今日の臨床サポート

胸痛

著者: 山田直樹 福井大学医学部附属病院 救急部

監修: 志賀隆 国際医療福祉大学 医学部救急医学/国際医療福祉大学病院 救急医療部

著者校正/監修レビュー済:2021/02/10
患者向け説明資料

概要・推奨   

  1. 病歴だけからは急性冠症候群(ACS)を診断することはできないが、いくつかの病歴(右肩への放散、発汗、胸壁の圧痛がない、など)に特に注意することは、ACSの診断および除外におそらく有用である(推奨度2)
  1. アクティブな胸痛があるときの心電図が正常であったとしても、ACSを決して除外すべきではない(推奨度4)
  1. 初回心筋酵素が陰性であるからという所見だけで、決してACSを除外すべきではない(推奨度4)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山田直樹 : 特に申告事項無し[2021年]
監修:志賀隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 2020年改訂版 ⼤動脈瘤・⼤動脈解離診療ガイドラインに基づいて、大動脈解離の診断について加筆した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 胸痛は救急外来で頻回に遭遇する主訴の1つであり、米国救急外来のデータによると、2番目に多い訴えである。
  1. 原因疾患は比較的多岐にわたるが、救急外来では常に緊急性の高い疾患から除外していく姿勢を忘れないことが重要である。
  1. 不安定な要素が少しでもある患者では、簡潔な病歴聴取と身体所見に続いて、必要な検査を速やかに行うことを心掛ける。詳細な病歴聴取と身体所見は後回しでよい。
  1. 緊急性の高い疾患が鑑別疾患として多いため、病歴・身体所見・心電図やX線などで少しでも疑いがあれば、さらなる検査や治療をためらわない。
問診・診察のポイント  
 
急性冠症候群(ACS):
  1. 女性は非典型的な症状(鋭く刺すような痛み、嘔気・消化不良など)を訴えやすい。

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文献 

著者: Judith M Poldervaart, Johannes B Reitsma, Barbra E Backus, Hendrik Koffijberg, Rolf F Veldkamp, Monique E Ten Haaf, Yolande Appelman, Herman F J Mannaerts, Jan-Melle van Dantzig, Madelon van den Heuvel, Mohamed El Farissi, Bernard J W M Rensing, Nicolette M S K J Ernst, Ineke M C Dekker, Frank R den Hartog, Thomas Oosterhof, Ghizelda R Lagerweij, Eugene M Buijs, Maarten W J van Hessen, Marcel A J Landman, Roland R J van Kimmenade, Luc Cozijnsen, Jeroen J J Bucx, Clara E E van Ofwegen-Hanekamp, Maarten-Jan Cramer, A Jacob Six, Pieter A Doevendans, Arno W Hoes
雑誌名: Ann Intern Med. 2017 May 16;166(10):689-697. doi: 10.7326/M16-1600. Epub 2017 Apr 25.
Abstract/Text Background: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown.
Objective: To measure the effect of use of the HEART score on patient outcomes and use of health care resources.
Design: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846).
Setting: Emergency departments in 9 Dutch hospitals.
Patients: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014.
Intervention: All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management.
Measurements: For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness.
Results: A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed.
Limitation: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score.
Conclusion: Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.
Primary Funding Source: Netherlands Organisation for Health Research and Development.

PMID 28437795  Ann Intern Med. 2017 May 16;166(10):689-697. doi: 10.73・・・
著者: Rudi Bruyninckx, Bert Aertgeerts, Pieter Bruyninckx, Frank Buntinx
雑誌名: Br J Gen Pract. 2008 Feb;58(547):105-11. doi: 10.3399/bjgp08X277014.
Abstract/Text BACKGROUND: Prompt diagnosis of acute myocardial infarction or acute coronary syndrome is very important.
AIM: A systematic review was conducted to determine the accuracy of 10 important signs and symptoms in selected and non-selected patients.
DESIGN OF STUDY: Diagnostic meta-analysis.
METHOD: Using MEDLINE, CINAHL, EMBASE, tracing references, and by contacting experts, studies were sought out that described one of the 10 signs and symptoms on one or both conditions. Studies were excluded if they were not based on original data. Validity was assessed using QUADAS and all data were pooled using a random effects model.
RESULTS: Sixteen of the 28 included studies were about patients who were non-selected. In this group, absence of chest-wall tenderness on palpation had a pooled sensitivity of 92% (95% confidence interval [CI] = 86 to 96) for acute myocardial infarction and 94% (95% CI = 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% CI = 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive likelihood ratio (LR+), namely 2.92 (95% CI = 1.97 to 4.23) for acute myocardial infarction. The other pooled LR+ fluctuated between 1.05 and 1.49. Negative LRs (LR-) varied between 0.98 and 0.23. Absence of chest-wall tenderness on palpation had a LR- of 0.23 (95% CI = 0.18 to 0.29).
CONCLUSIONS: Based on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings.

PMID 18307844  Br J Gen Pract. 2008 Feb;58(547):105-11. doi: 10.3399/b・・・
著者: Clifford J Swap, John T Nagurney
雑誌名: JAMA. 2005 Nov 23;294(20):2623-9. doi: 10.1001/jama.294.20.2623.
Abstract/Text CONTEXT: The chest pain history, physical examination, determination of coronary artery disease (CAD) risk factors, and the initial electrocardiogram compose the information immediately available to clinicians to help determine the probability of acute myocardial infarction (AMI) or acute coronary syndrome (ACS) in patients with chest pain. However, conflicting data exist about the usefulness of the chest pain history and which components are most useful.
OBJECTIVE: To identify the elements of the chest pain history that may be most helpful to the clinician in identifying ACS in patients presenting with chest pain.
EVIDENCE ACQUISITION: MEDLINE and Ovid were searched from 1970 to September 2005 by using specific key words and Medical Subject Heading terms. Reference lists of these articles and current cardiology textbooks were also consulted.
EVIDENCE SYNTHESIS: Certain chest pain characteristics decrease the likelihood of ACS or AMI, namely, pain that is stabbing, pleuritic, positional, or reproducible by palpation (likelihood ratios [LRs] 0.2-0.3). Conversely, chest pain that radiates to one shoulder or both shoulders or arms or is precipitated by exertion is associated with LRs (2.3-4.7) that increase the likelihood of ACS. The chest pain history itself has not proven to be a powerful enough predictive tool to obviate the need for at least some diagnostic testing. Combinations of elements of the chest pain history with other initially available information, such as a history of CAD, have identified certain groups that may be safe for discharge without further evaluation, but further study is needed before such a recommendation can be considered reasonable.
CONCLUSION: Although certain elements of the chest pain history are associated with increased or decreased likelihoods of a diagnosis of ACS or AMI, none of them alone or in combination identify a group of patients that can be safely discharged without further diagnostic testing.

PMID 16304077  JAMA. 2005 Nov 23;294(20):2623-9. doi: 10.1001/jama.294・・・
著者: Richard Body, Simon Carley, Christopher Wibberley, Garry McDowell, Jamie Ferguson, Kevin Mackway-Jones
雑誌名: Resuscitation. 2010 Mar;81(3):281-6. doi: 10.1016/j.resuscitation.2009.11.014. Epub 2009 Dec 29.
Abstract/Text OBJECTIVE: Patient history and physical examination are widely accepted as cornerstones of diagnosis in modern medicine. We aimed to assess the value of individual historical and examination findings for diagnosing acute myocardial infarction (AMI) and predicting adverse cardiac events in undifferentiated Emergency Department (ED) patients with chest pain.
METHODS: We prospectively recruited patients presenting to the ED with suspected cardiac chest pain. Clinical features were recorded using a custom-designed report form. All patients were followed up for the diagnosis of AMI and the occurrence of adverse events (death, AMI or urgent revascularization) within 6 months.
RESULTS: AMI was diagnosed in 148 (18.6%) of the 796 patients recruited. Following adjustment for age, sex and ECG changes, the following characteristics made AMI more likely (adjusted odds ratio, 95% confidence intervals): pain radiating to the right arm (2.23, 1.24-4.00), both arms (2.69, 1.36-5.36), vomiting (3.50, 1.81-6.77), central chest pain (3.29, 1.94-5.61) and sweating observed (5.18, 3.02-8.86). Pain in the left anterior chest made AMI significantly less likely (0.25, 0.14-0.46). The presence of rest pain (0.67, 0.41-1.10) or pain radiating to the left arm (1.36, 0.89-2.09) did not significantly alter the probability of AMI.
CONCLUSIONS: Our results challenge many widely held assertions about the value of individual symptoms and signs in ED patients with suspected acute coronary syndromes. Several 'atypical' symptoms actually render AMI more likely, whereas many 'typical' symptoms that are often considered to identify high-risk populations have no diagnostic value.

Copyright 2009. Published by Elsevier Ireland Ltd.
PMID 20036454  Resuscitation. 2010 Mar;81(3):281-6. doi: 10.1016/j.res・・・
著者: E M Balk, J P Ioannidis, D Salem, P W Chew, J Lau
雑誌名: Ann Emerg Med. 2001 May;37(5):478-94. doi: 10.1067/mem.2001.114905.
Abstract/Text STUDY OBJECTIVE: We sought to evaluate quantitatively the evidence on the diagnostic performance of presentation and serial biochemical markers for emergency department diagnosis of acute cardiac ischemia (ACI), including acute myocardial infarction (AMI) and unstable angina.
METHODS: We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998. We examined the diagnostic performance of creatine kinase, creatine kinase-MB, myoglobin, and troponin I and T testing. Diagnostic performance was assessed by using estimates of test sensitivity and specificity and was summarized by summary receiver-operating characteristic curves.
RESULTS: Only 4 studies were found that evaluated all patients with ACI; 73 were found that focused only on a diagnosis of AMI. To diagnose ACI, presentation biomarker tests had sensitivities of 16% to 19% and specificities of 96% to 100%; serial biomarker tests had sensitivities of 31% to 45% and specificities of 95% to 98%. Considering only the diagnosis of AMI, presentation biomarker tests had summary sensitivities of 37% to 49% and summary specificities of 87% to 97%; serial biomarker tests had summary sensitivities of 79% to 93% and summary specificities of 85% to 96%. Variation of test sensitivity was best explained by test timing. Longer symptom duration or time between serial tests yielded higher sensitivity.
CONCLUSION: The limited evidence available to evaluate the diagnostic accuracy of biomarkers for ACI suggests that biomarkers have very low sensitivity to diagnose ACI. Thus, biomarkers alone will greatly underdiagnose ACI and will be inadequate to make triage decisions. For AMI diagnosis alone, multiple testing of individual biomarkers over time substantially improves sensitivity, while retaining high specificity, at the expense of additional time. Further high-quality studies are needed on the clinical effect of using biomarkers for patients with ACI in the ED and on optimal timing of serial testing and in combination with other tests.

PMID 11326184  Ann Emerg Med. 2001 May;37(5):478-94. doi: 10.1067/mem.・・・
著者: R Scott Wright, Jeffrey L Anderson, Cynthia D Adams, Charles R Bridges, Donald E Casey, Steven M Ettinger, Francis M Fesmire, Theodore G Ganiats, Hani Jneid, A Michael Lincoff, Eric D Peterson, George J Philippides, Pierre Theroux, Nanette K Wenger, James Patrick Zidar, Jeffrey L Anderson, Cynthia D Adams, Elliott M Antman, Charles R Bridges, Robert M Califf, Donald E Casey, William E Chavey, Francis M Fesmire, Judith S Hochman, Thomas N Levin, A Michael Lincoff, Eric D Peterson, Pierre Theroux, Nanette Kass Wenger, James Patrick Zidar, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
雑誌名: J Am Coll Cardiol. 2011 May 10;57(19):e215-367. doi: 10.1016/j.jacc.2011.02.011.
Abstract/Text
PMID 21545940  J Am Coll Cardiol. 2011 May 10;57(19):e215-367. doi: 10・・・
著者: Hiraku Funakoshi, Michiko Mizobe, Yosuke Homma, Yoshiyuki Nakashima, Jin Takahashi, Takashi Shiga
雑誌名: J Gen Fam Med. 2018 Mar;19(2):45-49. doi: 10.1002/jgf2.155. Epub 2018 Jan 25.
Abstract/Text Background: Nontraumatic Stanford type A acute aortic dissection is a life-threatening condition; thus, the ability to make a precise diagnosis of nontraumatic Stanford type A acute aortic dissection is essential for the emergency physician. Several reports have shown that the mediastinal widening on a chest radiograph is useful for the diagnosis of nontraumatic Stanford type A acute aortic dissection; however, the exact cutoff value of the mediastinal width on plain radiographs is rarely defined.
Methods: A single-center retrospective case-control study was conducted between October 1, 2013, and March 31, 2015. We evaluated the maximal mediastinal width of the anteroposterior chest X-ray at the level of the aortic knob in the supine position between patient groups with and without nontraumatic Stanford type A acute aortic dissection.
Results: We enrolled 72 patients (36 patients with nontraumatic Stanford type A acute aortic dissection and 36 patients without nontraumatic Stanford type A acute aortic dissection). The median mediastinal width of patients with nontraumatic Stanford type A acute aortic dissection was significantly larger than that of patients without nontraumatic Stanford type A acute aortic dissection (100.7 mm vs 77.7 mm, P < .01). The optimal cutoff level was 87 mm (sensitivity, 81%; specificity, 89%). Using multivariable logistic regression, the odds ratio of a mediastinal width of >87 mm for a diagnosis nontraumatic Stanford type A acute aortic dissection was 57.1 (95% confidence interval, 11.2-290.2).
Conclusion: A mediastinal width of >87 mm showed high sensitivity in the diagnosis of probable nontraumatic Stanford type A acute aortic dissection.

PMID 29600127  J Gen Fam Med. 2018 Mar;19(2):45-49. doi: 10.1002/jgf2.・・・
著者: Michael Klompas
雑誌名: JAMA. 2002 May 1;287(17):2262-72.
Abstract/Text CONTEXT: The diagnosis of acute thoracic aortic dissection is difficult to make and often missed.
OBJECTIVE: To review the accuracy of clinical history taking, physical examination, and plain chest radiograph in the diagnosis of acute thoracic aortic dissection.
DATA SOURCES: A comprehensive review of the English-language literature was conducted using MEDLINE for the years 1966 through 2000. Additional sources were identified from the references of retrieved articles.
STUDY SELECTION: The search revealed 274 potential sources, which were reviewed for pertinence and quality. Articles included were original investigations describing the clinical findings for 18 or more consecutive patients with confirmed thoracic aortic dissection. Twenty-one studies were identified that met selection criteria.
DATA EXTRACTION: Critical appraisal and data extraction were performed by the author.
DATA SYNTHESIS: Most patients with thoracic aortic dissection have severe pain (pooled sensitivity, 90%) of sudden onset (sensitivity, 84%). The absence of sudden pain onset lowers the likelihood of dissection (negative likelihood ratio [LR], 0.3; 95% confidence interval [CI], 0.2-0.5). On examination, 49% of patients have an elevated blood pressure, 28% have a diastolic murmur, 31% have pulse deficits or blood pressure differentials, and 17% have focal neurological deficits. Presence of a diastolic murmur does little to change the pretest probability of dissection (positive LR, 1.4; 95% CI, 1.0-2.0), whereas pulse or blood pressure differentials and neurological deficits increase the likelihood of disease (positive LRs, 5.7 and 6.6-33.0, respectively). The plain chest radiograph results are usually abnormal (sensitivity, 90%); hence, the presence of a normal aorta and mediastinum decreases the probability of dissection (negative LR, 0.3; 95% CI, 0.2-0.4). Combinations of findings increase the likelihood of disease.
CONCLUSIONS: The presence of pulse deficits or focal neurological deficits increases the likelihood of an acute thoracic aortic dissection in the appropriate clinical setting. Conversely, a completely normal chest radiograph result or the absence of pain of sudden onset lowers the likelihood. Overall, however, the clinical examination is insufficiently sensitive to rule out aortic dissection given the high morbidity of missed diagnosis.

PMID 11980527  JAMA. 2002 May 1;287(17):2262-72.
著者: Loren F Hiratzka, George L Bakris, Joshua A Beckman, Robert M Bersin, Vincent F Carr, Donald E Casey, Kim A Eagle, Luke K Hermann, Eric M Isselbacher, Ella A Kazerooni, Nicholas T Kouchoukos, Bruce W Lytle, Dianna M Milewicz, David L Reich, Souvik Sen, Julie A Shinn, Lars G Svensson, David M Williams, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine
雑誌名: Circulation. 2010 Apr 6;121(13):e266-369. doi: 10.1161/CIR.0b013e3181d4739e. Epub 2010 Mar 16.
Abstract/Text
PMID 20233780  Circulation. 2010 Apr 6;121(13):e266-369. doi: 10.1161/・・・
著者: Manabu Kurabayashi, Naoyuki Miwa, Daisuke Ueshima, Koji Sugiyama, Kojiro Yoshimura, Tsukasa Shimura, Hideshi Aoyagi, Koji Azegami, Kaoru Okishige, Mitsuaki Isobe
雑誌名: J Cardiol. 2011 Nov;58(3):287-93. doi: 10.1016/j.jjcc.2011.07.008. Epub 2011 Sep 3.
Abstract/Text BACKGROUND: Acute aortic dissection (AAD) is often missed on initial assessment.
PURPOSE: The aim of our study was to identify features associated with misdiagnosis of AAD.
METHODS AND RESULTS: We examined a total of 109 emergency room (ER) patients who were ultimately diagnosed with AAD. Misdiagnosis of AAD was defined as failure to diagnose AAD at the end of the initial assessment in the ER, and occurred in 17 patients (16%). The alternate diagnosis consisted of acute coronary syndrome (n=10), other cardiovascular disease (n=3), abdominal disease (n=3), and cerebral infarction (n=1). In the misdiagnosed patients, walk-in mode of admission to the ER (29% vs. 10%, p=0.042) and anterior chest pain (71% vs. 41%, p=0.025) were more frequent, and widened mediastinum (25% vs. 55%, p=0.023) was less frequent than in diagnosed patients. The number of imaging studies performed per patient was also fewer in misdiagnosed patients than in diagnosed patients (0.82 ± 0.81 vs. 1.53 ± 0.52, p<0.001). However, there was no significant difference in in-hospital mortality (18% vs. 15%, p=0.520). Multivariate analysis showed that the strongest predictor of misdiagnosis was walk-in mode of admission (odds ratio 4.777; 95% confidence interval 1.267-18.007; p=0.021).
CONCLUSIONS: Both diversity of symptoms and variability of the severity of symptoms, especially walk-in mode of admission lead ER physicians to miss AAD in about 1 in 6 cases of AAD. It is therefore important to keep AAD as a differential diagnosis in mind, even when patients present with mild enough symptoms that allow them to walk into the ER.

Copyright © 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
PMID 21889877  J Cardiol. 2011 Nov;58(3):287-93. doi: 10.1016/j.jjcc.2・・・
著者: Firas F Mussa, Joshua D Horton, Rameen Moridzadeh, Joseph Nicholson, Santi Trimarchi, Kim A Eagle
雑誌名: JAMA. 2016 Aug 16;316(7):754-63. doi: 10.1001/jama.2016.10026.
Abstract/Text IMPORTANCE: Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary.
OBJECTIVE: To systematically review the current evidence on diagnosis and treatment of AAS.
EVIDENCE REVIEW: Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed.
FINDINGS: Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias.
CONCLUSIONS AND RELEVANCE: Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

PMID 27533160  JAMA. 2016 Aug 16;316(7):754-63. doi: 10.1001/jama.2016・・・
著者: Adam Torbicki, Arnaud Perrier, Stavros Konstantinides, Giancarlo Agnelli, Nazzareno Galiè, Piotr Pruszczyk, Frank Bengel, Adrian J B Brady, Daniel Ferreira, Uwe Janssens, Walter Klepetko, Eckhard Mayer, Martine Remy-Jardin, Jean-Pierre Bassand, ESC Committee for Practice Guidelines (CPG)
雑誌名: Eur Heart J. 2008 Sep;29(18):2276-315. doi: 10.1093/eurheartj/ehn310. Epub 2008 Aug 30.
Abstract/Text Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.

PMID 18757870  Eur Heart J. 2008 Sep;29(18):2276-315. doi: 10.1093/eur・・・
著者: Fay Crawford, Alina Andras, Karen Welch, Karen Sheares, David Keeling, Francesca M Chappell
雑誌名: Cochrane Database Syst Rev. 2016 Aug 5;(8):CD010864. doi: 10.1002/14651858.CD010864.pub2. Epub 2016 Aug 5.
Abstract/Text BACKGROUND: Pulmonary embolism (PE) can occur when a thrombus (blood clot) travels through the veins and lodges in the arteries of the lungs, producing an obstruction. People who are thought to be at risk include those with cancer, people who have had a recent surgical procedure or have experienced long periods of immobilisation and women who are pregnant. The clinical presentation can vary, but unexplained respiratory symptoms such as difficulty breathing, chest pain and an increased respiratory rate are common.D-dimers are fragments of protein released into the circulation when a blood clot breaks down as a result of normal body processes or with use of prescribed fibrinolytic medication. The D-dimer test is a laboratory assay currently used to rule out the presence of high D-dimer plasma levels and, by association, venous thromboembolism (VTE). D-dimer tests are rapid, simple and inexpensive and can prevent the high costs associated with expensive diagnostic tests.
OBJECTIVES: To investigate the ability of the D-dimer test to rule out a diagnosis of acute PE in patients treated in hospital outpatient and accident and emergency (A&E) settings who have had a pre-test probability (PTP) of PE determined according to a clinical prediction rule (CPR), by estimating the accuracy of the test according to estimates of sensitivity and specificity. The review focuses on those patients who are not already established on anticoagulation at the time of study recruitment.
SEARCH METHODS: We searched 13 databases from conception until December 2013. We cross-checked the reference lists of relevant studies.
SELECTION CRITERIA: Two review authors independently applied exclusion criteria to full papers and resolved disagreements by discussion.We included cross-sectional studies of D-dimer in which ventilation/perfusion (V/Q) scintigraphy, computerised tomography pulmonary angiography (CTPA), selective pulmonary angiography and magnetic resonance pulmonary angiography (MRPA) were used as the reference standard.•
PARTICIPANTS: Adults who were managed in hospital outpatient and A&E settings and were suspected of acute PE were eligible for inclusion in the review if they had received a pre-test probability score based on a CPR.•
INDEX TESTS: quantitative, semi quantitative and qualitative D-dimer tests.• Target condition: acute symptomatic PE.• Reference standards: We included studies that used pulmonary angiography, V/Q scintigraphy, CTPA and MRPA as reference standard tests.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed quality using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). We resolved disagreements by discussion. Review authors extracted patient-level data when available to populate 2 × 2 contingency tables (true-positives (TPs), true-negatives (TNs), false-positives (FPs) and false-negatives (FNs)).
MAIN RESULTS: We included four studies in the review (n = 1585 patients). None of the studies were at high risk of bias in any of the QUADAS-2 domains, but some uncertainty surrounded the validity of studies in some domains for which the risk of bias was uncertain. D-dimer assays demonstrated high sensitivity in all four studies, but with high levels of false-positive results, especially among those over the age of 65 years. Estimates of sensitivity ranged from 80% to 100%, and estimates of specificity from 23% to 63%.
AUTHORS' CONCLUSIONS: A negative D-dimer test is valuable in ruling out PE in patients who present to the A&E setting with a low PTP. Evidence from one study suggests that this test may have less utility in older populations, but no empirical evidence was available to support an increase in the diagnostic threshold of interpretation of D-dimer results for those over the age of 65 years.

PMID 27494075  Cochrane Database Syst Rev. 2016 Aug 5;(8):CD010864. do・・・
著者: American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Thromboembolic Disease:, Stephen J Wolf, Sigrid A Hahn, Lauren M Nentwich, Ali S Raja, Scott M Silvers, Michael D Brown
雑誌名: Ann Emerg Med. 2018 May;71(5):e59-e109. doi: 10.1016/j.annemergmed.2018.03.006.
Abstract/Text
PMID 29681319  Ann Emerg Med. 2018 May;71(5):e59-e109. doi: 10.1016/j.・・・
著者: Jin Takahashi, Takashi Shiga, Yuita Fukuyama, Yuiko Hoshina, Yosuke Homma, Michiko Mizobe, Kenji Numata, Tetsuya Inoue, Hiraku Funakoshi
雑誌名: Int J Emerg Med. 2019 Aug 28;12(1):23. doi: 10.1186/s12245-019-0242-y. Epub 2019 Aug 28.
Abstract/Text BACKGROUND: In the diagnosis of pulmonary embolism (PE), the D-dimer threshold is based on studies conducted in Western countries, where the incidence rate is 5 times higher than that in Asian countries, including Japan. If we could elevate the D-dimer threshold based on the low pre-test probability in the Japanese population, we could omit the computed tomography pulmonary angiography (CTPA) which might lead to radiation exposure and contrast-induced nephropathy. Therefore, we aimed to determine a new D-dimer threshold specific to Japanese individuals.
METHODS: We conducted a retrospective cohort study at an emergency department in Japan, using medical charts collected from January 2013 to July 2017. We included patients whose D-dimer were measured for suspicion of PE with low or intermediate probability of PE and CTPA were performed. The primary outcome was failure rate of the new D-dimer threshold, defined as the rate of PE detected by CTPA among patients with D-dimer under the new threshold ranging from 1000 to 1500 μg/L by 100. The new D-dimer threshold was appropriate if the upper limit of 95% confidence interval of the failure rate of PE was approximately 3%.
RESULTS: In 395 patients included, the number of patients with PE was 24 (the prevalence was 6.1%). If the D-dimer threshold was 1100 μg/L, the failure rate was 0% (0/119), the upper limit of the 95% confidence interval of the failure rate was 3.1%, and 30% (119/395) of the CTPA might be omitted.
CONCLUSION: The new D-dimer threshold could safely exclude PE. This result can be generalized to other Asian populations with a lower incidence of PE. Further prospective studies will be needed.

PMID 31455204  Int J Emerg Med. 2019 Aug 28;12(1):23. doi: 10.1186/s12・・・
著者: Trip J Meine, Matthew T Roe, Anita Y Chen, Manesh R Patel, Jeffrey B Washam, E Magnus Ohman, W Frank Peacock, Charles V Pollack, W Brian Gibler, Eric D Peterson, CRUSADE Investigators
雑誌名: Am Heart J. 2005 Jun;149(6):1043-9. doi: 10.1016/j.ahj.2005.02.010.
Abstract/Text BACKGROUND: Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments.
METHODS: The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin.
RESULTS: A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups.
CONCLUSIONS: Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

PMID 15976786  Am Heart J. 2005 Jun;149(6):1043-9. doi: 10.1016/j.ahj.・・・
著者: Robert E O'Connor, William Brady, Steven C Brooks, Deborah Diercks, Jonathan Egan, Chris Ghaemmaghami, Venu Menon, Brian J O'Neil, Andrew H Travers, Demetris Yannopoulos
雑誌名: Circulation. 2010 Nov 2;122(18 Suppl 3):S787-817. doi: 10.1161/CIRCULATIONAHA.110.971028.
Abstract/Text There has been tremendous progress in reducing disability and death from ACS. But many patients still die before reaching the hospital because patients and family members fail to recognize the signs of ACS and fail to activate the EMS system. Once the patient with ACS contacts the healthcare system, providers must focus on support of cardiorespiratory function, rapid transport, and early classification of the patient based on ECG characteristics. Patients with STEMI require prompt reperfusion; the shorter the interval from symptom onset to reperfusion, the greater the benefit. In the STEMI population, mechanical reperfusion with percutaenous coronary intervention improves survival and decreases major cardiovascular events compared to fibrinolysis. Patients with UA/NSTEMI (non-STEMI ACS) or nonspecific or normal ECGs require risk stratification and appropriate monitoring and therapy. Healthcare providers can improve survival rates and myocardial function of patients with ACS by providing skilled, efficient, and coordinated out-of-hospital and in-hospital care.

PMID 20956226  Circulation. 2010 Nov 2;122(18 Suppl 3):S787-817. doi: ・・・
著者: Samuel D Turnipseed, William S Trythall, Deborah B Diercks, Erik G Laurin, J Douglas Kirk, David S Smith, David N Main, Ezra A Amsterdam
雑誌名: Acad Emerg Med. 2009 Jun;16(6):495-9. doi: 10.1111/j.1553-2712.2009.00420.x. Epub 2009 May 7.
Abstract/Text OBJECTIVES: The authors hypothesized that patients with active chest pain at the time of a normal electrocardiogram (ECG) have a lower frequency of acute coronary syndrome (ACS) than patients being evaluated for chest pain but with no active chest pain at the time of a normal ECG. The study objective was to describe the association between chest pain in patients with a normal ECG and the diagnosis of ACS.
METHODS: This was a prospective observational study of emergency department (ED) patients with a chief complaint of chest pain and an initial normal ECG admitted to the hospital for chest pain evaluation over a 1-year period. Two groups were identified: patients with chest pain during the ECG and patients without chest pain during the ECG. Normal ECG criteria were as follow: 1) normal sinus rhythm with heart rate of 55-105 beats/min, 2) normal QRS interval and ST segment, and 3) normal T-wave morphology or T-wave flattening. "Normal" excludes pathologic Q waves, left ventricular hypertrophy, nonspecific ST-T wave abnormalities, any ST depression, and discrepancies in the axis between the T wave and the QRS. Patients' initial ED ECGs were interpreted as normal or abnormal by two emergency physicians (EPs); differences in interpretation were resolved by a cardiologist. ACS was defined as follows: 1) elevation and characteristic evolution of troponin I level, 2) coronary angiography demonstrating >70% stenosis in a major coronary artery, or 3) positive noninvasive cardiac stress test. Chi-square analysis was performed and odds ratios (ORs) are presented.
RESULTS: A total of 1,741 patients were admitted with cardiopulmonary symptoms; 387 met study criteria. The study group comprised 199 males (51%) and 188 females (49%), mean age was 56 years (range, 25-90 years), and 106 (27%) had known coronary artery disease (CAD). A total of 261 (67%) patients experienced chest pain during ECG; 126 (33%) patients experienced no chest pain during ECG. There was no difference between the two groups in age, sex, cardiac risk factors, or known CAD. The frequency of ACS for the total study group was 17% (67/387). There was no difference in prevalence of ACS based on the presence or absence of chest pain (16% or 42/261 vs. 20% or 25/126; OR = 0.77, 95% confidence interval = 0.45 to 1.33, p = 0.4).
CONCLUSIONS: Contrary to our hypothesis concerning patients who presented to the ED with a chief complaint of chest pain, our study demonstrated no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram.

PMID 19426294  Acad Emerg Med. 2009 Jun;16(6):495-9. doi: 10.1111/j.15・・・
著者: Maureen Chase, Aaron M Brown, Jennifer L Robey, Charles V Pollack, Frances S Shofer, Judd E Hollander
雑誌名: Acad Emerg Med. 2006 Oct;13(10):1034-9. doi: 10.1197/j.aem.2006.06.051. Epub 2006 Sep 13.
Abstract/Text OBJECTIVES: Emergency department (ED) patients with symptoms concerning for acute coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for adverse cardiovascular events. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do those who are asymptomatic.
METHODS: This was a prospective cohort study of ED patients with potential ACS. Outcomes were acute myocardial infarction (AMI), ACS, and 30-day cardiovascular events (death, AMI, revascularization). Fisher's exact test, t-tests, and logistic regression were used for data analysis.
RESULTS: Of 2,593 patient visits, 2,007 patients had normal or nonspecific ECG findings. There were 1,196 who had symptoms during ECG, whereas 811 did not. Patients with symptoms at ECG acquisition were younger (49.9 vs. 55.2 years; p < 0.001) and were more likely to be black (70% vs. 64%; p = 0.002), female (63% vs. 58%; p = 0.03), and to have used cocaine (5% vs. 2%; p = 0.004). They were less likely to have hypertension (49% vs. 58%; p < 0.001), and diabetes (22% vs. 17%; p = 0.002). Patients with and without symptoms were equally likely to have AMI (both 2.8%; p > 0.99), ACS (10.1% vs. 11.5%; p = 0.34), and 30-day adverse outcomes (both 5.3%; p > 0.99). After adjustment for baseline cardiovascular-risk factors, odds ratios for patients with symptoms at the time of ECG acquisition were not significantly different for any of the outcomes: AMI (1.1; 95% confidence interval [CI] = 0.6 to 1.9); ACS (1.1; 95% CI = 0.8 to 1.4); or 30-day events (1.2; 95% CI = 0.8 to 1.9).
CONCLUSIONS: Patients who are symptomatic during acquisition of a normal or nonspecific ECG have rates of adverse cardiovascular events similar to those of patients without symptoms. Clinicians should not rely on the absence of ECG abnormalities during symptoms to help exclude ACS.

PMID 16973638  Acad Emerg Med. 2006 Oct;13(10):1034-9. doi: 10.1197/j.・・・
著者: Alexander C Fanaroff, Jennifer A Rymer, Sarah A Goldstein, David L Simel, L Kristin Newby
雑誌名: JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.2015.12735.
Abstract/Text IMPORTANCE: About 10% of patients with acute chest pain are ultimately diagnosed with acute coronary syndrome (ACS). Early, accurate estimation of the probability of ACS in these patients using the clinical examination could prevent many hospital admissions among low-risk patients and ensure that high-risk patients are promptly treated.
OBJECTIVE: To review systematically the accuracy of the initial history, physical examination, electrocardiogram, and risk scores incorporating these elements with the first cardiac-specific troponin.
STUDY SELECTION: MEDLINE and EMBASE were searched (January 1, 1995-July 31, 2015), along with reference lists from retrieved articles, to identify prospective studies of diagnostic test accuracy among patients admitted to the emergency department with symptoms suggesting ACS.
DATA EXTRACTION AND SYNTHESIS: We identified 2992 unique articles; 58 met inclusion criteria.
MAIN OUTCOMES AND MEASURES: Sensitivity, specificity, and likelihood ratio (LR) of findings for the diagnosis of ACS. The reference standard for ACS was either a final hospital diagnosis of ACS or occurrence of a cardiovascular event within 6 weeks.
RESULTS: The clinical findings and risk factors most suggestive of ACS were prior abnormal stress test (specificity, 96%; LR, 3.1 [95% CI, 2.0-4.7]), peripheral arterial disease (specificity, 97%; LR, 2.7 [95% CI, 1.5-4.8]), and pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]). The most useful electrocardiogram findings were ST-segment depression (specificity, 95%; LR, 5.3 [95% CI, 2.1-8.6]) and any evidence of ischemia (specificity, 91%; LR, 3.6 [95% CI,1.6-5.7]). Both the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) risk scores performed well in diagnosing ACS: LR, 13 (95% CI, 7.0-24) for the high-risk range of the HEART score (7-10) and LR, 6.8 (95% CI, 5.2-8.9) for the high-risk range of the TIMI score (5-7). The most useful for identifying patients less likely to have ACS were the low-risk range HEART score (0-3) (LR, 0.20 [95% CI, 0.13-0.30]), low-risk range TIMI score (0-1) (LR, 0.31 [95% CI, 0.23-0.43]), or low to intermediate risk designation by the Heart Foundation of Australia and Cardiac Society of Australia and New Zealand risk algorithm (LR, 0.24 [95% CI, 0.19-0.31]).
CONCLUSIONS AND RELEVANCE: Among patients with suspected ACS presenting to emergency departments, the initial history, physical examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores, which incorporate the first cardiac troponin, provided more diagnostic information.

PMID 26547467  JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.20・・・
著者: Jeffrey L Anderson, Cynthia D Adams, Elliott M Antman, Charles R Bridges, Robert M Califf, Donald E Casey, William E Chavey, Francis M Fesmire, Judith S Hochman, Thomas N Levin, A Michael Lincoff, Eric D Peterson, Pierre Theroux, Nanette K Wenger, R Scott Wright, Hani Jneid, Steven M Ettinger, Theodore G Ganiats, A Michael Lincoff, George J Philippides, James Patrick Zidar, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
雑誌名: Circulation. 2013 Jun 11;127(23):e663-828. doi: 10.1161/CIR.0b013e31828478ac. Epub 2013 Apr 29.
Abstract/Text
PMID 23630129  Circulation. 2013 Jun 11;127(23):e663-828. doi: 10.1161・・・
著者: Edward Hulten, Christopher Pickett, Marcio Sommer Bittencourt, Todd C Villines, Sara Petrillo, Marcelo F Di Carli, Ron Blankstein
雑誌名: J Am Coll Cardiol. 2013 Feb 26;61(8):880-92. doi: 10.1016/j.jacc.2012.11.061. Epub 2013 Feb 6.
Abstract/Text OBJECTIVES: The aim of the study was to systematically review and perform a meta-analysis of randomized, controlled trials of coronary computed tomography angiography (CCTA) versus usual care (UC) triage of acute chest pain in the emergency department (ED).
BACKGROUND: CCTA allows rapid evaluation of patients presenting to the ED with acute chest pain syndromes; however, the impact of such testing on patient management and downstream testing has emerged as a concern.
METHODS: We systematically searched for randomized, controlled trials of CCTA in the ED and performed a meta-analysis of clinical outcomes.
RESULTS: Four randomized, controlled trials were included, with 1,869 patients undergoing CCTA and 1,397 undergoing UC. There were no deaths and no difference in the incidence of myocardial infarction, post-discharge ED visits, or rehospitalizations. Four studies reported decreased length of stay with CCTA and 3 reported cost savings; 8.4% of patients undergoing CCTA versus 6.3% of those receiving UC underwent invasive coronary angiography (ICA), whereas 4.6% of patients undergoing CCTA versus 2.6% of those receiving UC underwent coronary revascularization. The odds ratio of ICA for CCTA patients versus UC patients was 1.36 (95% confidence interval [CI]: 1.03 to 1.80, p = 0.030), and for revascularization, it was 1.81 (95% CI: 1.20 to 2.72, p = 0.004). The absolute increase in ICA after CCTA was 21 per 1,000 CCTA patients (95% CI: 1.8 to 44.9), and the number needed to scan was 48. The absolute increase in revascularization after CCTA was 20 per 1,000 patients (95% CI: 5.0 to 41.4); the number needed to scan was 50. Both percutaneous coronary intervention and coronary artery bypass graft surgery independently contributed to the significant increase in revascularization.
CONCLUSIONS: Compared with UC, the use of CCTA in the ED is associated with decreased ED cost and length of stay but increased ICA and revascularization.

Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
PMID 23395069  J Am Coll Cardiol. 2013 Feb 26;61(8):880-92. doi: 10.10・・・
著者: J G Canto, M G Shlipak, W J Rogers, J A Malmgren, P D Frederick, C T Lambrew, J P Ornato, H V Barron, C I Kiefe
雑誌名: JAMA. 2000 Jun 28;283(24):3223-9.
Abstract/Text CONTEXT: Although chest pain is widely considered a key symptom in the diagnosis of myocardial infarction (MI), not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown.
OBJECTIVES: To determine the frequency with which patients with MI present without chest pain and to examine their subsequent management and outcome.
DESIGN: Prospective observational study.
SETTING AND PATIENTS: A total of 434,877 patients with confirmed MI enrolled June 1994 to March 1998 in the National Registry of Myocardial Infarction 2, which includes 1674 hospitals in the United States.
MAIN OUTCOME MEASURES: Prevalence of presentation without chest pain; clinical characteristics, treatment, and mortality among MI patients without chest pain vs those with chest pain.
RESULTS: Of all patients diagnosed as having MI, 142,445 (33%) did not have chest pain on presentation to the hospital. This group of MI patients was, on average, 7 years older than those with chest pain (74.2 vs 66.9 years), with a higher proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6% vs 25. 4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3 hours), were less likely to be diagnosed as having confirmed MI at the time of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), beta-blockers (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients without chest pain had a 23.3% in-hospital mortality rate compared with 9.3% among patients with chest pain (adjusted odds ratio for mortality, 2. 21 [95% confidence interval, 2.17-2.26]).
CONCLUSIONS: Our results suggest that patients without chest pain on presentation represent a large segment of the MI population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality. JAMA. 2000;283:3223-3229

PMID 10866870  JAMA. 2000 Jun 28;283(24):3223-9.
著者: Massimo Imazio, Antonio Brucato, Roberto Cemin, Stefania Ferrua, Stefano Maggiolini, Federico Beqaraj, Daniela Demarie, Davide Forno, Silvia Ferro, Silvia Maestroni, Riccardo Belli, Rita Trinchero, David H Spodick, Yehuda Adler, ICAP Investigators
雑誌名: N Engl J Med. 2013 Oct 17;369(16):1522-8. doi: 10.1056/NEJMoa1208536. Epub 2013 Aug 31.
Abstract/Text BACKGROUND: Colchicine is effective for the treatment of recurrent pericarditis. However, conclusive data are lacking regarding the use of colchicine during a first attack of acute pericarditis and in the prevention of recurrent symptoms.
METHODS: In a multicenter, double-blind trial, eligible adults with acute pericarditis were randomly assigned to receive either colchicine (at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg) or placebo in addition to conventional antiinflammatory therapy with aspirin or ibuprofen. The primary study outcome was incessant or recurrent pericarditis.
RESULTS: A total of 240 patients were enrolled, and 120 were randomly assigned to each of the two study groups. The primary outcome occurred in 20 patients (16.7%) in the colchicine group and 45 patients (37.5%) in the placebo group (relative risk reduction in the colchicine group, 0.56; 95% confidence interval, 0.30 to 0.72; number needed to treat, 4; P<0.001). Colchicine reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P=0.001), the number of recurrences per patient (0.21 vs. 0.52, P=0.001), and the hospitalization rate (5.0% vs. 14.2%, P=0.02). Colchicine also improved the remission rate at 1 week (85.0% vs. 58.3%, P<0.001). Overall adverse effects and rates of study-drug discontinuation were similar in the two study groups. No serious adverse events were observed.
CONCLUSIONS: In patients with acute pericarditis, colchicine, when added to conventional antiinflammatory therapy, significantly reduced the rate of incessant or recurrent pericarditis. (Funded by former Azienda Sanitaria Locale 3 of Turin [now Azienda Sanitaria Locale 2] and Acarpia; ICAP ClinicalTrials.gov number, NCT00128453.).

PMID 23992557  N Engl J Med. 2013 Oct 17;369(16):1522-8. doi: 10.1056/・・・
著者: Leonard S Lilly
雑誌名: Circulation. 2013 Apr 23;127(16):1723-6. doi: 10.1161/CIRCULATIONAHA.111.066365.
Abstract/Text
PMID 23609551  Circulation. 2013 Apr 23;127(16):1723-6. doi: 10.1161/C・・・
著者: Massimo Imazio, Enrico Cecchi, Brunella Demichelis, Salvatore Ierna, Daniela Demarie, Aldo Ghisio, Franco Pomari, Luisella Coda, Riccardo Belli, Rita Trinchero
雑誌名: Circulation. 2007 May 29;115(21):2739-44. doi: 10.1161/CIRCULATIONAHA.106.662114. Epub 2007 May 14.
Abstract/Text BACKGROUND: The clinical search for indicators of poor prognosis of acute pericarditis may be useful for clinical triage of patients at high risk of specific causal conditions or complications. The aim of the present article is to assess the relationship between clinical features at presentation and specific causes or complications.
METHODS AND RESULTS: A total of 453 patients aged 17 to 90 years (mean age 52+/-18 years, 245 men) with acute pericarditis (post-myocardial infarction pericarditis was excluded) were prospectively evaluated from January 1996 to August 2004. A specific cause was found in 76 of 453 patients (16.8%): autoimmune in 33 patients (7.3%), neoplastic in 23 patients (5.1%), tuberculous in 17 patients (3.8%), and purulent in 3 patients (0.7%). In multivariable analysis, women (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03 to 2.70; P=0.036) and patients with fever >38 degrees C (HR 3.56, 95% CI 1.82 to 6.95; P<0.001), subacute course (HR 3.97, 95% CI 1.66 to 9.50; P=0.002), large effusion or tamponade (HR 2.15, 95% CI 1.09 to 4.23; P=0.026), and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 2.50, 95% CI 1.28 to 4.91; P=0.008) were at increased risk of specific causal conditions. After a mean follow-up of 31 months, complications were detected in 95 patients (21.0%): recurrences in 83 patients (18.3%), tamponade in 14 patients (3.1%), and constriction in 7 patients (1.5%). In multivariable analysis, women (HR 1.65, 95% CI 1.08 to 2.52; P=0.020) and patients with large effusion or tamponade (HR 2.51, 95% CI 1.37 to 4.61; P=0.003) and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 5.50, 95% CI 3.56 to 8.51; P<0.001) were at increased risk of complications.
CONCLUSIONS: Specific clinical features (fever >38 degrees C, subacute course, large effusion or tamponade, and aspirin or NSAID failure) may be useful to identify higher risk of specific causal conditions and complications.

PMID 17502574  Circulation. 2007 May 29;115(21):2739-44. doi: 10.1161/・・・
著者: Massimo Imazio, David H Spodick, Antonio Brucato, Rita Trinchero, Yehuda Adler
雑誌名: Circulation. 2010 Feb 23;121(7):916-28. doi: 10.1161/CIRCULATIONAHA.108.844753.
Abstract/Text
PMID 20177006  Circulation. 2010 Feb 23;121(7):916-28. doi: 10.1161/CI・・・
著者: Massimo Imazio, Antonio Brucato, Andrea Barbieri, Francesca Ferroni, Silvia Maestroni, Guido Ligabue, Alessandra Chinaglia, Davide Cumetti, Giovanni Della Casa, Federica Bonomi, Francesca Mantovani, Paola Di Corato, Roberta Lugli, Riccardo Faletti, Stefano Leuzzi, Rodolfo Bonamini, Maria Grazia Modena, Riccardo Belli
雑誌名: Circulation. 2013 Jul 2;128(1):42-9. doi: 10.1161/CIRCULATIONAHA.113.001531. Epub 2013 May 24.
Abstract/Text BACKGROUND: The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study.
METHODS AND RESULTS: A total of 486 patients (median age, 39 years; range, 18-83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P<0.001). Troponin elevation was not associated with an increase in complications.
CONCLUSIONS: The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting.

PMID 23709669  Circulation. 2013 Jul 2;128(1):42-9. doi: 10.1161/CIRCU・・・
著者: Grégoire Le Gal, Marc Righini, Pierre-Marie Roy, Olivier Sanchez, Drahomir Aujesky, Henri Bounameaux, Arnaud Perrier
雑誌名: Ann Intern Med. 2006 Feb 7;144(3):165-71.
Abstract/Text BACKGROUND: Diagnosis of pulmonary embolism requires clinical probability assessment. Implicit assessment is accurate but is not standardized, and current prediction rules have shortcomings.
OBJECTIVE: To construct a simple score based entirely on clinical variables and independent from physicians' implicit judgment.
DESIGN: Derivation and external validation of the score in 2 independent management studies on pulmonary embolism diagnosis.
SETTING: Emergency departments of 3 university hospitals in Europe.
PATIENTS: Consecutive patients admitted for clinically suspected pulmonary embolism.
MEASUREMENTS: Collected data included demographic characteristics, risk factors, and clinical signs and symptoms suggestive of venous thromboembolism. The variables statistically significantly associated with pulmonary embolism in univariate analysis were included in a multivariate logistic regression model. Points were assigned according to the regression coefficients. The score was then externally validated in an independent cohort.
RESULTS: The score comprised 8 variables (points): age older than 65 years (1 point), previous deep venous thrombosis or pulmonary embolism (3 points), surgery or fracture within 1 month (2 points), active malignant condition (2 points), unilateral lower limb pain (3 points), hemoptysis (2 points), heart rate of 75 to 94 beats/min (3 points) or 95 beats/min or more (5 points), and pain on lower-limb deep venous palpation and unilateral edema (4 points). In the validation set, the prevalence of pulmonary embolism was 8% in the low-probability category (0 to 3 points), 28% in the intermediate-probability category (4 to 10 points), and 74% in the high-probability category (> or =11 points).
LIMITATIONS: Interobserver agreement for the score items was not studied.
CONCLUSIONS: The proposed score is entirely standardized and is based on clinical variables. It has sustained internal and external validation and should now be tested for clinical usefulness in an outcome study.

PMID 16461960  Ann Intern Med. 2006 Feb 7;144(3):165-71.
著者: Michael R Jaff, M Sean McMurtry, Stephen L Archer, Mary Cushman, Neil Goldenberg, Samuel Z Goldhaber, J Stephen Jenkins, Jeffrey A Kline, Andrew D Michaels, Patricia Thistlethwaite, Suresh Vedantham, R James White, Brenda K Zierler, American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology
雑誌名: Circulation. 2011 Apr 26;123(16):1788-830. doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21.
Abstract/Text Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.

PMID 21422387  Circulation. 2011 Apr 26;123(16):1788-830. doi: 10.1161・・・
著者: Brian T Fengler, William J Brady
雑誌名: Am J Emerg Med. 2009 Jan;27(1):84-95. doi: 10.1016/j.ajem.2007.10.021.
Abstract/Text Patients presenting with pulmonary embolism (PE) have a wide spectrum of clinical severity. Although some patients may present with frank hemodynamic collapse and cardiac arrest, others may present with an asymptomatic PE that is discovered incidentally during workup of another condition. Fibrinolytic therapy is an option in the treatment of patients with PE due to its ability to rapidly dissolve thromboemboli clots. However, the use of fibrinolytics in the treatment of PE is a controversial topic that has left many practicing physicians confused on how to best treat these patients. A rational approach to deciding whether fibrinolytic therapy is indicated is based on an assessment of the benefit that each particular patient will derive from fibrinolytic therapy weighed against that patients risk for major bleeding and intracranial hemorrhage. There is a clear benefit/risk ratio for fibrinolytic therapy in patients with PE who present with cardiac arrest and in those who are hemodynamically unstable from a massive PE. With proper risk assessment, select patients with stable hemodynamics and right ventricular dysfunction may also benefit from fibrinolytic therapy. There is no benefit to fibrinolytic treatment in patients with stable hemodynamics and normal right ventricular function. This article sets out to review the literature on fibrinolytic therapy in the treatment of patients with PE and will propose an evidence based treatment algorithm.

PMID 19041539  Am J Emerg Med. 2009 Jan;27(1):84-95. doi: 10.1016/j.aj・・・
著者: Clive Kearon, Susan R Kahn, Giancarlo Agnelli, Samuel Goldhaber, Gary E Raskob, Anthony J Comerota, American College of Chest Physicians
雑誌名: Chest. 2008 Jun;133(6 Suppl):454S-545S. doi: 10.1378/chest.08-0658.
Abstract/Text This chapter about treatment for venous thromboembolic disease is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see "Grades of Recommendation" chapter). Among the key recommendations in this chapter are the following: for patients with objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE), we recommend anticoagulant therapy with subcutaneous (SC) low-molecular-weight heparin (LMWH), monitored IV, or SC unfractionated heparin (UFH), unmonitored weight-based SC UFH, or SC fondaparinux (all Grade 1A). For patients with a high clinical suspicion of DVT or PE, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C). For patients with confirmed PE, we recommend early evaluation of the risks to benefits of thrombolytic therapy (Grade 1C); for those with hemodynamic compromise, we recommend short-course thrombolytic therapy (Grade 1B); and for those with nonmassive PE, we recommend against the use of thrombolytic therapy (Grade 1B). In acute DVT or PE, we recommend initial treatment with LMWH, UFH or fondaparinux for at least 5 days rather than a shorter period (Grade 1C); and initiation of vitamin K antagonists (VKAs) together with LMWH, UFH, or fondaparinux on the first treatment day, and discontinuation of these heparin preparations when the international normalized ratio (INR) is > or = 2.0 for at least 24 h (Grade 1A). For patients with DVT or PE secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A). For patients with unprovoked DVT or PE, we recommend treatment with a VKA for at least 3 months (Grade 1A), and that all patients are then evaluated for the risks to benefits of indefinite therapy (Grade 1C). We recommend indefinite anticoagulant therapy for patients with a first unprovoked proximal DVT or PE and a low risk of bleeding when this is consistent with the patient's preference (Grade 1A), and for most patients with a second unprovoked DVT (Grade 1A). We recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). We recommend at least 3 months of treatment with LMWH for patients with VTE and cancer (Grade 1A), followed by treatment with LMWH or VKA as long as the cancer is active (Grade 1C). For prevention of postthrombotic syndrome (PTS) after proximal DVT, we recommend use of an elastic compression stocking (Grade 1A). For DVT of the upper extremity, we recommend similar treatment as for DVT of the leg (Grade 1C). Selected patients with lower-extremity (Grade 2B) and upper-extremity (Grade 2C). DVT may be considered for thrombus removal, generally using catheter-based thrombolytic techniques. For extensive superficial vein thrombosis, we recommend treatment with prophylactic or intermediate doses of LMWH or intermediate doses of UFH for 4 weeks (Grade 1B).

PMID 18574272  Chest. 2008 Jun;133(6 Suppl):454S-545S. doi: 10.1378/ch・・・
著者: Balwinder Singh, Ajay K Parsaik, Dipti Agarwal, Alok Surana, Soniya S Mascarenhas, Subhash Chandra
雑誌名: Ann Emerg Med. 2012 Jun;59(6):517-20.e1-4. doi: 10.1016/j.annemergmed.2011.10.022. Epub 2011 Dec 15.
Abstract/Text STUDY OBJECTIVE: To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED).
METHODS: We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios.
RESULTS: We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I(2)=97.2%) and positive likelihood ratio (I(2)=84.2%).
CONCLUSION: The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability.

Copyright © 2011. Published by Mosby, Inc.
PMID 22177109  Ann Emerg Med. 2012 Jun;59(6):517-20.e1-4. doi: 10.1016・・・
著者: J A Kline, A M Mitchell, C Kabrhel, P B Richman, D M Courtney
雑誌名: J Thromb Haemost. 2004 Aug;2(8):1247-55. doi: 10.1111/j.1538-7836.2004.00790.x.
Abstract/Text Overuse of the d-dimer to screen for possible pulmonary embolism (PE) can have negative consequences. This study derives and tests clinical criteria to justify not ordering a d-dimer. The test threshold was estimated at 1.8% using the method of Pauker and Kassirer. The PE rule-out criteria were derived from logistic regression analysis with stepwise backward elimination of 21 variables collected on 3148 emergency department patients evaluated for PE at 10 US hospitals. Eight variables were included in a block rule: Age < 50 years, pulse < 100 bpm, SaO(2) > 94%, no unilateral leg swelling, no hemoptysis, no recent trauma or surgery, no prior PE or DVT, no hormone use. The rule was then prospectively tested in a low-risk group (1427 patients from two hospitals initially tested for PE with a d-dimer) and a very low-risk group (convenience sample of 382 patients with chief complaint of dyspnea, PE not suspected). The prevalence of PE was 8% (95% confidence interval: 7-9%) in the low-risk group and 2% (1-4%) in the very low-risk group on longitudinal follow-up. Application of the rule in the low-risk and very low-risk populations yielded sensitivities of 96% and 100% and specificities of 27% and 15%, respectively. The prevalence of PE in those who met the rule criteria was 1.4% (0.5-3.0%) and 0% (0-6.2%), respectively. The derived eight-factor block rule reduced the pretest probability below the test threshold for d-dimer in two validation populations, but the rule's utility was limited by low specificity.

PMID 15304025  J Thromb Haemost. 2004 Aug;2(8):1247-55. doi: 10.1111/j・・・
著者: S A Sahn, J E Heffner
雑誌名: N Engl J Med. 2000 Mar 23;342(12):868-74. doi: 10.1056/NEJM200003233421207.
Abstract/Text
PMID 10727592  N Engl J Med. 2000 Mar 23;342(12):868-74. doi: 10.1056/・・・
著者: Kar-mun C Woo, Jeffrey I Schneider
雑誌名: Emerg Med Clin North Am. 2009 Nov;27(4):685-712, x. doi: 10.1016/j.emc.2009.07.007.
Abstract/Text Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.

PMID 19932401  Emerg Med Clin North Am. 2009 Nov;27(4):685-712, x. doi・・・
著者: A G Fam, H A Smythe
雑誌名: CMAJ. 1985 Sep 1;133(5):379-89.
Abstract/Text The musculoskeletal structures of the thoracic wall and the neck are a relatively common source of chest pain. Pain arising from these structures is often mistaken for angina pectoris, pleurisy or other serious disorders. In this article the clinical features, pathogenesis and management of the various musculoskeletal chest wall disorders are discussed. The more common causes are costochondritis, traumatic muscle pain, trauma to the chest wall, "fibrositis" syndrome, referred pain, psychogenic regional pain syndrome, and arthritis involving articulations of the sternum, ribs and thoracic spine. Careful analysis of the history, physical findings and results of investigation is essential for precise diagnosis and effective treatment.

PMID 4027804  CMAJ. 1985 Sep 1;133(5):379-89.
著者: Benjamin Bautz, Jeffrey I Schneider
雑誌名: Emerg Med Clin North Am. 2020 May;38(2):453-498. doi: 10.1016/j.emc.2020.01.009.
Abstract/Text Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

Copyright © 2020 Elsevier Inc. All rights reserved.
PMID 32336336  Emerg Med Clin North Am. 2020 May;38(2):453-498. doi: 1・・・
著者: David A Katerndahl
雑誌名: Prim Care Companion J Clin Psychiatry. 2008;10(5):376-83.
Abstract/Text CONTEXT: Chest pain is a common symptom in primary care settings, associated with considerable morbidity and health care utilization. Failure to recognize panic disorder as the source of chest pain leads to increased health care costs and inappropriate management.
OBJECTIVE: To identify characteristics of the chest pain associated with the presence of panic disorder, review the consequences and possible mechanisms of chest pain in panic disorder, and discuss the recognition of panic disorder in patients presenting with chest pain.
DATA SOURCES: Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking.
STUDY SELECTION: The diagnosis of panic disorder in eligible studies was based on DSM criteria, and studies must have used objective criteria for coronary artery disease and risk factors. Only case control and cohort studies were included.
DATA SYNTHESIS: Although numerous chest pain characteristics (believed to be both associated and not associated with coronary artery disease) have been reportedly linked to panic disorder, only nonanginal chest pain is consistently associated with panic disorder (relative risk = 2.03, 95% CI = 1.41 to 2.92).
CONCLUSION: Chest pain during panic attacks is associated with increased health care utilization, poor quality of life, and phobic avoidance. Because the chest pain during panic attacks may be due to ischemia, the presence of panic attacks may go unrecognized. Ultimately, the diagnosis of panic disorder must be based on DSM criteria. However, once panic disorder is recognized, clinicians must remain open to the possibility of co-occurring coronary artery disease.

PMID 19158976  Prim Care Companion J Clin Psychiatry. 2008;10(5):376-8・・・

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