weeks with respect to the primary outcome of numeric change in pain intensity., Conclusions: To the best of our knowledge, this is the first randomized trial assessing chiropractic treatment vs minimal intervention in patients without acute coronary syndrome but with musculoskeletal chest pain. Results suggest that chiropractic treatment might be useful; but further research in relation to patient selection, standardization of interventions, and identification of potentially active ingredients is needed., (Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Chest pain may be caused by joint and muscle dysfunction of the neck and thorax (termed musculoskeletal chest pain). The objectives of this study were (1) to determine inter-observer reliability of the diagnosis 'musculoskeletal chest pain' in patients with acute chest pain of non-cardiac origin using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0.01 to 0.59. Provided adequate training of observers, the examination protocol can be used in carefully selected patients in clinical settings and should be included in pre- and post-graduate clinical training., (Copyright 2009 Elsevier Ltd. All rights reserved.)

The musculoskeletal system is a recognized source of chest pain. However, despite the apparently benign origin, patients with musculoskeletal chest pain remain under-diagnosed, untreated, and potentially continuously disabled in terms of anxiety, depression, and activities of daily living. Several overlapping conditions and syndromes of focal disorders, including Tietze syndrome, costochondritis, chest wall syndrome, muscle tenderness, slipping rib, cervical angina, and segmental dysfunction of the cervical and thoracic spine, have been reported to cause pain. For most of these syndromes, evidence arises mainly from case stories and empiric knowledge. For segmental dysfunction, clinical features of musculoskeletal chest pain have been characterized in a few clinical trials. This article summarizes the most commonly encountered syndromes of focal musculoskeletal disorders in clinical practice.

Objective: This study examines the relationship between the existence of chest wall tenderness evoked by palpation and the absence of ischemic heart disease defined by myocardial perfusion imaging in patients with known or suspected stable angina pectoris., Methods: Two hundred seventy-five patients were recruited. Myocardial perfusion imaging was performed on 273 of the subjects. Chest pain was classified according to type by criteria given by the Danish Society of Cardiology and severity by the Canadian Cardiovascular Society. Pectoralis major and pectoralis minor were palpated for tenderness using a standardized procedure., Results: The association between tenderness and myocardial perfusion imaging (normal vs abnormal) produced an odds ratio (OR) of 2.24 (confidence interval, 1.26-3.99; P = .009). The OR was the same magnitude and significance when stratified by sex, age, type of pain, or class. When adjusting simultaneously for sex, age, type of pain, and class, the association between tenderness and myocardial perfusion imaging (normal vs abnormal) was still present (OR = 2.57; confidence interval, 1.342-4.902; P = .004)., Conclusion: Presence of tenderness in the anterior chest wall is associated with a higher prevalence of normal myocardial perfusion imaging in patients with known or suspected angina pectoris, and this association cannot be explained by a common association to age, sex, or pain.

Background: Acute chest pain is a major health problem all over the western world. Active approaches are directed towards diagnosis and treatment of potentially life threatening conditions, especially acute coronary syndrome/ischemic heart disease. However, according to the literature, chest pain may also be due to a variety of extra-cardiac disorders including dysfunction of muscles and joints of the chest wall or the cervical and thoracic part of the spine. The diagnostic approaches and treatment options for this group of patients are scarce and formal clinical studies addressing the effect of various treatments are lacking., Methods/design: We present an ongoing trial on the potential usefulness of chiropractic diagnosis and treatment in patients dismissed from an acute chest pain clinic without a diagnosis of acute coronary syndrome. The aims are to determine the proportion of patients in whom chest pain may be of musculoskeletal rather than cardiac origin and to investigate the decision process of a chiropractor in diagnosing these patients; further, to examine whether chiropractic treatment can reduce pain and improve physical function when compared to advice directed towards promoting self-management, and, finally, to estimate the cost-effectiveness of these procedures. This study will include 300 patients discharged from a university hospital acute chest pain clinic without a diagnosis of acute coronary syndrome or any other obvious cardiac or non-cardiac disease. After completion of the clinic's standard cardiovascular diagnostic procedures, trial patients will be examined according to a standardized protocol including a) a self-report questionnaire; b) a semi-structured interview; c) a general health examination; and d) a specific manual examination of the muscles and joints of the neck, thoracic spine, and thorax in order to determine whether the pain is likely to be of musculoskeletal origin. To describe the patients status with regards to ischemic heart disease, and to compare and indirectly validate the musculoskeletal diagnosis, myocardial perfusion scintigraphy is performed in all patients 2-4 weeks following discharge. Descriptive statistics including parametric and non-parametric methods will be applied in order to compare patients with and without musculoskeletal chest pain in relation to their scintigraphic findings. The decision making process of the chiropractor will be elucidated and reconstructed using the CART method. Out of the 300 patients 120 intended patients with suspected musculoskeletal chest pain will be randomized into one of two groups: a) a course of chiropractic treatment (therapy group) of up to ten treatment sessions focusing on high velocity, low amplitude manipulation of the cervical and thoracic spine, mobilisation, and soft tissue techniques. b) Advice promoting self-management and individual instructions focusing on posture and muscle stretch (advice group). Outcome measures are pain, physical function, overall health, self-perceived treatment effect, and cost-effectiveness., Discussion: This study may potentially demonstrate that a chiropractor is able to identify a subset of patients suffering from chest pain predominantly of musculoskeletal origin among patients discharged from an acute chest pain clinic with no apparent cardiac condition. Furthermore knowledge about the benefits of manual treatment of patients with musculoskeletal chest pain will inform clinical decision and policy development in relation to clinical practice., Trial Registration: NCT00462241 and NCT00373828.

Objective: To examine the association between changes in chest pain and changes in perfusion following revascularization as assessed by clinical evaluation and myocardial perfusion imaging (MPI) in patients with stable angina., Design: In a prospective series of 380 patients (58.8 +/- 8.8 years) referred to angiography because of known or suspected stable angina, changes in chest discomfort and changes in perfusion after 2 years were assessed in 144 patients, who underwent revascularization, and 236, who did not. The decision to treat invasively was made without knowledge of the result of MPI., Results: In revascularized patients, the presence of typical/atypical angina was reduced from 93% to 36% and the improvement was associated with improvement in perfusion. A small improvement in perfusion induced a high frequency of change from angina to no pain, whereas a further reduction caused little extra change. In non-revascularized patients the change in chest discomfort was not related to changes in perfusion, which were rarely present., Conclusion: Alleviation of chest discomfort 2 years after revascularization is associated with improvements in perfusion. This association appeared to be an all-or-nothing phenomenon. Non-revascularized patients also exhibited improvements in chest discomfort despite insignificant changes in perfusion.

Objective: To describe the Funen Neck and Chest Pain (FNCP) study and carry out a comprehensive non-response analysis of the quality of the survey., Methods: The FNCP questionnaire was sent out to 7000 randomly selected individuals aged 20-71 years living in Funen County, Denmark. A full description of the FNCP survey, analysis of selection bias (representativeness of the background population), selective bias (non-responder bias), and item non-response bias was performed by using Danish vital statistics., Results: The adjusted response rate was 60%. Men, retired individuals, and individuals with lower income tended to be late responders. Women, people aged 50+, married individuals, and individuals with two or three children, with a higher educational level, living in a single house or with a high income were more likely to participate. Conversely, men, younger individuals, singles or divorced persons, individuals living in residential caring homes, and with lower educational level were less likely to participate. Adjustments based on design and logical omissions gave an overall missing data rate of 1.0%. In general, the frequency of missing data increased with age and was higher for women. The frequency of inconsistent answers was 0.34%., Conclusions: A comprehensive non-response analysis showed some sociodemographic discrepancies between the FNCP study and the background population. The pattern of missing data was strongly associated with the design of the questionnaire and with participants' willingness to answer only questions they considered relevant. These factors must be taken into consideration when results from the FNCP study are presented.

We compared exercise electrocardiograms with myocardial perfusion images and coronary angiograms in 186 patients who had been referred to coronary angiography for stable angina pectoris. All had normal electrocardiographic findings at rest, and none had undergone coronary revascularization. Sensitivity, specificity, and positive and negative predictive values with the exercise electrocardiogram for prediction of reversible and/or irreversible hypoperfusion were 58%, 89%, 76%, and 77% and 70%, 88%, 72%, and 87%, respectively, for prediction of reversibility only. Corresponding values for comparison with coronary angiography were 65%, 89%, 74%, and 83%, respectively. Sensitivities were considerably lower in women than in men. Exercise electrocardiographic findings were normal in 50% of women and 25% of men who had reversible perfusion defects.