CHEST PAIN AT REST IN PATIENTS WITH CORONARY-ARTERY DISEASE - MYOCARDIAL-ISCHEMIA, ESOPHAGEAL DYSFUNCTION, OR PANIC DISORDER

Severe nonexertional (resting) chest pain may be due to myocardial isc hemia, esophageal dysfunction, psychiatric disorder, or any combinatio n thereof and frequently poses a difficult diagnostic challenge. Our a im was to investigate causes of chest pain in patients with coronary a rtery disease. Forty-five patients with angiographically proven obstru ctive coronary lesions and recurrent chest pain at rest were studied; 18 had refractory pain despite cardiac therapy (problem group), and 27 had documented myocardial ischemia (control group). Esophageal manome try, edrophonium provocation, 24-hr pH studies, and psychiatric interv iew were performed in all patients. The clinical evolution and the out come of specific treatment during follow-up was used to establish the etiology of chest pain. Esophageal dysfunction was identified in all p roblem patients and in 52% of controls, and the esophagus was incrimin ated as the source of pain in 8 (44%) and 5 (18.5%), respectively. Aft er a mean follow-up of 49 months (range 24-76 months), the cause of ch est pain in the problem group was identified as panic disorder in 9 pa tients (50%), gastroesophageal reflux in 6 (33%), esophageal dysmotili ty in 2 (11%), and gallstone disease in 1 (6%). Of the control patient s, 18 (67%) had ischemic pain alone, while 9 had concurrent causes: pa nic disorder in 5 (19%) and esophageal dysfunction in 4 (15%). Esophag eal dysfunction and psychiatric disturbances are common in patients wi th coronary artery disease presenting with resting chest pain, and may contribute to patients' symptoms.