Panic disorder in coronary artery disease patients with noncardiac chest pain.

In this study we address the following questions: (1) What percentage of coronary artery disease (CAD) patients that present with chest pain, but whose symptoms cannot be fully explained by their cardiac status, suffer from panic disorder (PD)? (2) How do patients with both CAD and PD compare to patients without CAD and to patients without either PD or CAD in terms of psychological distress? Four hundred forty-one consecutive walk-in emergency department patients with chest pain underwent a structured psychiatric interview (ADIS-R) and completed psychological scales. Fifty-seven percent (250 of 441) of these patients were diagnosed as having noncardiac chest pain and constituted this study's sample. A total of 30% (74 of 250) of noncardiac chest pain patients had a documented history of CAD. Thirty-four percent (25 of 74) of CAD patients met criteria for PD. Patients with both PD and CAD displayed significantly more psychological distress than CAD patients without PD and patients with neither CAD nor PD. However, they did not differ from non-CAD patients with PD. PD is highly prevalent in patients with CAD that are discharged with noncardiac diagnoses. The psychological distress in these patients appears to be related to the panic syndrome and not to the presence of the cardiac condition.

Remnants of the right valve of the sinus venosus presenting as a right atrial mass on transthoracic echocardiography.

Three patients were referred for suspicion of intracardiac tumour on transthoracic echocardiography. In all patients, the mass appeared as a nonobstructive oval structure measuring approximately 12 x 4 mm, located near the posterior third of the interatrial septum in the right atrium in the apical four-chamber view. The characteristics of the mass were not those of a Eustachian valve or a Chiari network. Multiplane transesophageal echocardiography performed in each of these patients did not reveal a tumour but rather a fibrous band in the right atrium, extending from the inferior to the superior vena cava. These findings are consistent with remnants of the right valve of the sinus venosus. Inclusion of a persistent right valve of the sinus venosus in the differential diagnosis of a right atrial mass can alleviate concern and spare an unnecessary transesophageal examination when the typical transthoracic echocardiographic characteristics are identified.

Detecting panic disorder in emergency department chest pain patients: a validated model to improve recognition.

OBJECTIVE: To develop and validate a detection model to improve the probability of recognizing panic disorder in patients consulting the emergency department for chest pain. METHODS: Through logistic regression analysis, demographic, self-report psychological, and pain variables were explored as factors predictive of the presence of panic disorder in 180 consecutive patients consulting an emergency department with a chief complaint of chest pain. The detection model was then prospectively validated on a sample of 212 patients recruited following the same procedure. RESULTS: Panic-agoraphobia (Agoraphobia Cognitions Questionnaire, Mobility Inventory for Agoraphobia), chest pain quality (Short Form McGill Pain Questionnaire), pain loci, and gender variables were the best predictors of the presence of panic disorder. These variables correctly classified 84% of chest pain subjects in panic and non-panic disorder categories. Model properties: sensitivity 59%; specificity 93%; positive predictive power 75%; negative predictive power 87% at a panic disorder sample prevalence of 26%. The model correctly classified 73% of subjects in the validation phase. CONCLUSION: The scales in this model take approximately ten minutes to complete and score. It may improve upon current physician recognition of panic disorder in patients consulting for chest pain.

Transthoracic echocardiographic assessment of periprosthetic mitral regurgitation using intravenous injection of sonicated albumin.

Mechanical prostheses induce artifacts that decrease the accuracy of conventional transthoracic echocardiographic imaging for the detection and quantitation of periprosthetic mitral regurgitation. In 15 patients undergoing transthoracic echocardiography, injection of sonicated albumin significantly enhanced the assessment of periprosthetic mitral regurgitation with an accuracy similar to that of transesophageal echocardiography.

Nifedipine gastrointestinal therapeutic system (GITS) for hypertensive patients in a primary care setting: results of the Extended Release Adalat Canadian Trial (EXACT).

Nifedipine gastrointestinal therapeutic system (GITS) is an extended-release dosage formulation that provides sustained blood concentrations of nifedipine over 24 hours. A 20-week, postmarketing surveillance study of the effectiveness and patient tolerability of nifedipine GITS 30 or 60 mg was conducted in the offices of 187 Canadian general practitioners from September 1992 to March 1994. A total of 1700 patients previously or newly diagnosed with mild-to-moderate essential hypertension (sitting diastolic blood pressure, 95 to 114 mm Hg) were included. The 20-week treatment period was completed by 1326 patients. Patients received nifedipine GITS 30 mg initially; the dose could be titrated upward to 60 mg after 3 and 6 weeks. Of all patients entered, 605 (35.6%) reported one or more adverse events. The three most frequently occurring adverse events were headache (12.2%), peripheral edema (8.1%), and dizziness (2.9%). The frequency of adverse events was highest in the first 3 weeks and decreased subsequently. The overall incidence of adverse events was 29.8% in patients receiving 30 mg of nifedipine GITS and 25.3% in those receiving 60 mg; adverse events were the cause of study discontinuation in 12.3% of patients. The overall health status of patients as measured by the SF-36 questionnaire was comparable to that previously reported for healthy individuals. At baseline, mean (+/- SE) systolic/diastolic blood pressure values for all patients were 160.1 +/- 0.4/97.4 +/- 0.2 mm Hg. Final blood pressure readings after 20 weeks of treatment in the 30-mg group (141.5 +/- 0.4/84.8 +/- 0.2 mm Hg) and the 60-mg group (146.6 +/- 0.8/88.8 +/- 0.4 mm Hg) were significantly decreased from baseline. At week 20, the 30-mg dose was sufficient to maintain blood pressure in 74.5% of patients; 25.5% of patients required 60 mg. Subgroup analysis revealed similar responses in patients who had received blood pressure medication before study initiation and those who had not. Response was also independent of age and type of previous antihypertensive therapy. In general medical practice, the 30-mg and 60-mg doses of nifedipine GITS were both effective and well tolerated and had minimal or no negative effects on the overall health status of treated individuals.

Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition.

PURPOSE: To establish the prevalence of panic disorder in emergency department (ED) chest pain patients; compare psychological distress and recent suicidal ideation in panic and non-panic disorder patients; assess psychiatric and cardiac comorbidity; and examine physician recognition of this disorder. DESIGN: Cross-sectional survey (for psychiatric data). Prospective evaluation of patient discharge diagnoses and physician recognition of panic disorder. SETTING: The ambulatory ED of a major teaching hospital specializing in cardiac care located in Montreal, Canada. SUBJECTS: Four hundred and forty-one consenting, consecutive patients consulting the ED with a chief complaint of chest pain. PRIMARY OUTCOME MEASURE: Psychiatric diagnoses (AXIS I). Psychological and pain test scores, discharge diagnoses, and cardiac history. RESULTS: Approximately 25% (108/441) of chest pain patients met DSM-III-R criteria for panic disorder. Panic disorder patients displayed significantly higher panic-agoraphobia, anxiety, depression, and pain scores than non-panic disorder patients (P < 0.01). Twenty-five percent of panic disorder patients had thoughts of killing themselves in the week preceding their ED visit compared with 5% of the patients without this disorder (P = 0.0001) even when controlling for co-existing major depression. Fifty-seven percent (62/108) panic disorder patients also met criteria for one or more current AXIS I disorder. Although 44% (47/108) of the panic disorder patients had a prior documented history of coronary artery disease (CAD), 80% had atypical or nonanginal chest pain and 75% were discharged with a "noncardiac pain" diagnosis. Ninety-eight percent of the panic patients were not recognized by attending ED cardiologists. CONCLUSIONS: Panic disorder is a significantly distressful condition highly prevalent in ED chest pain patients that is rarely recognized by physicians. Nonrecognition may lead to mismanagement of a significant group of distressed patients with or without coronary artery disease.

[Is the quantification of mitral valve involvement by transesophageal echography useful before percutaneous mitral commissurotomy?]. / La quantification de l'atteinte valvulaire mitrale par échographie transoesophagienne est-elle utile avant commissurotomie mitrale percutanée?

The aims of this study were to determine the value of quantifying mitral valve disease by transoesophageal echocardiography before percutaneous mitral commissurotomy (PMC) and to analyse the incidence of embolic complications during PMC since the introduction of transoesophageal echocardiography. From March 1987 to December 1991, 317 patients with pure or dominant mitral stenosis were selected by Doppler echocardiography to undergo PMC at the Montreal Institute of Cardiology. The clinical features of the first 138 patients (Group I) were the same as those of the last 179 patients (Group 2) who also underwent routine transoesophageal echocardiography the day before the procedure. A thrombus in the left atrial appendage was observed in 8 patients in Group 2 (4.4%). No embolic complications have occurred since the protocol was changed to include routine transoesophageal echocardiography, whereas 4 embolic episodes, 3 of which were fatal, occurred in patients in group 1. The indication of PMC was turned down because of angiographically severe mitral regurgitation which was underestimated by transthoracic echocardiography in 2 patients in Group 1 (1.4%) and in 3 patients in group 2 (1.6%). The mobility, thickness and degree of calcification of the valves were attributed a score from 0-4 at transthoracic and transoesophageal echocardiography. No difference was observed in the scores of mobility (2.3 +/- 0.5 versus 2.3 +/- 0.05, NS) or valve thickness (2.1 +/- 0.4 versus 2.1 +/- 0.4, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Panic disorder, chest pain and coronary artery disease: literature review.

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.

Results of percutaneous mitral commissurotomy in patients with a left atrial appendage thrombus detected by transesophageal echocardiography.

To evaluate whether the presence of a left atrial appendage (LAA) thrombus increases the embolic risk of percutaneous mitral commissurotomy (PMC), we reviewed 240 transesophageal echocardiographic studies performed before intended PMC for mitral stenosis. We found 14 patients (5.8%) with left atrial clots, 12 located in the LAA (none detected by transthoracic echocardiography [TTE]) and two in the body of the left atrium. In the two patients who had a left atrial body thrombus, TTE did not unequivocally show the thrombus. Seven patients with an LAA thrombus underwent PMC by the double-balloon technique. The hemodynamic and echocardiographic results were comparable to those of the larger series. No embolic complications were noted either during the procedure, in the 48 hours of observation after the procedure, or at a mean follow-up of 12 months. We conclude that PMC by the double-balloon technique can be performed safely in patients with an LAA thrombus who have been given anticoagulants. Transesophageal echocardiography is still indicated before PMC because TTE is suboptimal for detection of left atrial clots.