Chest pain, cough and dyspnea

Jump to navigation Jump to search

Chest pain Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Chest pain from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Chest Pain in Pregnancy

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Chest pain, cough and dyspnea On the Web

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chest pain, cough and dyspnea

CDC on Chest pain, cough and dyspnea

Chest pain, cough and dyspnea in the news

Blogs on Chest pain, cough and dyspnea

to Hospitals Treating Chest pain, cough and dyspnea

Risk calculators and risk factors for Chest pain, cough and dyspnea

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning


Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Cardiac Pericarditis[1][2][3] Acute or subacute May last for hours to days + + + -
Pericardial Tamponade[4][5] Acute or subacute May last for hours to days +/- + + - EKG findings:
Myocarditis[6][7][8] Acute or subacute Variable +/- + + -
Heart Failure[9][10][11] Subacute or chronic Variable
  • Dull
  • Left sided chest pain
+ +/- + + Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Pulmonary Pulmonary Embolism[12][13] Acute May last minutes to hours + +/- + -  Hormone replacement therapy

Cancer Oral contraceptive pills Stroke  Pregnancy Postpartum  Prior history of VTE Thrombophilia 

Pneumonia[14][15][16] Acute or chronic Variable
  • Dull
  • Localized to side of lesion
+ + + +/-
  • Long hospital stay
  • Ill contact exposure
  • Aspiration
Tracheitis/ Bronchitis[17][18][19][20] Acute Variable + + + -
  • Peaked P-wave
Pleuritis Acute or subacute or chronic May last minutes to hours + + + -
  • EKG done to rule out other causes in differential diagnoses
Pulmonary Hypertension[21][22][23] Acute or subacute or chronic Variable + - + -
Pleural Effusion[24][25][26] Acute or subacute or chronic Variable + +/- + +/-
  • Typically not indicated
Asthma & COPD[27][28][29][30] Acute or subacute or chronic Variable
  • Tightness
+ +/- + +/-
Pulmonary Malignancy[31][32][33][34] Chronic Variable
  • Dull aching
+ +/- + +
  • EKG may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage
Sarcoidosis[35][36][37][38] Chronic Days to week
  • Chest fullness
+ - + +
  • Diminished respiratory sounds
Acute chest syndrome (Sickle cell anemia)[39][40][41] Acute May last minutes to hours
  • Chest tightness
+ +/- + -
  • EKG typically not indicated
---
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Gastrointestinal Diffuse Esophageal Spasm[42][43][44][45] Acute
  • Minutes to hours
  • 5 to 60 minutes
+ - +/- +/- --- ---
  • Barium swallow: Multiple areas of spasm throughout the length of the esophagus
  • Impedance testing: Higher amplitudes and better transit of swallowed boluses
  • No ECG findings associated with DES, but ECG is done to exclude variant angina due to higher concurrent association of variant angina with DES 
  • Esophageal manometry : ≥20 percent premature contractions (distal latency <4.5 seconds)
Mediastinitis[46][47][48][49] Acute, Chronic Variable
  • Retrosternal irritation
+/- + + -
  • Nonspecific
  • Infection
  • Esophageal perforation
  • Post operative complication
  • Positive organisms in sternal culture
  • Leukocytosis
  • Positive blood cultures
  • Diffuse ST elevation
  • CT: Localize the infection and extent of spread
  • MRI: Assesses vascular involvement and complications
CT scan
Sliding Hiatal Hernia[50][51][52] Acute Variable + - + -
  • Trauma
  • Iatrogenic
  • Congenital malformation
  • Bowel sounds may be heard in the chest
  • Non specific
  • T wave inversion in anterior lead.
  • Barium swallow: At least three rugal folds traversing the diaphragm 
  • Upper endoscopy: A greater than 2-cm separation between the squamocolumnar junction and the diaphragmatic impression
  • High resolution manometry: The separation of the crural diaphragm from the lower esophageal sphincter (LES) by a pressure trough
  • Upper endoscopy
  • High resolution manometry (for smaller hernias)
Rheumatic Relapsing polychondritis[53] Chronic Years Intermittent pain in: + + + +
  • Autoimmune diseases
  • Negative rheumatoid factor
  • Anti-type II collagen antibodies
  • Antineutrophil cytoplasmic antibodies
  • ECG is done to rule out the cardiovascular complications of this disease
  • Non specific
  • Related to specific organ involvent
  • No gold standard test for this disease
Psychiatric Panic attack/ Disorder[54][55][56] Acute or subacute or chronic Variable Variable + - + -
  • Psychiatric disorders
  • Anxious
  • Tachypneic
  • Thyroid function tests
  • Complete blood count
  • Chemistry panel
  • Sinus Tachycardia
  • No any specific radiographic test is done
---

Others

Substance abuse

(Cocaine)[57][58][59]

Acute (hours) Minutes to hours Pressure like pain in the center of chest + + + +
  • Psychiatric disorders
    • QT prolongation
    • Sinus Tachycardia
    • Arrhythmias
    • Cardiac conduction abnormalities
---
  • Gold standard test depends on the type of substance is abuse

References

  1. Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R (March 2004). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". J. Am. Coll. Cardiol. 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364.
  2. Troughton RW, Asher CR, Klein AL (February 2004). "Pericarditis". Lancet. 363 (9410): 717–27. doi:10.1016/S0140-6736(04)15648-1. PMID 15001332.
  3. Spodick DH (March 2003). "Acute pericarditis: current concepts and practice". JAMA. 289 (9): 1150–3. PMID 12622586.
  4. Ewart W (March 1896). "Practical Aids in the Diagnosis of Pericardial Effusion, in Connection with the Question as to Surgical Treatment". Br Med J. 1 (1838): 717–21. PMC 2406464. PMID 20756103.
  5. Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W, Achenbach S, Agewall S, Al-Attar N, Angel Ferrer J, Arad M, Asteggiano R, Bueno H, Caforio AL, Carerj S, Ceconi C, Evangelista A, Flachskampf F, Giannakoulas G, Gielen S, Habib G, Kolh P, Lambrinou E, Lancellotti P, Lazaros G, Linhart A, Meurin P, Nieman K, Piepoli MF, Price S, Roos-Hesselink J, Roubille F, Ruschitzka F, Sagristà Sauleda J, Sousa-Uva M, Uwe Voigt J, Luis Zamorano J (November 2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS)". Eur. Heart J. 36 (42): 2921–64. doi:10.1093/eurheartj/ehv318. PMID 26320112.
  6. Dec GW, Palacios IF, Fallon JT, Aretz HT, Mills J, Lee DC, Johnson RA (April 1985). "Active myocarditis in the spectrum of acute dilated cardiomyopathies. Clinical features, histologic correlates, and clinical outcome". N. Engl. J. Med. 312 (14): 885–90. doi:10.1056/NEJM198504043121404. PMID 3974674.
  7. Caforio AL, Calabrese F, Angelini A, Tona F, Vinci A, Bottaro S, Ramondo A, Carturan E, Iliceto S, Thiene G, Daliento L (June 2007). "A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis". Eur. Heart J. 28 (11): 1326–33. doi:10.1093/eurheartj/ehm076. PMID 17493945.
  8. Ukena C, Mahfoud F, Kindermann I, Kandolf R, Kindermann M, Böhm M (April 2011). "Prognostic electrocardiographic parameters in patients with suspected myocarditis". Eur. J. Heart Fail. 13 (4): 398–405. doi:10.1093/eurjhf/hfq229. PMID 21239404.
  9. Anker SD, Sharma R (September 2002). "The syndrome of cardiac cachexia". Int. J. Cardiol. 85 (1): 51–66. PMID 12163209.
  10. Horwich TB, Kalantar-Zadeh K, MacLellan RW, Fonarow GC (May 2008). "Albumin levels predict survival in patients with systolic heart failure". Am. Heart J. 155 (5): 883–9. doi:10.1016/j.ahj.2007.11.043. PMID 18440336.
  11. Breathett K, Allen LA, Udelson J, Davis G, Bristow M (October 2016). "Changes in Left Ventricular Ejection Fraction Predict Survival and Hospitalization in Heart Failure With Reduced Ejection Fraction". Circ Heart Fail. 9 (10). doi:10.1161/CIRCHEARTFAILURE.115.002962. PMC 5082710. PMID 27656000.
  12. Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK (October 2007). "Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II". Am. J. Med. 120 (10): 871–9. doi:10.1016/j.amjmed.2007.03.024. PMC 2071924. PMID 17904458.
  13. "Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED)". JAMA. 263 (20): 2753–9. 1990. PMID 2332918.
  14. File TM (December 2003). "Community-acquired pneumonia". Lancet. 362 (9400): 1991–2001. doi:10.1016/S0140-6736(03)15021-0. PMID 14683661.
  15. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin. Infect. Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
  16. Musher DM, Thorner AR (October 2014). "Community-acquired pneumonia". N. Engl. J. Med. 371 (17): 1619–28. doi:10.1056/NEJMra1312885. PMID 25337751.
  17. Conley SF, Beste DJ, Hoffmann RG (May 1993). "Measles-associated bacterial tracheitis". Pediatr. Infect. Dis. J. 12 (5): 414–5. PMID 8327305.
  18. Salamone FN, Bobbitt DB, Myer CM, Rutter MJ, Greinwald JH (December 2004). "Bacterial tracheitis reexamined: is there a less severe manifestation?". Otolaryngol Head Neck Surg. 131 (6): 871–6. doi:10.1016/j.otohns.2004.06.708. PMID 15577783.
  19. Hopkins A, Lahiri T, Salerno R, Heath B (October 2006). "Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis". Pediatrics. 118 (4): 1418–21. doi:10.1542/peds.2006-0692. PMID 17015531.
  20. Liston SL, Gehrz RC, Siegel LG, Tilelli J (August 1983). "Bacterial tracheitis". Am. J. Dis. Child. 137 (8): 764–7. PMID 6869336.
  21. Mesquita SM, Castro CR, Ikari NM, Oliveira SA, Lopes AA (March 2004). "Likelihood of left main coronary artery compression based on pulmonary trunk diameter in patients with pulmonary hypertension". Am. J. Med. 116 (6): 369–74. doi:10.1016/j.amjmed.2003.11.015. PMID 15006585.
  22. Rich S, McLaughlin VV, O'Neill W (October 2001). "Stenting to reverse left ventricular ischemia due to left main coronary artery compression in primary pulmonary hypertension". Chest. 120 (4): 1412–5. PMID 11591592.
  23. Kawut SM, Silvestry FE, Ferrari VA, DeNofrio D, Axel L, Loh E, Palevsky HI (March 1999). "Extrinsic compression of the left main coronary artery by the pulmonary artery in patients with long-standing pulmonary hypertension". Am. J. Cardiol. 83 (6): 984–6, A10. PMID 10190427.
  24. Feinsilver SH, Barrows AA, Braman SS (October 1986). "Fiberoptic bronchoscopy and pleural effusion of unknown origin". Chest. 90 (4): 516–9. PMID 3757561.
  25. Collins TR, Sahn SA (June 1987). "Thoracocentesis. Clinical value, complications, technical problems, and patient experience". Chest. 91 (6): 817–22. PMID 3581930.
  26. Venekamp LN, Velkeniers B, Noppen M (2005). "Does 'idiopathic pleuritis' exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy". Respiration. 72 (1): 74–8. doi:10.1159/000083404. PMID 15753638.
  27. Kuempel ED, Wheeler MW, Smith RJ, Vallyathan V, Green FH (August 2009). "Contributions of dust exposure and cigarette smoking to emphysema severity in coal miners in the United States". Am. J. Respir. Crit. Care Med. 180 (3): 257–64. doi:10.1164/rccm.200806-840OC. PMID 19423717.
  28. Lamprecht B, McBurnie MA, Vollmer WM, Gudmundsson G, Welte T, Nizankowska-Mogilnicka E, Studnicka M, Bateman E, Anto JM, Burney P, Mannino DM, Buist SA (April 2011). "COPD in never smokers: results from the population-based burden of obstructive lung disease study". Chest. 139 (4): 752–763. doi:10.1378/chest.10-1253. PMC 3168866. PMID 20884729.
  29. Rennard S, Decramer M, Calverley PM, Pride NB, Soriano JB, Vermeire PA, Vestbo J (October 2002). "Impact of COPD in North America and Europe in 2000: subjects' perspective of Confronting COPD International Survey". Eur. Respir. J. 20 (4): 799–805. PMID 12412667.
  30. Badgett RG, Tanaka DJ, Hunt DK, Jelley MJ, Feinberg LE, Steiner JF, Petty TL (February 1993). "Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?". Am. J. Med. 94 (2): 188–96. PMID 8430714.
  31. Kocher F, Hilbe W, Seeber A, Pircher A, Schmid T, Greil R, Auberger J, Nevinny-Stickel M, Sterlacci W, Tzankov A, Jamnig H, Kohler K, Zabernigg A, Frötscher J, Oberaigner W, Fiegl M (February 2015). "Longitudinal analysis of 2293 NSCLC patients: a comprehensive study from the TYROL registry". Lung Cancer. 87 (2): 193–200. doi:10.1016/j.lungcan.2014.12.006. PMID 25564398.
  32. Hyde L, Hyde CI (March 1974). "Clinical manifestations of lung cancer". Chest. 65 (3): 299–306. PMID 4813837.
  33. Chute CG, Greenberg ER, Baron J, Korson R, Baker J, Yates J (October 1985). "Presenting conditions of 1539 population-based lung cancer patients by cell type and stage in New Hampshire and Vermont". Cancer. 56 (8): 2107–11. PMID 2992757.
  34. Hiraki A, Ueoka H, Takata I, Gemba K, Bessho A, Segawa Y, Kiura K, Eguchi K, Yoneda T, Tanimoto M, Harada M (March 2004). "Hypercalcemia-leukocytosis syndrome associated with lung cancer". Lung Cancer. 43 (3): 301–7. doi:10.1016/j.lungcan.2003.09.006. PMID 15165088.
  35. Ungprasert P, Carmona EM, Utz JP, Ryu JH, Crowson CS, Matteson EL (February 2016). "Epidemiology of Sarcoidosis 1946-2013: A Population-Based Study". Mayo Clin. Proc. 91 (2): 183–8. doi:10.1016/j.mayocp.2015.10.024. PMC 4744129. PMID 26727158.
  36. Baughman RP, Teirstein AS, Judson MA, Rossman MD, Yeager H, Bresnitz EA, DePalo L, Hunninghake G, Iannuzzi MC, Johns CJ, McLennan G, Moller DR, Newman LS, Rabin DL, Rose C, Rybicki B, Weinberger SE, Terrin ML, Knatterud GL, Cherniak R (November 2001). "Clinical characteristics of patients in a case control study of sarcoidosis". Am. J. Respir. Crit. Care Med. 164 (10 Pt 1): 1885–9. doi:10.1164/ajrccm.164.10.2104046. PMID 11734441.
  37. Rizzato G, Tinelli C (2005). "Unusual presentation of sarcoidosis". Respiration. 72 (1): 3–6. doi:10.1159/000083392. PMID 15753626.
  38. Rizzato G, Palmieri G, Agrati AM, Zanussi C (June 2004). "The organ-specific extrapulmonary presentation of sarcoidosis: a frequent occurrence but a challenge to an early diagnosis. A 3-year-long prospective observational study". Sarcoidosis Vasc Diffuse Lung Dis. 21 (2): 119–26. PMID 15281433.
  39. Vichinsky EP, Styles LA, Colangelo LH, Wright EC, Castro O, Nickerson B (March 1997). "Acute chest syndrome in sickle cell disease: clinical presentation and course. Cooperative Study of Sickle Cell Disease". Blood. 89 (5): 1787–92. PMID 9057664.
  40. Castro O, Brambilla DJ, Thorington B, Reindorf CA, Scott RB, Gillette P, Vera JC, Levy PS (July 1994). "The acute chest syndrome in sickle cell disease: incidence and risk factors. The Cooperative Study of Sickle Cell Disease". Blood. 84 (2): 643–9. PMID 7517723.
  41. Vichinsky EP, Neumayr LD, Earles AN, Williams R, Lennette ET, Dean D, Nickerson B, Orringer E, McKie V, Bellevue R, Daeschner C, Manci EA (June 2000). "Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group". N. Engl. J. Med. 342 (25): 1855–65. doi:10.1056/NEJM200006223422502. PMID 10861320.
  42. Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO (April 1987). "Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients". Ann. Intern. Med. 106 (4): 593–7. PMID 3826958.
  43. Kahrilas PJ (May 2010). "Esophageal motor disorders in terms of high-resolution esophageal pressure topography: what has changed?". Am. J. Gastroenterol. 105 (5): 981–7. doi:10.1038/ajg.2010.43. PMC 2888528. PMID 20179690.
  44. Pandolfino JE, Ghosh SK, Rice J, Clarke JO, Kwiatek MA, Kahrilas PJ (January 2008). "Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls". Am. J. Gastroenterol. 103 (1): 27–37. doi:10.1111/j.1572-0241.2007.01532.x. PMID 17900331.
  45. Kahrilas PJ, Ghosh SK, Pandolfino JE (2008). "Esophageal motility disorders in terms of pressure topography: the Chicago Classification". J. Clin. Gastroenterol. 42 (5): 627–35. doi:10.1097/MCG.0b013e31815ea291. PMC 2895002. PMID 18364587.
  46. Loyd JE, Tillman BF, Atkinson JB, Des Prez RM (September 1988). "Mediastinal fibrosis complicating histoplasmosis". Medicine (Baltimore). 67 (5): 295–310. PMID 3045478.
  47. Feigin DS, Eggleston JC, Siegelman SS (January 1979). "The multiple roentgen manifestations of sclerosing mediastinitis". Johns Hopkins Med J. 144 (1): 1–8. PMID 762913.
  48. Garrett HE, Roper CL (December 1986). "Surgical intervention in histoplasmosis". Ann. Thorac. Surg. 42 (6): 711–22. PMID 3539049.
  49. Sherrick AD, Brown LR, Harms GF, Myers JL (August 1994). "The radiographic findings of fibrosing mediastinitis". Chest. 106 (2): 484–9. PMID 7774324.
  50. Weston AP (October 1996). "Hiatal hernia with cameron ulcers and erosions". Gastrointest. Endosc. Clin. N. Am. 6 (4): 671–9. PMID 8899401.
  51. Bredenoord AJ, Weusten BL, Timmer R, Smout AJ (February 2006). "Intermittent spatial separation of diaphragm and lower esophageal sphincter favors acidic and weakly acidic reflux". Gastroenterology. 130 (2): 334–40. doi:10.1053/j.gastro.2005.10.053. PMID 16472589.
  52. Kahrilas PJ, Kim HC, Pandolfino JE (2008). "Approaches to the diagnosis and grading of hiatal hernia". Best Pract Res Clin Gastroenterol. 22 (4): 601–16. doi:10.1016/j.bpg.2007.12.007. PMC 2548324. PMID 18656819.
  53. Chopra R, Chaudhary N, Kay J (May 2013). "Relapsing polychondritis". Rheum. Dis. Clin. North Am. 39 (2): 263–76. doi:10.1016/j.rdc.2013.03.002. PMID 23597963.
  54. Fleet RP, Martel JP, Lavoie KL, Dupuis G, Beitman BD (2000). "Non-fearful panic disorder: a variant of panic in medical patients?". Psychosomatics. 41 (4): 311–20. doi:10.1176/appi.psy.41.4.311. PMID 10906353.
  55. Fleet RP, Dupuis G, Marchand A, Burelle D, Beitman BD (October 1994). "Panic disorder, chest pain and coronary artery disease: literature review". Can J Cardiol. 10 (8): 827–34. PMID 7954018.
  56. Simpson RJ, Kazmierczak T, Power KG, Sharp DM (August 1994). "Controlled comparison of the characteristics of patients with panic disorder". Br J Gen Pract. 44 (385): 352–6. PMC 1238951. PMID 8068393.
  57. Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, Pickering RP, Ruan WJ, Smith SM, Huang B, Hasin DS (August 2015). "Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III". JAMA Psychiatry. 72 (8): 757–66. doi:10.1001/jamapsychiatry.2015.0584. PMC 5240584. PMID 26039070.
  58. Cosci F, Schruers KR, Abrams K, Griez EJ (June 2007). "Alcohol use disorders and panic disorder: a review of the evidence of a direct relationship". J Clin Psychiatry. 68 (6): 874–80. PMID 17592911.
  59. George DT, Nutt DJ, Dwyer BA, Linnoila M (February 1990). "Alcoholism and panic disorder: is the comorbidity more than coincidence?". Acta Psychiatr Scand. 81 (2): 97–107. PMID 2183544.