Denis Burelle

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 studys 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.

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

ObjectiveTo develop and validate a detection model to improve the probability of recognizing panic disorder in patients consulting the emergency department for chest pain.MethodsThrough 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 proceduce.ResultsPanic-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.ConclusionThe 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.

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.

A study of myocardial perfusion in patients with panic disorder and low risk coronary artery disease after 35% CO2 challenge.

BACKGROUND We have previously reported that 35% CO2 challenge induced myocardial ischemia in 81% of coronary artery disease (CAD) patients with comorbid panic disorder (PD) and previous positive nuclear exercise stress tests. However, it is yet unclear whether this is the case among CAD patients with PD and normal nuclear exercise stress test results. We hypothesized that a potent mental stressor such as a panic challenge among CAD patients with PD would also induce ischemia in patients with normal exercise stress tests. METHODS Forty-one coronary artery disease patients with normal nuclear exercise stress tests (21 patients with PD and 20 without PD) were submitted to a well-established panic challenge test (with 1 vital capacity inhalation of a gas mixture containing 35% CO2 and 65% O2) and injected with Tc-99m-tetrofosmin (Myoview), upon inhalation. Single photon emission computed tomography imaging was used to assess per-panic challenge reversible myocardial ischemia and HR, BP, and a 12 lead ECG was continuously measured during the procedure. RESULTS Fifty-eight percent of panic disorder patients (12/21) had a panic attack during the panic challenge vs 15% (3/20) of controls (p=0.005). Only 10% of patients in each group displayed myocardial ischemia per panic challenge. CONCLUSIONS These findings suggest that panic attacks among panic disorder patients with lower-risk coronary artery disease may not confer a risk for myocardial ischemia.

Silent ischemia: Silent after all?

OBJECTIVE To examine the association of nonpain symptoms in men and women with exercise-related silent ischemia, as well as the independence of these findings from other clinical factors. METHODS A prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging. Analyses were performed on 60 women and 155 men with no angina but medical perfusion imaging evidence of ischemia during exercise. MEASURES The presence of various non-pain-related symptoms. Ischemia is indicated by myocardial perfusion defects on exercise stress testing with single photon emission computed tomography. RESULTS Women reported more nonangina symptoms than men (P<0.05). They experienced fatigue, hot flushes, tense muscles, shortness of breath and headaches more frequently (P<0.05). Symptoms relating to muscle tension and diaphoresis were associated with ischemia after controlling for pertinent clinical covariates. However, the direction of association differed according to sex and history of coronary artery disease events or procedures. Sensitivity of the detection models showed modest improvements with the addition of these symptoms. CONCLUSIONS While patients who experience silent ischemia experience a number of nonpain symptoms, those symptoms may not be sufficiently specific to ischemia, nor sensitive in detecting ischemia, to be of particular help to physicians in the absence of other clinical information.

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.