The diagnostic value of oesophageal radionuclide transit in patients admitted for but without acute myocardial infarction.

The use of radionuclide transit (RT) as a screening test for chest pain of oesophageal origin has been debated. The aim of this study was to determine the value of RT as a screening test for oesophageal disorders in comparison with oesophageal manometry in patients admitted with acute chest pain but without acute myocardial infarction (non-AMI patients), and to assess the frequency of oesophageal disease present in these patients. A total of 222 non-AMI patients entered the study. An extensive examination programme comprised noninvasive cardiac studies, pulmonary studies, a careful physical examination of the musculoskeletal system, and oesophago-gastric examinations including endoscopy, pH monitoring of the oesophagus and a Bernstein test. In 91% of the patients one or more diagnoses were obtained. Based on clinical and laboratory data a 'consensus' diagnosis was made. With manometry as the reference RT had a poor sensitivity (35%) but an acceptable specificity (82%). With the consensus diagnosis as the gold standard the sensitivities of both manometry and RT were poor (29%), whereas the specificity of RT, but not of manometry, was very high (97%). Gastrointestinal diagnoses were found in 57% of the patients. In conclusion, none of the applied oesophageal examinations are valuable as single screening tests. Both RT and manometry have low sensitivities. RT may be used as a cheap, noninvasive and rapid supplementary examination. When positive, it strongly supports further invasive studies of the oesophagus in non-AMI patients with unexplained chest pain.

[The long-term prognosis of patients with acute chest pain of various origins]. / Langtidsprognosen for patienter med akutte brystsmerter af forskellig oprindelse.

A total of 204 patients with acute chest pain, but without myocardial infarction (non-AMI) were included. In 56 a definite diagnosis was obtained within 24-48 hours of admission. The remaining 148 patients underwent a comprehensive examination program. Ischaemic heart disease (IHD) was diagnosed in 64 patients, 81 had gastro-oesophageal disorders, 58 chest wall disorders, nine pericarditis, five pulmonary embolism, four pneumonia/pleuritis, three pulmonary cancer, two dissecting aortic aneurysm, one aortic stenosis and one herpes zoster. During 33 months of follow-up, 31 of the 64 patients with IHD had a cardiac event (cardiac deaths, non-fatal AMI, bypass surgery or PTCA) whereas only three events occurred among the 140 patients without IHD (p < 0.00001). However, the frequency of readmissions and of recurrent episodes of chest pain were similar in the three major diagnostic groups (NS). It is concluded that the high risk subset of a non-AMI population can be identified by means of non-invasive cardiac examination. The remainder who have other diagnoses are at low risk. However, the morbidity is high with frequent readmissions and recurrent episodes of chest pain, and the need for development of strategies with regard to diagnosis and treatment of these patients is emphasized.

Frequency of pulmonary embolism in patients admitted with chest pain and suspicion of acute myocardial infarction but in whom this diagnosis is ruled out.

The purpose of this study was to determine the frequency of pulmonary embolism in patients admitted with acute chest pain but without myocardial infarction (non-AMI patients). We examined 175 consecutive non-AMI patients without unstable angina pectoris within the first 48 h of admission. The patients were first examined by perfusion pulmonary scintigraphy. If the scintigraphy was abnormal, it was combined with a 81mKr ventilation scintigraphy. Perfusion scintigraphy was abnormal in 21 patients, and the subsequent combined perfusion/ventilation scintigraphy was used to identify 5 patients (2.5%) who had a high probability for pulmonary embolism, which was not clinically suspected at the time of admission. Three of these 5 patients had a decreased arterial oxygen tension upon admission, and 3 had abnormalities in their electrocardiogram. Pulmonary embolism only occurred in 2.5% of the non-AMI patients. The prognosis of untreated patients, however, it markedly worse as compared with treated patients. We, therefore, suggest that pulmonary scintigraphy be performed in non-AMI patients who have uncharacteristic electrocardiographic changes and/or a low arterial partial oxygen tension when no other abnormality has been found within 24 h of admission.

The diagnoses of patients admitted with acute chest pain but without myocardial infarction.

OBJECTIVE: The purpose of this study was to describe the frequencies of various diagnoses in patients admitted with acute chest pain, but without acute myocardial infarction, and to evaluate a non-invasive screening programme for these patients. PATIENTS: A total of 204 consecutive non-acute myocardial infarction patients were included. Fifty-six had a definite diagnosis within 48 h, whereas 148 patients underwent an examination programme including pulmonary scintigraphy, echocardiography, exercise electrocardiography, myocardial scintigraphy, Holter monitoring, hyperventilation test, oesophago-gastro-duodenoscopy, 3 h monitoring of oesophageal pH, oesophageal manometry, Bernstein test, physical examination of the chest wall and thoracic spine, bronchial histamine provocation test and ultrasonic examination of the abdomen. RESULTS: According to predefined criteria, 186 patients (91%) had at least one diagnosis, 144 had one, whereas 39 had two, and three patients had three diagnoses. In 18 patients no diagnosis was obtained. The diagnoses belonged mainly to three groups: (1) ischaemic heart disease (n = 64); (2) gastro-oesophageal diseases (n = 85); (3) chest-wall syndromes (n = 58). Less frequent diagnoses included pulmonary embolism, pleuritis/pneumonia, lung cancer, aortic stenosis, aortic aneurysm and herpes zoster. CONCLUSIONS: The high risk subset of a non-acute myocardial infarction population can be identified by means of a clinical evaluation and non-invasive cardiac examinations. Among the remainder, pulmonary embolism, gastro-oesophageal diseases and chest-wall syndromes should be paid special attention. A careful physical examination of the chest wall and upper endoscopy seems to be the most cost-beneficial examination to employ in this subset.

Long-term risk of death, cardiac events and recurrent chest pain in patients with acute chest pain of different origin.

The purpose of the study was to describe the prognosis of patients with acute chest pain of different origin, but without myocardial infarction (non-AMI). A total of 204 patients were included. In 56, a definite diagnosis was obtained within 24-48 H of admission. The remaining 148 patients underwent the following examinations: exercise test, myocardial scintigraphy, echocardiography, Holter monitoring, hyperventilation test, oesophago-gastro-duodenoscopy, oesophageal manometry, oesophageal pH monitoring, Bernstein test, physical chest wall examination, bronchial histamine test, chest X-ray and ultrasonic upper abdominal examination. Ischaemic heart disease (IHD) was diagnosed in 64 patients, 81 had gastro-oesophageal disorders, 58 chest wall disorders, 9 pericarditis, 5 pulmonary embolism, 4 pneumonia/pleuritis, 3 pulmonary cancer, 2 dissecting aortic aneurysm, 1 aortic stenosis and 1 herpes zoster. During follow-up of 33 months, 31 of the 64 patients with IHD had a cardiac event (cardiac deaths, non-fatal AMI, bypass surgery or PTCA), whereas only 3 event occurred among the 140 patients without IHD (p < 0.00001). However, the frequency of readmissions and of recurrent episodes of chest pain were similar in the 3 major diagnostic groups (NS). To conclude, the high-risk subset of a non-AMI population can be identified by means of non-invasive cardiac examination. The remainder who have other diagnoses are at low risk. However, the morbidity is high with frequent readmissions and recurrent episodes of chest pain and the need for development of strategies with regard to diagnosis and treatment of these patients are emphasized.

[10-year mortality of patients admitted to coronary units with or without confirmed diagnosis of myocardial infarction. A relation to anamnesis and diagnosis at discharge]. / Tiårsmortalitet for patienter indlagt på koronarafsnit med og uden bekaeftet akut myokardieinfarkt. Relation til anamnese og udskrivelsesdiagnose.

The ten-year mortality in patients with suspected myocardial infarction with (AMI) and without (non-AMI) confirmed diagnosis was evaluated in 1897 non-AMI patients and 1401 AMI patients who were consecutively admitted to hospital during The Danish Verapamil Infarction Study. The following risk factors contained independent prognostic information about mortality for non-AMI patients: age, previous AMI, sex and diabetes. In patients with AMI the risk factors were: age, previous AMI, clinical heart failure, diabetes and angina pectoris. When the diagnosis at discharge for non-AMI patients was included in the Cox-analysis, only the diagnoses of bronchopneumonia, musculoskeletal disorders and observation only of added prognostic information. We conclude that non-AMI patients are at high risk for mortal events in the long-term. High risk patients can be identified from the medical history and should be carefully evaluated regarding coronary artery disease at the time of discharge in order to improve the risk stratification, treatment and prognosis.

Long-term risk factors from non-invasive evaluation of patients with acute chest pain, but without myocardial infarction.

The aims were to identify long-term risk factors for cardiac events, i.e. cardiac death and non-fatal acute myocardial infarction (AMI), and for development of angina pectoris among patients admitted with acute chest pain, but without confirmed AMI (non-AMI). A total of 257 consecutive non-AMI patients without other severe disease and below 76 years of age were included. Medical history and variables from the ECG while exercising, thallium scintigrams, Holter-monitoring, echocardiography and chest X-ray were recorded. The patients were followed for 7 years regarding cardiac death, non-fatal AMI and development of angina pectoris. The variables recorded at admission were compared to follow-up results by means of Uni- and multivariate analyses. During follow-up, 69 cardiac events, 44 cardiac deaths and 25 non-fatal AMIs occurred. The following variables provided independent prognostic information (relative risk factors with 95% confidence limits in brackets): age (1.05, 1.01-1.09), abnormal ECG at rest (2.81, 1.33-5.90), low increase in rate pressure product (4.57, 2.21-9.44), multiform premature ventricular beats (VPB) (2.61, 1.34-5.09) and transient thallium defects (2.64, 1.33-5.24). Sub-analysis of patients with and without a history of coronary artery disease (CAD) prior to admission identified the following risk factors: (1) Patients with previous CAD: abnormal ECG on admission, low increase in rate pressure product, ST depression during exercise. (2) Patients without previous CAD: abnormal ECG at rest, multiform VPBs and low increase in rate pressure product. Development of angina pectoris during follow-up of patients without previous CAD could not be predicted by any of the variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Ten year mortality in patients with suspected acute myocardial infarction.

OBJECTIVE: To describe the 10 year mortality in patients with suspected acute myocardial infarction. DESIGN: Follow up of all patients below 76 years of age admitted with acute chest pain to 16 coronary care units participating in the Danish verapamil infarction trial in 1979-81. SUBJECTS: Of the 5993 patients included, 2586 had definite infarction, 402 had probable infarction, and 3005 did not have infarction. MAIN OUTCOME MEASURES: Death and cause of death. Standardised mortality ratio (observed mortality/expected mortality in background population). RESULTS: The estimated 10 year mortalities were 58.8%, 55.5%, and 42.8% in patients with definite, probable, and no infarction, respectively (P < 0.0001). Stratified Cox's analysis identified a hazard ratio for mortality of 1.25 (95% confidence interval 1.08 to 1.44) for probable infarction compared with no infarction and of 1.15 (1.00 to 1.32) for definite compared with probable infarction. The standardised mortality ratio in the first year was 7.1 (6.5 to 7.8) for definite infarction, 5.0 (3.6 to 6.3) for probable infarction, and 4.7 (4.2 to 5.2) for no infarction. From the second year and onwards the annual standardised mortality ratio in the three groups did not differ significantly. Cardiac causes of deaths were recorded in 89%, 84%, and 71% of the deaths in patients with definite, probable, and no infarction, respectively. CONCLUSIONS: The 10 year mortality of patients with and without infarction is significantly higher than in the background population. Most deaths are caused by coronary heart disease, and these patients should consequently be further evaluated at the time of discharge and followed up closely.

[Long-term prognosis in patients with acute chest pain. The predictive value of myocardial scintigraphy]. / Langtidsprognosen for patienter med akutte brystsmerter. Den proediktive voerdi af myokardieskintigrafi.

UNLABELLED: In order to perform risk stratification 158 patients with acute chest pain, but without myocardial infarction (non-AMI) underwent exercise 201-thallium scintigraphy at the time of discharge. The patients, of whom 38 (24%) were women, were followed for seven years. The diagnostic sensitivity, specificity and predictive values of the outcome of the examination for identification of patients, who had a cardiac event (cardiac death or later non-fatal AMI) during follow-up, was calculated. Forty-one had a cardiac event during follow-up. The highest sensitivity (85%) was achieved by the combination of transient defect and/or persistent defect and/or abnormal ST-segment response. The highest specificity was provided by a transient defect (90%) and the predictive value of a positive test was 60%-17 of 29 patients with a transient defect had a cardiac event during follow-up. Patients with a normal test had an excellent prognosis, 94% of 82 patients were free of cardiac events during follow-up. CONCLUSIONS: Exercise 201-thallium scintigraphy is suitable for long-term risk stratification in patients with chest pain and suspicion of but unconfirmed myocardial infarction, because high and very low risk subsets can be identified at the time of discharge.

Characteristics of 46 heterozygous carriers and 57 unaffected relatives in five Danish families with familial defective apolipoprotein B-100.

Plasma concentrations of cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, apolipoprotein (apo) B, and lipoprotein(a) (Lp[a]) in 46 persons heterozygous for the apo B-3500 mutation causing familial defective apo B-100 (FDB) were compared with those in 57 non-FDB relatives. FDB patients had 50% to 70% higher mean concentrations of cholesterol, LDL cholesterol, and apo B than non-FDB relatives (P < 10(-4) for all three variables). Triglycerides were higher (P = .016) and HDL cholesterol was lower (P = .021) in FDB patients. The concentration ranges of these variables were broad in each family, and there was no between-family difference in means for cholesterol and LDL cholesterol. There was no phenotype-specific difference in Lp(a) concentrations between FDB patients and non-FDB relatives. Apo E4 is normally associated with higher concentrations of LDL and apo E2 with lower concentrations. This relation was partly reversed in FDB patients: apo E4 was associated with lower apo B concentrations and apo E2 with higher apo B concentrations. Tendon xanthomata were found in members of two of the five families. Six of 12 FDB patients > 50 years old had atherosclerotic disease. In contrast, all 18 non-FDB relatives > 50 years old were apparently healthy. A total of 8 FDB patients with atherosclerotic disease had 36% higher cholesterol concentrations, 28% higher apo B concentrations, 50% higher triglyceride concentrations, and 120% higher Lp(a) concentrations than FDB patients without clinical atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Ten-year mortality of patients admitted to coronary care units with and without myocardial infarction. Risk factors from medical history and diagnosis at discharge. DAVIT-Study Group. Danish Verapamil Infarction Trial.

The purpose was to evaluate the 10-year mortality in patients with acute chest pain suspected of myocardial infarction with (AMI) and without (non-AMI) confirmed diagnosis and to determine risk factors from the medical history and the diagnosis at discharge. One-thousand eight-hundred and ninety-seven non-AMI patients and 1,401 patients with AMI consecutively admitted to 1 of 16 coronary care units participating in The Danish Verapamil Infarction Study were included. During follow-up, 630 deaths occurred among the non-AMI patients and 415 of these could be classified as cardiac deaths. Multivariate analysis identified the following risk factors containing independent prognostic information about mortality for non-AMI patients: age, previous AMI, sex, and diabetes. In patients with AMI the risk factors were: age, previous AMI, clinical heart failure, diabetes, and angina pectoris. By including the diagnosis at discharge for non-AMI patients in the Cox analysis, the prognostic significance was compared to the variables from the medical history. Only the diagnoses bronchopneumonia, musculoskeletal disorders and observatio sine indicatione therapiae added independent prognostic information. We conclude that non-AMI patients are at high risk for mortal events in the long term. High-risk patients can be identified from their medical history, whereas the diagnosis at discharge only adds limited prognostic information. All non-AMI patients should be carefully evaluated regarding coronary artery disease at the time of discharge in order to improve the risk stratification, treatment and prognosis.

[Long-term prognosis of patients with suspected myocardial infarction confirmed and not confirmed by diagnosis]. / Langtidsprognosen for patienter mistaenkt for akut myokardieinfarkt med og uden bekraeftet diagnose.

This study prospectively evaluates the long-term prognosis of patients admitted with chest pain under suspicion of acute myocardial infarction (AMI) with and without confirmed diagnosis. Altogether 275 patients with and 257 patients without confirmed AMI (non-AMI) were consecutively included. During seven years of follow-up 122 cardiac events occurred in the AMI patients (i.e. 96 cardiac deaths and 26 nonfatal-AMI), and 69, occurred in the non-AMI patients (44 cardiac deaths and 25 non-fatal AMI). In multivariate Cox-analysis the following risk factors contained independent prognostic information for non-AMI patients: 1) a history of angina pectoris and 2) ST or T changes in the ECG on admission. In patients with AMI the risk factors were 1) previous AMI and 2) clinical heart failure. We conclude that a subset of non-AMI patients who have an increased long-term risk of cardiac events, can be identified from the medical history and the ECG at admission. These patients should be carefully evaluated prior to discharge.

Seven-year prognostic value of the electrocardiogram at rest and an exercise test in patients admitted for, but without, confirmed myocardial infarction.

The seven-year prognosis for cardiac events (non-fatal acute myocardial infarction (AMI) or cardiac death) following discharge was related to an electrocardiogram (ECG) at rest and a symptom-limited exercise test in 217 patients admitted with chest pain without confirmed AMI. The follow-up time was 86-98 months, median 88 months. Although the 7-year prognosis was better than in a comparable group of patients with AMI (P < 0.0001), the frequency of cardiac events was still very high. Patients with negative T waves, ST depression or elevation, intraventricular block or Q waves at rest, ST abnormalities during exercise or both constituted a high-risk group. In patients without these ECG abnormalities the prognosis was significantly better (P << 0.0001). The percentages without cardiac events after 7 years were 53 and 92 respectively. Patients with a low rise in the rate-pressure product indicative of decreased function of the left ventricle and patients who developed angina pectoris during exercise also had a significantly impaired 7-year prognosis. This non-invasive approach to risk stratification identified a group of non-AMI patients with a high risk for cardiac events, and a group comprising more than 50% of the patients with a very low risk.

The long-term predictive value of an exercise thallium-201 scintigraphy for patients with acute chest pain but without myocardial infarction.

BACKGROUND: Patients who are hospitalized because of chest pain and suspected acute myocardial infarction, but in whom the diagnosis is ruled out, are at high risk for subsequent cardiac events (cardiac death or nonfatal acute myocardial infarction). Risk stratification was done for 158 such patients who underwent exercise thallium-201 scintigraphy at the time of discharge. METHODS: Thirty-eight patients (24%) were women, and all patients were followed for 7 years. The diagnostic sensitivity, specificity, and predictive value of thallium scintigraphy for the identification of patients having subsequent cardiac events during follow-up was calculated. RESULTS: A cardiac event occurred in 41 patients during the follow-up period. Presence of both transient and permanent defects and abnormal ST-segment responses during thallium scintigraphy were significantly associated with an impaired prognosis (P < 0.0001). The highest sensitivity (85%) was achieved by the combination of transient defect with or without persistent defect and with or without abnormal ST-segment response. The highest specificity was provided by a transient defect (90%), and the predictive value of a positive test result was 60%. Seventeen of 29 patients with a transient defect had a cardiac event during follow-up. Patients with normal test results had excellent prognoses; 93% of 82 patients were free of cardiac events during follow-up. CONCLUSIONS: Exercise thallium-201 scintigraphy is suitable for long-term risk stratification in patients with chest pain and suspected but unconfirmed myocardial infarction, because high- and very low-risk subsets can be identified at the time of discharge.

Long-term cardiac mortality in patients admitted with noncoronary chest pain under suspicion of acute myocardial infarction.

The long-term prognosis for cardiac death was prospectively evaluated in three subpopulations admitted to a coronary care unit with chest pain under suspicion of acute myocardial infarction (AMI) with (1) confirmed AMI (n = 275), (2) AMI ruled out, but suspicion of coronary artery disease (n = 257) and (3) AMI ruled out and an obvious noncoronary reason for chest pain (n = 63). The latter subgroup included patients with pericarditis, valvular disease, arrhythmia, pneumonia, pulmonary embolism, gastric ulcer and musculoskeletal disorders. The 7-year cardiac mortality rates of the three subpopulations were 34, 17 and 32%, respectively (p < 0.0001). Despite the 'benign' nature of the chest pain, the cardiac mortality was high in all diagnostic categories of noncoronary chest pain. In conclusion, patients admitted with chest pain of apparently noncoronary origin are at high risk for later cardiac death. This indicates the presence of severe coronary artery disease in some of the patients. Consequently, all patients with chest pain and AMI ruled out should be evaluated carefully regarding coronary artery disease at the time of discharge.

Sensitivity and specificity of echocardiographic identification of patients eligible for safe early discharge after acute myocardial infarction.

In a prospective clinical trial of 195 consecutive unselected patients with acute myocardial infarction (AMI), systematic blinded clinical and echocardiographic examinations were performed by two observers on day 5. The purpose was to define low-risk patients with regard to in-hospital and 2-month mortality and predict the potential costs (lost patient lives) and benefits (saved in-patient days) if as a routine procedure these low-risk patients were discharged earlier. By design, low-risk patients as defined by clinical criteria were allocated to discharge on days 7 to 10 and by echocardiographic criteria on days 5 to 7 after AMI. The sensitivity of the echocardiographic low-risk identification procedure was more than twofold higher than the sensitivity of clinical low-risk identification (49% vs 24%). Both procedures were safe with a specificity of 100% for cardiac mortality. Optimal identification of low-risk patients was provided by combining data from echocardiographic and clinical evaluations (sensitivity 59%). Results of the study suggest that a bedside echocardiographic approach to estimation of global left ventricular function is more sensitive and equally specific and therefore more efficient for risk stratification on post-AMI day 5 than clinical examination alone. Thus echocardiographic examination allows identification of a larger subset of patients with AMI (greater than 40% of the population alive on day 5) who can be discharged earlier and safely, with a potential saving of in-patient days of 436 days in 87 low-risk patients minus the cost of echocardiographic studies in 195 patients. However, the best prediction was obtained by combining clinical and echocardiographic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early discharge after acute myocardial infarction. Cost-effectiveness of early echocardiographic risk evaluation]. / Tidlig udskrivelse efter akut myokardieinfarkt. Cost-effectiveness af tidlig ekkokardiografisk risikobedømmelse.

A total of 195 consecutive patients with acute myocardial infarction were examined and risk classified (low or middle/high risk) on the fifth day by two physicians. These two physicians employed two different sets of criteria: conventional clinical examination compared with 2-D echocardiographic assessment of the wall motion of the left ventricle (wall motion index, WMI). Both physicians concluded their examination by determination of a theoretical time for discharge. By design this was on the 5th-7th days for low risk patients by echocardiography, while low risk patients by clinical criteria are normally discharged on the 7th to 8th days. The most sensitive method of identifying the low risk patients was achieved by combining the clinical examination with echocardiographic WMI determination. In this manner, a total of 104 (53%) low risk patients could be identified. A potential saving of 18% of the total duration of hospitalization could be calculated from the two theoretical times of discharge for the total population. All of the patients in this study could be assessed by echocardiography which provided valuable information and thus may be implemented in the routine treatment of acute myocardial infarction.

[Relation between 1-year mortality after acute myocardial infarction and left ventricular ejection function estimated by echocardiography]. / Sammenhaengen mellem et-års mortalitet efter akut myokardieinfarkt og venstre ventrikels pumpefunktion bedømt med ekkokardiografi.

The pump function of the left ventricle was characterized by means of early echocardiographic determination of the motion of the ventricular walls (wall motion index, WMI) in a consecutive unselected series of 195 patients with acute myocardial infarction. The pump function, WMI, was related to one-year mortality after infarction. The patients were subdivided prospectively into three risk groups (low, middle and high) depending on WMI. One-year mortality in the three groups were 2%, 34% and 37%, respectively (p less than 0.0001). Patients with previous infarcts had significantly lower WMI and greater one-year mortality than patients with first infarct (p less than 0.001 and less than 0.05, respectively). Among patients with first infarct with inferior localization, significantly higher WMI and lower one-year mortality were found than with anterior localization (p less than 0.001 and = 0.15, respectively, (NS)). Women had significantly higher one-year mortality than men (30.2% compared with 16.9% (p less than 0.04)) although this was reflected by a corresponding difference in WMI. Regardless of sex, age, localization of the infarct and signs of residual ischaemia, patients who were allocated to the low risk group solely on the basis of WMI, had particularly good prognoses. Among patients with more extensive myocardial damage, WMI less than or equal to 1.3, other risk factors probably played a greater role.

[Acute recurrent chest pain originating in the esophagus. A review]. / Akutte og recidiverende brystsmerter udløstsmeter udløst fra esophagus.e En overightkikel.

In half of the patients admitted for observation for acute myocardial infarction, this diagnosis is disproved. Gastro-oesophageal reflux and/or disturbances of oesophageal motility are the cause of the thoracic pain resulting in hospitalization in 16-34% of these patients. In 13-59% of the patients with chronic recurrent thoracic pain without demonstrable ischaemic cardiac disease (IHD), oesophageal disease is, similarly, considered to be the cause of the pain. It is not possible to distinguish whether the pain is caused by oesophageal disease or IHD on the basis of the history, but the differential diagnosis is important as patients with pain on account of oesophageal disease have a good prognosis as regards mortality. The physical and mental conditions of the patients may be improved if the correct diagnosis is established and treatment instituted. Methods of examination to demonstrate oesophageal disease are described. On account of the frequency of the condition and the extent of the methods of examination, a programme of investigation is proposed for patients suspected of having thoracic pain due to oesophageal disease.

Risk factors related to the 7-year prognosis for patients suspected of myocardial infarction with and without confirmed diagnosis.

This study prospectively evaluates the long-term prognosis of patients admitted with chest pain under suspicion of acute myocardial infarction (AMI) with and without confirmed diagnosis. All patients below 76 years of age, free of other severe diseases and alive at discharge, who were admitted to a coronary care unit of a well-defined region during 1 year, constituted the study population. In all, 275 patients with and 257 patients without confirmed AMI (non-AMI) were included. During 7 years of follow-up, 122 cardiac events (96 cardiac deaths and 26 nonfatal AMI) occurred in the AMI patients, and 69 (44 cardiac deaths and 25 nonfatal AMI) were observed in the non-AMI patients. Using univariate analysis, the following risk variables were significantly related to an impaired prognosis of non-AMI patients: age, a history of previous AMI, angina pectoris, clinical heart failure, diabetes and ST or T changes in the electrocardiogram (ECG) on admission. By multivariate analysis, the following risk factors contained independent prognostic information for non-AMI patients: (1) a history of angina pectoris and (2) ST and T changes on the ECG on admission. We conclude that a subset of non-AMI patients at high risk for cardiac events even in the long term can be identified from the medical history and the ECG on admission. These patients should be carefully evaluated prior to discharge, whereas patients without signs of ischemic heart disease have an excellent prognosis.