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==Overview==
 
==Overview==
  
Prinzmetal's angina is a syndrome typically consisting of [[Angina pectoris|angina]] (cardiac chest pain) at rest that occurs in periodic cycles. Prinzmetal's angina is caused by [[vasospasm]], a narrowing of the [[coronary arteries]] caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to [[atherosclerosis]] (buildup of fatty plaque and hardening of the arteries).
+
Vasospastic angina was previously referred to as Prinzmetal or variant angina. Vasospastic angina is a syndrome typically consisting of [[Angina pectoris|angina]] (cardiac chest pain) at rest that occurs in periodic cycles. Vasospastic angina is caused by [[vasospasm]], a narrowing of the [[coronary arteries]] caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to [[atherosclerosis]] (buildup of fatty plaque and hardening of the arteries).
  
 
==Historical Perspective==
 
==Historical Perspective==

Revision as of 07:14, 9 March 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Roukoz A. Karam, M.D.[3] Synonyms and Keywords: Variant angina; angina inversa; vasospastic angina

Overview

Vasospastic angina was previously referred to as Prinzmetal or variant angina. Vasospastic angina is a syndrome typically consisting of angina (cardiac chest pain) at rest that occurs in periodic cycles. Vasospastic angina is caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to atherosclerosis (buildup of fatty plaque and hardening of the arteries).

Historical Perspective

Printzmetal's angina was first described as a variant form in 1959 by the American cardiologist Dr. Myron Prinzmetal.[1]

It was first documented by coronary arteriography in 1973.[2]

Classification

Classification by Location

Coronary artery spasm can be classified according to the location of vasoconstriction:

Focal coronary spasm

Focal coronary spasm is limited to a localized segment of the coronary artery.

Multifocal coronary spasm

Multifocal coronary spasm involves several localized segments of the same coronary artery.

Multivessel coronary spasm

Multivessel coronary spasm involves several coronary arteries.[3][4]

Classification by Clinical Syndrome

Coronary artery vasospasm can be classified into either spontaneous or iatrogenic.

Spontaneous

Iatrogenic

Pathophysiology

  • The exact pathogenesis of coronary vasospasm is not well understood, but some causes and contributing factors are known.
  • A significant group of patients with variant angina have underlying obstructive coronary artery disease.[7]

Epidemiology and Demographics

  • Incidence or prevalence of Prinzmetal angina is still unknown.
  • Young patients with fewer cardiovascular risk factors (with the exception of smoking) are at a higher risk for coronary vasospasm, as are noncalcified lesions and eccentric plaques.
  • Some studies show that the Japanese population has an increased risk of developing vasospastic angina when compared with Caucasian populations.
  • The average age of presentation of vasospastic angina is around the fifth decade of life.[8]

Risk Factors

  • Smoking[9]
  • Genetic factors and insulin resistance
    • There is some evidence that genetic factors and insulin resistance are associated with vasospastic angina

Differential diagnosis

Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders

The following table outlines the major differential diagnoses of chest pain:[10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45]

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
Stable Angina[46] Sudden (acute) 2-10 minutes - - +/- -
  • Exercise EKG: ST-segment depression
Unstable Angina[47][48][49] Acute 10-20 minutes
  • Same as stable angina but often more severe
- - + -
Myocardial Infarction[10][11][12][13] Acute Commonly > 20 minutes - - + -
  • ST elevation MI (STEMI)
  • Non-ST elevation MI (NSTEMI) or Non Q wave
  • CCTA combined with MPI
Cardiac Vasospastic/ Prinzmetal/ Variant Angina[50][51] Gradual in onset and offset Episodic, gradual in onset and offset
  • Chest discomfort described as squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, ache, and heavy weight on chest
- - + -
  • Multiple drugs (ephedrine-based products, cocaine, marijuana, alcohol, butane, sumatriptan, and amphetamines)
  • Food-born botulism
  • Guide wire or balloon dilatation while doing PCI
  • Magnesium deficiency
  • Urine drug screen may be positive for cocaine or other drugs
  • Transient (less than 15 minutes) ischemic ST changes in multiple leads
  • A tall and broad R wave,
  • Disappearance of the S wave
  • A taller T wave
  • Negative U waves
Aortic Dissection[52][53] Sudden severe progressive pain (common) or chronic (rare) Variable
  • Tearing, ripping sensation, knife like
- - + -
  • Nonspecific ST and T wave changes
Pericarditis[54][55][56] Acute or subacute May last for hours to days + + + -
Pericardial Tamponade[57][58] Acute or subacute May last for hours to days +/- + + - EKG findings:
Myocarditis[59][60][61] Acute or subacute Variable +/- + + -
Hypertrophic cardiomyopathy[62][63][64] Acute or subacute Variable Typical or atypical chest pain - - + - Non-specific

Echocardiography:

Genetic testing for HCM
Stress (takotsubo)

Cardiomyopathy[65][66][67][68]

Acute Commonly > 20 minutes - - + -
  • Setting of physical or emotional stress or critical illness
Stress
Aortic Stenosis[69][70][71] Acute, recurrent episodes of angina 2-10 minutes - - + -
Heart Failure[72][73][74] 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[75][76] Acute May last minutes to hours + +/- + -  Hormone replacement therapy

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

Spontaneous Pneumothorax[77][78] Acute May last minutes to hours - - + -
  • Rightward shift in the mean electrical axis
  • Loss of precordial R waves
  • Diminution of the QRS voltage
  • Precordial T wave inversions
  • CXR: White visceral pleural line on the chest radiograph
  • CT: small amounts of intrapleural gas, atypical collections of pleural gas, and loculated pneumothoraces
  • CT scan
Tension Pneumothorax[79][80] Acute May last minutes to hours - - + -
  • Trauma
  • Significant elevation of the ST-T segment from leads V1 to V4
Pneumonia[81][82][83] Acute or chronic Variable
  • Dull
  • Localized to side of lesion
+ + + +/-
  • Long hospital stay
  • Ill contact exposure
  • Aspiration
Tracheitis/ Bronchitis[84][85][86][87] 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[88][89][90] Acute or subacute or chronic Variable + - + -
Pleural Effusion[91][92][93] Acute or subacute or chronic Variable + +/- + +/-
  • Typically not indicated
Asthma & COPD[94][95][96][97] Acute or subacute or chronic Variable
  • Tightness
+ +/- + +/-
Pulmonary Malignancy[98][99][100][101] 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[102][103][104][105] Chronic Days to week
  • Chest fullness
+ - + +
  • Diminished respiratory sounds
Acute chest syndrome (Sickle cell anemia)[106][107][108] 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 GERD, Peptic Ulcer[109][110][111] Acute +/- - - +/-
  • Not any auscultatory findings associated with this disease
  • Enamel erosion or other dental manifestations
Diffuse Esophageal Spasm[112][113][114][115] 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)
Esophagitis[116][117][118] Acute Variable + + - +/-
  • No auscultatory finding
Eosinophilic Esophagitis[119][120][121][122][123][124] Chronic Variable + - - -
  • No auscultatory finding in the this disease
  • Typically no finding on EKG
Esophageal Perforation[15] Acute Minutes to hours
  • Burning
  • Upper abdominal
- +/- + -
    • Confirmed by water-soluble contrast esophagram
Mediastinitis[125][126][127][128] 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
 Cholelithiasis[129][130][131][132] Acute, subacute Minutes to hours - +/- - -
  • The presence of a common bile duct stone on transabdominal ultrasound

•Clinical acute cholangitis •A serum bilirubin greater than 4 mg/dL (68 micromol/L)

  • Murphy sign negative
  • Jaundice
  • ↑ALT
  • ↑AST
  • Amylase levels
  • ↑ALP
  • Typically not indicated
  • Transabdominal ultrasound (TAUS): shows gallstones
  • EUS: Detects biliary sludge
  • MRCP: Detects stones >6mm
  • Endoscopic Retrograde Cholangiopancreatography (ERCP): Diagnostic and therapeutic removal of stones
Endoscopic ultrasound and MECP
Pancreatitis[133][134][135][136][137] Acute, Chronic Variable - + + +/-
  • Alcohol abuse
  • Smoking
  • Genetic predisposition
  •  Tachypnea
  • Hypoxemia
  • Hypotension
  • Cullen's sign
  • Grey Turner sign 
  • T-wave inversion
  • ST-segment depression
  •  ST-segment elevation rarely
  • Q-waves
  • CT: focal or diffuse enlargement of the pancreas
  • MRI: Pancreatic enlargement
  • CT Scan
Sliding Hiatal Hernia[138][139][140] 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)
Musculoskeletal Costosternal syndromes (costochondritis)[141][142][143][144] Acute, subacute Days to weeks
  • Pressure like on anterior part of chest wall
- + - -
  • History of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) 
  • Trauma
  • Pain by palpation of tender areas
  • Maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuver
  • Non specific
  • EKG is done to rule out other cardiovascular causes
  • CXR: To rule out fracture
Pain by palpation of tender areas
Lower rib pain syndromes[145] Chronic Variable
  • Aching
  • Lower chest
  • Upper abdomen
- - + -
  • Common in women with a mean age in the mid-40s
---
  • Hooking maneuver
  • Reproduces pain by pressing a tender spot on the costal margin
  • Non specific
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • CXR: To rule out fracture
---
Sternalis syndrome Chronic Variable Pressure like pain
  • Over the body of sternum
  • Sternalis muscle
  • Left or middle side of the chest wall
- - - -
  • Localized tenderness is found directly over the body of the sternum or overlying sternalis muscle
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray : To rule out fracture
  • Physical exam
Tietze's syndrome[146] Acute Weeks Pressure like pain over - - - -
  • Most often involve the areas of 2nd and 3rd ribs
  • More common in young adults
  • Sternocostoclavicular hyperostosis
  • Ankylosing spondylitis
  • Upper respiratory infections
  • Excessive coughing
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray: To rule out fracture
  • Tests are done to rule out other diseases
Xiphoidalgia[147] Acute Variable Pressure like pain over
  • Over the xiphoid process
  • Sternum
  • Xiphisternal joint
- - - -
  • Symptoms are aggravated by twisting and bending movements
  • Cough
  • Heavy work
  • Provocative test
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray: To rule out fracture
  • Tests are done to rule out other diseases
Spontaneous sternoclavicular subluxation[148] Acute, Chronic Variable Aching pain over Sternoclavicular joint - - - -
  • More common in middle age women
  • Occurs in dominant hands with repetitive tasks of heavy or moderate quality
  • Trauma
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray: Sclerosis of the medial clavicle 
  • X-ray
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
Rheumatic Fibromyalgia[149][150][151] Chronic Variable - - + - ---
  • Presence of tenderness in soft-tissue anatomic locations
  • Non specific
  • Normal Blood and urine test (mandatory to rule out other diseases)
  • P-wave dispersions (Pd)
--- ---
Rheumatoid arthritis[152] Chronic Years Symmetrical joint pain in
  • Wrist
  • Fingers
  • Knees
  • Feet
  • Ankles
- + - +
  • Old age
  • Smoking
  • Autoimmune conditions
  • Positive Rheumatic Factor
  • Anti-CCP body 
  • Synovial fluid analysis: WBC between 1500 and 25,000/cubicmm, low glucose, low C3 and C4 complement level.
  • Thrombocytosis
  • Anemia
  • Mild leukocytosis
  • ECG is done rule out the heart failure as RA is one of the causes of heart failure
  • Plain film radiography: periarticular osteopenia, joint space narrowing, and bone erosions
  • MRI: Bone erosions
  • Ultrasonography: Degree of inflammation and the volume of inflamed tissue
---
Ankylosing spondylitis[153][154][155][156] Chronic Years Intermittent pain in - - - -
  • Patients with HLA-27 variant
  • Extra-articular joint involvements
  • Restrictive pulmonary disease
  • Acute coronary syndromes (ACS), strokes, venous thromboembolism, conduction abnormalities
  • Genetics (Monozygotic twins)
  • ↑ESR
  • ↑CRP
  • ↑ALP
  • ↑IgA
  • Antigen HLA-27 positive
  • Negative Rheumatic Factor
  • ECG is done to rule out conductions defects and aortic insufficiency
  • Plain radiography: Erosions, ankylosis, changes in joint width, or sclerosis.
  • Magnetic resonance imaging (MRI): Osteitis" or "bone marrow edema" (BME)
  • Plain films of the sacroiliac joints
Psoriatic arthritis[155] Chronic Years Asymmetrical intermittent pain in - - - -
  • Psoriasis
  • HLA-B*27 positive
Non specific
  • Longer PR interval 
  • X-ray: "pencil-in-cup" deformity, erosive changes and new bone formation, lysis of the terminal phalanges; fluffy periostitis
  • MRI: Detects articular, periarticular, and soft-tissue inflammation, enthesitis
  • X-ray
Sternocostoclavicular hyperostosis (SAPHO syndrome)[155][157][158][159][160] Chronic Years Recurrent and multifocal pain in

Sternoclavicular joint

- + - -

Positive family history of:

  • Spondyloarthritis
  • IBD
  • Psoriasis
  • Rheumatoid arthritis
  • Other autoimmune/autoinflammatory disease
  • Hyperostosis
  • Osteitis
  • Synovitis
  • Pustular eruptions
  • Inflammatory nodules or plaques
  • Serologic testing to exclude other diseases
  • Non specific
  • ECG is done to rule out conductions defects and aortic insufficiency
  • Plain radiography: Hyperostotic changes (thickening of periosteum, cortex, and endosteum), sclerotic lesions, osteolysis, periosteal reaction, and osteoproliferation
  • Bone scan: "bull's head" change
  • Magnetic resonance imaging: Osteitis and soft tissue involvement
  • Fluorodeoxyglucose positron emission tomography (FDG-PET)/CT: Differentiates active versus inactive lesions 
  • Bone scan
Systemic lupus erythematosus[161] [162][163] Chronic Years
  • Skin
  • Joints (fingers, wrist, knees)
  • Kidneys
  • SLE can affect any organ of the body
+/- + + +
  • HLA-genetic mutations
  • Female gender
  • Being younger than 50 
  • Autoimmune conditions
  • Genetic predisposition
  • Positive family history
  • Related to specific organ involvent
  • Anti-dsDNA antibody test
Relapsing polychondritis[164] 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[165][16][166] 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)[167][168][169]

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
Herpes Zoster[170][171][172] Acute or Chronic Variable Burning pain on
  • Chest
  • Upper back
  • Lower back
- + - -
  • Immunosuppression
  • Viral culture
  • Direct immunofluorescence testing,
  • Polymerase chain reaction assay (PCR)
  • ECG is done to rule out other cardiovascular causes of chest pain
  • Magnetic resonance imaging (MRI): To rule out encephalitis
  • Viral tissue culture

Natural History, Complications and Prognosis

  • If left untreated, 25% of patients with prinzmetal angina may progress to develop myocardial infarction and life threatening arrhythmias.[173][174]
  • Two-thirds of patients have concurrent atherosclerosis of a major coronary artery. This is often mild or not in proportion to the degree of symptoms.
  • Coronary vasospasm can lead to life-threatening arrhythmias, depending on the vessel that is involved.
  • Once detected, aggressive management of coronary vasospasm is necessary, as vasospasm can provoke fatal arrhythmias or myocardial infarction.[175]
  • Patients who have coronary artery disease in addition to coronary vasospasm have an overall worse prognosis.[176]
  • The prognosis of vasospastic angina depends on the extent of underlying coronary artery disease (CAD).

History and Symptoms

While the symptoms of chronic stable angina occur with exertion, the symptoms of Prinzmetal's angina typically occur at rest. The symptoms may occur reproducibly at certain times of the day or night. In the classic description, the symptoms often come on at night.

Diagnosis

  • Physicians should suspect vasospasm if ST segment elevation is detected in patients experiencing angina, and if the ECG completely returns to baseline upon resolution of symptoms.
    • These changes are usually transient (less than 15 minutes) and may occur in multiple leads of a 12-lead ECG.
  • Patients who develop cardiac chest pain are generally treated empirically as an "acute coronary syndrome" patient, and are generally evaluated with serial testing of cardiac enzymes such as creatine kinase isoenzymes or troponin I or T. These may in some cases be abnormal or positive, as coronary spasm can lead to myocardial necrosis in severe cases.
  • The gold standard test is coronary angiography including the administration of provocative agents, such as acetylcholine or ergonovine, via the intracoronary route. The definitive diagnosis of coronary vasospasm is made angiographically by demonstration of reduction of luminal diameter in a discrete segment of the vessel, which is proven to be reversible. Reversibility may be demonstrated by previous or subsequent enlargement of luminal diameter, often after the administration of intracoronary vasodilators.
  • It should be noted that two-thirds of patients with Prinzmetal's angina have concurrent atherosclerosis of a major coronary artery, but the extent of the atherosclerosis is generally mild, and the symptoms are out of proportion to the extent of disease. Depending on the local protocol, provocative testing may utilize either ergonovine, methylergonovine or acetylcholine. Exaggerated spasm is diagnostic of Prinzmetal's angina. Care should be taken to have nitrates and calcium channel agents readily available to reverse the spasm.

Electrocardiogram

Prinzmetal's angina is associated with transmural injury and ST segment elevation rather than ST segment depression.

The most important ECG change during a focal proximal coronary spasm is in around 50% of cases the appearance of peaked and symmetrical T wave that is followed, if the spasm persist, by progressive ST-segment elevation that last for a few minutes, and later progressively resolve.[177]

The most frequent ECG changes associated with ST-segment elevation are:

  • Increased height of the R wave
  • Coincident S-wave diminution
  • Upsloping TQ in many cases
  • Alternans of the elevated ST-segment
  • Negative T wave deepness
    • In 20% of cases.

Treatment

Prinzmetal angina typically responds to nitrates and calcium channel blockers. Patients with multivessel spasm, refractory spasm, spasm that results in sudden death may benefit from dual calcium channel blocker therapy.

  • Calcium channel blockers:
    • Generally, well tolerated and can aid with hypertension control.[178]
    • A combination of dihyropyridine and non-dihydropyridine calcium channel blockers should be used in patients with refractory coronary vasospasm, particularly if it has resulted in ventricular arrhythmia.
    • Multiple calcium channel blockers may be required in patients with refractory or multi-vessel spasm.
    • A patient who has suffered ventricular tachycardia or ventricular fibrillation due to spontaneous vasospasm (not due to acute infarction) should also likely undergo ICD placement.
      • Diltiazem 240-360 mg PO qd
      • Verapamil 240-480 mg PO qd
      • Nifedipine XL 60-120 mg PO qd
      • Nicardipine 40-160 mg PO qd
  • Long-acting nitrates:
    • Generally, well tolerated and can aid with hypertension control.[179]
      • Isosorbide mononitrate (Imdur) 60-240 mg PO qd
      • Isosorbide dinitrate (Isordil) 20-40 mg PO tid
  • Statins:
    • May improve endothelial dysfunction and lower inflammation. A small, randomized control trial showed that fluvastatin 30 mg daily reduced rates of vasospasm. Statins also provide benefits of LDL lowering and plaque stabilization.[180]
      • Fluvastatin 30 mg PO qd
  • Hormone replacement therapy:
    • This remains controversial, particularly due to the risk of concern of increased cardiac events.
  • Smoking cessation:
  • Percutaneous coronary intervention:
    • While resolution occurs following PTCA/stenting in some cases, spasm can propagate to a new location, proximal or distal to the stented site.[182]
    • PCI is not commonly indicated for patients with focal spasm and minimal obstructive disease. However, it may be helpful if significant obstructive coronary disease is present and thought to be a potential trigger for focal spasm.
  • ICD placement:
  • Surgical autonomic denervation/plexectomy:
    • Can be useful in cases that are refractory to medical therapy or percutaneous intervention. It's reserved only for the most refractory cases.

Making a Selection

  • Treatment of chronic vasospasm should be performed in this order (step-wise fashion): medical therapy, percutaneous intervention, and then, surgery.

Medical Therapy

  • Risk factor modification (smoking cessation, lipid control) is recommended for all patients.
  • Begin pharmacologic therapy with oral calcium channel blockers (diltiazem, verapamil, nifedipine) and/or nitrates. If monotherapy is ineffective, begin combination therapy which is generally well tolerated (10% of patients may require 2 calcium channel blockers). If refractory or multi-vessel spasm is present, multiple CCBs are likely necessary, as these patients are at high risk for ventricular arrhythmias. Alpha blockers may also be useful if there is incomplete response to CCB and nitrates.
  • Due to their ability to improve endothelial function, statins should be considered for vasospasm.
  • Certain medications should be avoided: nonselective beta blockers, aspirin, and sumatriptan can exacerbate vasospasm. Hormone replacement therapy (estrogen-progestin) have been associated with an increase in cardiac events (HERS-II and WHI trials) and should also be avoided.

Percutaneous Intervention (PCI)

  • If vasospasm has a clearly definable area that is associated with coronary artery disease and refractory to medical therapy, stenting may be an effective strategy. However, stenting may simply propagate the spasm to a proximal or distal location in the vessel.
  • Following any PCI, adjunctive medical therapy must be continued.
  • Resolution of symptoms, ECG changes, and angiographic vasospasm is usually apparent within one minute post-procedure.
  • Refractory spasm occurring during PCI is likely secondary to dissection, which requires stenting unless the artery is small and the patient is clinically stable.
  • The role of revascularization in the setting of multivessel vasospasm is uncertain.

Surgery

  • In the rare circumstance that a patient is refractory to pharmacologic and percutaneous therapy, surgical denervation and plexectomy have been effective.

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [183]

Recommendations for Prizmental's angina

Class I
"1.CCBs alone or in combination with long-acting nitrates are useful to treat and reduce the frequency of vasospastic angina.(Level of Evidence: B)"
"2.Treatment with HMG-CoA reductase inhibitor, cessation of tobacco use, and additional atherosclerosis risk factor modification and are useful in patients with vasospastic angina. (Level of Evidence: B)"
"3.Coronary angiography (invasive or noninvasive) is recommended in patients with episodic chest pain accompanied by transient ST-elevation to rule out severe obstructive CAD. (Level of Evidence: C)"
Class IIb
"1. Provocative testing during invasive coronary angiography†† may be considered in patients with suspected vasospastic angina when clinical criteria and noninvasive testing fail to establish the diagnosis (Level of Evidence: B)"

ESC Guidelines for Diagnostic Tests in Suspected Vasospastic Angina (DO NOT EDIT)[184]

Class I
"1. ECG during angina if possible. (Level of Evidence: B)"
"2. Coronary arteriography in patients with characteristic episodic chest pain and ST-segment changes that resolve with nitrates and/or calcium channel blockers to determine the extent of underlying coronary disease. (Level of Evidence: B)"
Class IIa
"1. Intracoronary provocative testing to identify coronary spasm in patients with normal findings or nonobstructive lesions on coronary arteriography and the clinical picture of coronary spasm. (Level of Evidence: B)"
"2. Ambulatory ST Segment Monitoring to identify ST-deviation. (Level of Evidence: C)"

ESC Guidelines for Pharmacological Therapy of Vasospastic Angina (DO NOT EDIT)[184]

Class I
"1. Treatment with calcium channel blocker and if necessary nitrates in patients whose coronary arteriogram is normal or shows only non-obstructive lesions. (Level of Evidence: B)"

References

  1. Prinzmetal M, Kennamer R, Merliss R. of angina pectoris. Am J Med 1959;27:375-88. PMID 14434946.
  2. Oliva PB, Potts DE, Pluss RG (1973). "Coronary arterial spasm in Prinzmetal angina. Documentation by coronary arteriography". N Engl J Med. 288 (15): 745–51. doi:10.1056/NEJM197304122881501. PMID 4688712.
  3. Ahooja V, Thatai D (2007). "Multivessel coronary vasospasm mimicking triple-vessel obstructive coronary artery disease". J Invasive Cardiol. 19 (7): E178–81. PMID 17620681. Unknown parameter |month= ignored (help)
  4. Miwa K, Ishii K, Makita T, Okuda N (2004). "Diagnosis of multivessel coronary vasospasm by detecting postischemic regional left ventricular delayed relaxation on echocardiography using color kinesis". Circ. J. 68 (5): 483–7. PMID 15118293. Unknown parameter |month= ignored (help)
  5. Lanza GA, Careri G, Crea F (2011). "Mechanisms of coronary artery spasm". Circulation. 124 (16): 1774–82. doi:10.1161/CIRCULATIONAHA.111.037283. PMID 22007100.
  6. Mahemuti A, Abudureheman K, Schiele F, Ecarnot F, Abudureyimu S, Tang B; et al. (2014). "Association between inflammatory markers, hemostatic markers, and traditional risk factors on coronary artery spasm in patients with normal coronary angiography". J Interv Cardiol. 27 (1): 29–35. doi:10.1111/joic.12086. PMID 24345233.
  7. Maseri A, Severi S, Nes MD, L'Abbate A, Chierchia S, Marzilli M et al. (1978) "Variant" angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. Pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients. Am J Cardiol 42 (6):1019-35. PMID: 727129
  8. Kim HL, Lee SH, Kim J, Kim HJ, Lim WH, Seo JB; et al. (2016). "Incidence and Risk Factors Associated With Hospitalization for Variant Angina in Korea". Medicine (Baltimore). 95 (13): e3237. doi:10.1097/MD.0000000000003237. PMC 4998556. PMID 27043695.
  9. Takaoka K, Yoshimura M, Ogawa H, Kugiyama K, Nakayama M, Shimasaki Y; et al. (2000). "Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking". Int J Cardiol. 72 (2): 121–6. doi:10.1016/s0167-5273(99)00172-2. PMID 10646952.
  10. 10.0 10.1 Svavarsdóttir AE, Jónasson MR, Gudmundsson GH, Fjeldsted K (June 1996). "Chest pain in family practice. Diagnosis and long-term outcome in a community setting". Can Fam Physician. 42: 1122–8. PMC 2146490. PMID 8704488.
  11. 11.0 11.1 Klinkman MS, Stevens D, Gorenflo DW (April 1994). "Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network". J Fam Pract. 38 (4): 345–52. PMID 8163958.
  12. 12.0 12.1 Bösner S, Becker A, Haasenritter J, Abu Hani M, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Seitz G, Baum E, Donner-Banzhoff N (2009). "Chest pain in primary care: epidemiology and pre-work-up probabilities". Eur J Gen Pract. 15 (3): 141–6. doi:10.3109/13814780903329528. PMID 19883149.
  13. 13.0 13.1 Ebell MH (March 2011). "Evaluation of chest pain in primary care patients". Am Fam Physician. 83 (5): 603–5. PMID 21391528.
  14. von Kodolitsch Y, Schwartz AG, Nienaber CA (October 2000). "Clinical prediction of acute aortic dissection". Arch. Intern. Med. 160 (19): 2977–82. PMID 11041906.
  15. 15.0 15.1 Pate JW, Walker WA, Cole FH, Owen EW, Johnson WH (May 1989). "Spontaneous rupture of the esophagus: a 30-year experience". Ann. Thorac. Surg. 47 (5): 689–92. PMID 2730190.
  16. 16.0 16.1 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.
  17. Bass C, Chambers JB, Kiff P, Cooper D, Gardner WN (December 1988). "Panic anxiety and hyperventilation in patients with chest pain: a controlled study". Q. J. Med. 69 (260): 949–59. PMID 3270082.
  18. Evans DW, Lum LC (January 1977). "Hyperventilation: An important cause of pseudoangina". Lancet. 1 (8004): 155–7. PMID 64694.
  19. Ros E, Armengol X, Grande L, Toledo-Pimentel V, Lacima G, Sanz G (July 1997). "Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder?". Dig. Dis. Sci. 42 (7): 1344–53. PMID 9246027.
  20. Ben Freedman S, Tennant CC (April 1998). "Panic disorder and coronary artery spasm". Med. J. Aust. 168 (8): 376–7. PMID 9594945.
  21. Smoller JW, Pollack MH, Wassertheil-Smoller S, Jackson RD, Oberman A, Wong ND, Sheps D (October 2007). "Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study". Arch. Gen. Psychiatry. 64 (10): 1153–60. doi:10.1001/archpsyc.64.10.1153. PMID 17909127.
  22. Mehta NJ, Khan IA (November 2002). "Cardiac Munchausen syndrome". Chest. 122 (5): 1649–53. PMID 12426266.
  23. Swap CJ, Nagurney JT (November 2005). "Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes". JAMA. 294 (20): 2623–9. doi:10.1001/jama.294.20.2623. PMID 16304077.
  24. Marcus GM, Cohen J, Varosy PD, Vessey J, Rose E, Massie BM, Chatterjee K, Waters D (January 2007). "The utility of gestures in patients with chest discomfort". Am. J. Med. 120 (1): 83–9. doi:10.1016/j.amjmed.2006.05.045. PMID 17208083.
  25. Verdon F, Burnand B, Herzig L, Junod M, Pécoud A, Favrat B (September 2007). "Chest wall syndrome among primary care patients: a cohort study". BMC Fam Pract. 8: 51. doi:10.1186/1471-2296-8-51. PMC 2072948. PMID 17850647.
  26. Davies HA, Jones DB, Rhodes J, Newcombe RG (December 1985). "Angina-like esophageal pain: differentiation from cardiac pain by history". J. Clin. Gastroenterol. 7 (6): 477–81. PMID 4086742.
  27. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL (October 1998). "The rational clinical examination. Is this patient having a myocardial infarction?". JAMA. 280 (14): 1256–63. PMID 9786377.
  28. Berger JP, Buclin T, Haller E, Van Melle G, Yersin B (March 1990). "Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain". J. Intern. Med. 227 (3): 165–72. PMID 2313224.
  29. Yelland MJ (September 2001). "Back, chest and abdominal pain. How good are spinal signs at identifying musculoskeletal causes of back, chest or abdominal pain?". Aust Fam Physician. 30 (9): 908–12. PMID 11676323.
  30. Chan S, Maurice AP, Davies SR, Walters DL (October 2014). "The use of gastrointestinal cocktail for differentiating gastro-oesophageal reflux disease and acute coronary syndrome in the emergency setting: a systematic review". Heart Lung Circ. 23 (10): 913–23. doi:10.1016/j.hlc.2014.03.030. PMID 24791662.
  31. Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, Bushnell AC, Chandra-Strobos N (December 2003). "Chest pain relief by nitroglycerin does not predict active coronary artery disease". Ann. Intern. Med. 139 (12): 979–86. PMID 14678917.
  32. Pryor DB, Harrell FE, Lee KL, Califf RM, Rosati RA (November 1983). "Estimating the likelihood of significant coronary artery disease". Am. J. Med. 75 (5): 771–80. PMID 6638047.
  33. Buntinx F, Knockaert D, Bruyninckx R, de Blaey N, Aerts M, Knottnerus JA, Delooz H (December 2001). "Chest pain in general practice or in the hospital emergency department: is it the same?". Fam Pract. 18 (6): 586–9. PMID 11739341.
  34. Tierney WM, Roth BJ, Psaty B, McHenry R, Fitzgerald J, Stump DL, Anderson FK, Ryder KW, McDonald CJ, Smith DM (July 1985). "Predictors of myocardial infarction in emergency room patients". Crit. Care Med. 13 (7): 526–31. PMID 4006491.
  35. Sequist TD, Marshall R, Lampert S, Buechler EJ, Lee TH (November 2006). "Missed opportunities in the primary care management of early acute ischemic heart disease". Arch. Intern. Med. 166 (20): 2237–43. doi:10.1001/archinte.166.20.2237. PMID 17101942.
  36. Norell M, Lythall D, Coghlan G, Cheng A, Kushwaha S, Swan J, Ilsley C, Mitchell A (January 1992). "Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic". Br Heart J. 67 (1): 53–6. PMC 1024701. PMID 1739527.
  37. Law K, Elley R, Tietjens J, Mann S (July 2006). "Troponin testing for chest pain in primary healthcare: a survey of its use by general practitioners in New Zealand". N. Z. Med. J. 119 (1238): U2082. PMID 16868579.
  38. Wilhelmsen L, Rosengren A, Hagman M, Lappas G (July 1998). ""Nonspecific" chest pain associated with high long-term mortality: results from the primary prevention study in Göteborg, Sweden". Clin Cardiol. 21 (7): 477–82. PMID 9669056.
  39. Ruigómez A, Rodríguez LA, Wallander MA, Johansson S, Jones R (April 2006). "Chest pain in general practice: incidence, comorbidity and mortality". Fam Pract. 23 (2): 167–74. doi:10.1093/fampra/cmi124. PMID 16461444.
  40. Robinson JG, Wallace R, Limacher M, Sato A, Cochrane B, Wassertheil-Smoller S, Ockene JK, Blanchette PL, Ko MG (December 2006). "Elderly women diagnosed with nonspecific chest pain may be at increased cardiovascular risk". J Womens Health (Larchmt). 15 (10): 1151–60. doi:10.1089/jwh.2006.15.1151. PMID 17199456.
  41. Geraldine McMahon C, Yates DW, Hollis S (February 2008). "Unexpected mortality in patients discharged from the emergency department following an episode of nontraumatic chest pain". Eur J Emerg Med. 15 (1): 3–8. doi:10.1097/MEJ.0b013e32827b14cd. PMID 18180659.
  42. Yelland M, Cayley WE, Vach W (March 2010). "An algorithm for the diagnosis and management of chest pain in primary care". Med. Clin. North Am. 94 (2): 349–74. doi:10.1016/j.mcna.2010.01.011. PMID 20380960.
  43. Wang WH, Huang JQ, Zheng GF, Wong WM, Lam SK, Karlberg J, Xia HH, Fass R, Wong BC (June 2005). "Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis". Arch. Intern. Med. 165 (11): 1222–8. doi:10.1001/archinte.165.11.1222. PMID 15956000.
  44. Borzecki AM, Pedrosa MC, Prashker MJ (March 2000). "Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis". Arch. Intern. Med. 160 (6): 844–52. PMID 10737285.
  45. Wertli MM, Ruchti KB, Steurer J, Held U (November 2013). "Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis". BMC Med. 11: 239. doi:10.1186/1741-7015-11-239. PMC 4226211. PMID 24207111.
  46. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL (December 2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): e354–471. doi:10.1161/CIR.0b013e318277d6a0. PMID 23166211.
  47. Tatum JL, Jesse RL, Kontos MC, Nicholson CS, Schmidt KL, Roberts CS, Ornato JP (January 1997). "Comprehensive strategy for the evaluation and triage of the chest pain patient". Ann Emerg Med. 29 (1): 116–25. PMID 8998090.
  48. Ornato JP (August 1999). "Chest pain emergency centers: improving acute myocardial infarction care". Clin Cardiol. 22 (8 Suppl): IV3–9. PMID 10492848.
  49. Gibler WB (August 1995). "Evaluation of chest pain in the emergency department". Ann. Intern. Med. 123 (4): 315, author reply 317–8. PMID 7611601.
  50. PRINZMETAL M, KENNAMER R, MERLISS R, WADA T, BOR N (September 1959). "Angina pectoris. I. A variant form of angina pectoris; preliminary report". Am. J. Med. 27: 375–88. PMID 14434946.
  51. Kaski JC, Crea F, Meran D, Rodriguez L, Araujo L, Chierchia S, Davies G, Maseri A (December 1986). "Local coronary supersensitivity to diverse vasoconstrictive stimuli in patients with variant angina". Circulation. 74 (6): 1255–65. PMID 3779913.
  52. Takagi H, Ando T, Umemoto T (November 2017). "Meta-Analysis of Circadian Variation in the Onset of Acute Aortic Dissection". Am. J. Cardiol. 120 (9): 1662–1666. doi:10.1016/j.amjcard.2017.07.067. PMID 28847596.
  53. Kojima S, Sumiyoshi M, Nakata Y, Daida H (March 2002). "Triggers and circadian distribution of the onset of acute aortic dissection". Circ. J. 66 (3): 232–5. PMID 11922269.
  54. 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.
  55. Troughton RW, Asher CR, Klein AL (February 2004). "Pericarditis". Lancet. 363 (9410): 717–27. doi:10.1016/S0140-6736(04)15648-1. PMID 15001332.
  56. Spodick DH (March 2003). "Acute pericarditis: current concepts and practice". JAMA. 289 (9): 1150–3. PMID 12622586.
  57. 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.
  58. 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.
  59. 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.
  60. 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.
  61. 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.
  62. Elliott PM, Kaski JC, Prasad K, Seo H, Slade AK, Goldman JH, McKenna WJ (July 1996). "Chest pain during daily life in patients with hypertrophic cardiomyopathy: an ambulatory electrocardiographic study". Eur. Heart J. 17 (7): 1056–64. PMID 8809524.
  63. Pasternac A, Noble J, Streulens Y, Elie R, Henschke C, Bourassa MG (April 1982). "Pathophysiology of chest pain in patients with cardiomyopathies and normal coronary arteries". Circulation. 65 (4): 778–89. PMID 7199403.
  64. Webb JG, Sasson Z, Rakowski H, Liu P, Wigle ED (January 1990). "Apical hypertrophic cardiomyopathy: clinical follow-up and diagnostic correlates". J. Am. Coll. Cardiol. 15 (1): 83–90. PMID 2295747.
  65. Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ (February 2005). "Acute and reversible cardiomyopathy provoked by stress in women from the United States". Circulation. 111 (4): 472–9. doi:10.1161/01.CIR.0000153801.51470.EB. PMID 15687136.
  66. Krishnamoorthy P, Garg J, Sharma A, Palaniswamy C, Shah N, Lanier G, Patel NC, Lavie CJ, Ahmad H (July 2015). "Gender Differences and Predictors of Mortality in Takotsubo Cardiomyopathy: Analysis from the National Inpatient Sample 2009-2010 Database". Cardiology. 132 (2): 131–136. doi:10.1159/000430782. PMID 26159108.
  67. Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, Cammann VL, Sarcon A, Geyer V, Neumann CA, Seifert B, Hellermann J, Schwyzer M, Eisenhardt K, Jenewein J, Franke J, Katus HA, Burgdorf C, Schunkert H, Moeller C, Thiele H, Bauersachs J, Tschöpe C, Schultheiss HP, Laney CA, Rajan L, Michels G, Pfister R, Ukena C, Böhm M, Erbel R, Cuneo A, Kuck KH, Jacobshagen C, Hasenfuss G, Karakas M, Koenig W, Rottbauer W, Said SM, Braun-Dullaeus RC, Cuculi F, Banning A, Fischer TA, Vasankari T, Airaksinen KE, Fijalkowski M, Rynkiewicz A, Pawlak M, Opolski G, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Crea F, Dichtl W, Franz WM, Empen K, Felix SB, Delmas C, Lairez O, Erne P, Bax JJ, Ford I, Ruschitzka F, Prasad A, Lüscher TF (September 2015). "Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy". N. Engl. J. Med. 373 (10): 929–38. doi:10.1056/NEJMoa1406761. PMID 26332547.
  68. Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS (December 2004). "Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction". Ann. Intern. Med. 141 (11): 858–65. PMID 15583228.
  69. Green SJ, Pizzarello RA, Padmanabhan VT, Ong LY, Hall MH, Tortolani AJ (April 1985). "Relation of angina pectoris to coronary artery disease in aortic valve stenosis". Am. J. Cardiol. 55 (8): 1063–5. PMID 3984868.
  70. Silaruks S, Clark D, Thinkhamrop B, Sia B, Buxton B, Tonkin A (2001). "Angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis". Heart Lung Circ. 10 (1): 14–23. doi:10.1046/j.1444-2892.2001.00060.x. PMID 16352020.
  71. Munt B, Legget ME, Kraft CD, Miyake-Hull CY, Fujioka M, Otto CM (February 1999). "Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome". Am. Heart J. 137 (2): 298–306. doi:10.1053/hj.1999.v137.95496. PMID 9924164.
  72. Anker SD, Sharma R (September 2002). "The syndrome of cardiac cachexia". Int. J. Cardiol. 85 (1): 51–66. PMID 12163209.
  73. 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.
  74. 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.
  75. 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.
  76. "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.
  77. Bense L, Wiman LG, Hedenstierna G (September 1987). "Onset of symptoms in spontaneous pneumothorax: correlations to physical activity". Eur J Respir Dis. 71 (3): 181–6. PMID 3678419.
  78. Seow A, Kazerooni EA, Pernicano PG, Neary M (February 1996). "Comparison of upright inspiratory and expiratory chest radiographs for detecting pneumothoraces". AJR Am J Roentgenol. 166 (2): 313–6. doi:10.2214/ajr.166.2.8553937. PMID 8553937.
  79. Stark P, Leung A (1996). "Effects of lobar atelectasis on the distribution of pleural effusion and pneumothorax". J Thorac Imaging. 11 (2): 145–9. PMID 8820023.
  80. Jalli R, Sefidbakht S, Jafari SH (April 2013). "Value of ultrasound in diagnosis of pneumothorax: a prospective study". Emerg Radiol. 20 (2): 131–4. doi:10.1007/s10140-012-1091-7. PMID 23179505.
  81. File TM (December 2003). "Community-acquired pneumonia". Lancet. 362 (9400): 1991–2001. doi:10.1016/S0140-6736(03)15021-0. PMID 14683661.
  82. 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.
  83. Musher DM, Thorner AR (October 2014). "Community-acquired pneumonia". N. Engl. J. Med. 371 (17): 1619–28. doi:10.1056/NEJMra1312885. PMID 25337751.
  84. Conley SF, Beste DJ, Hoffmann RG (May 1993). "Measles-associated bacterial tracheitis". Pediatr. Infect. Dis. J. 12 (5): 414–5. PMID 8327305.
  85. 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.
  86. 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.
  87. Liston SL, Gehrz RC, Siegel LG, Tilelli J (August 1983). "Bacterial tracheitis". Am. J. Dis. Child. 137 (8): 764–7. PMID 6869336.
  88. 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.
  89. 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.
  90. 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.
  91. Feinsilver SH, Barrows AA, Braman SS (October 1986). "Fiberoptic bronchoscopy and pleural effusion of unknown origin". Chest. 90 (4): 516–9. PMID 3757561.
  92. Collins TR, Sahn SA (June 1987). "Thoracocentesis. Clinical value, complications, technical problems, and patient experience". Chest. 91 (6): 817–22. PMID 3581930.
  93. 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.
  94. 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.
  95. 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.
  96. 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.
  97. 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.
  98. 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.
  99. Hyde L, Hyde CI (March 1974). "Clinical manifestations of lung cancer". Chest. 65 (3): 299–306. PMID 4813837.
  100. 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.
  101. 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.
  102. 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.
  103. 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.
  104. Rizzato G, Tinelli C (2005). "Unusual presentation of sarcoidosis". Respiration. 72 (1): 3–6. doi:10.1159/000083392. PMID 15753626.
  105. 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.
  106. 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.
  107. 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.
  108. 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.
  109. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R (August 2006). "The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus". Am. J. Gastroenterol. 101 (8): 1900–20, quiz 1943. doi:10.1111/j.1572-0241.2006.00630.x. PMID 16928254.
  110. Vakil NB, Traxler B, Levine D (August 2004). "Dysphagia in patients with erosive esophagitis: prevalence, severity, and response to proton pump inhibitor treatment". Clin. Gastroenterol. Hepatol. 2 (8): 665–8. PMID 15290658.
  111. Giannini EG, Zentilin P, Dulbecco P, Vigneri S, Scarlata P, Savarino V (February 2008). "Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment". Am. J. Gastroenterol. 103 (2): 267–75. doi:10.1111/j.1572-0241.2007.01659.x. PMID 18289194.
  112. 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.
  113. 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.
  114. 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.
  115. 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.
  116. Bott S, Prakash C, McCallum RW (August 1987). "Medication-induced esophageal injury: survey of the literature". Am. J. Gastroenterol. 82 (8): 758–63. PMID 3605035.
  117. Parfitt JR, Jayakumar S, Driman DK (September 2008). "Mycophenolate mofetil-related gastrointestinal mucosal injury: variable injury patterns, including graft-versus-host disease-like changes". Am. J. Surg. Pathol. 32 (9): 1367–72. PMID 18763324.
  118. Jaspersen D (March 2000). "Drug-induced oesophageal disorders: pathogenesis, incidence, prevention and management". Drug Saf. 22 (3): 237–49. PMID 10738847.
  119. Kapel RC, Miller JK, Torres C, Aksoy S, Lash R, Katzka DA (May 2008). "Eosinophilic esophagitis: a prevalent disease in the United States that affects all age groups". Gastroenterology. 134 (5): 1316–21. doi:10.1053/j.gastro.2008.02.016. PMID 18471509.
  120. Straumann A, Rossi L, Simon HU, Heer P, Spichtin HP, Beglinger C (March 2003). "Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis?". Gastrointest. Endosc. 57 (3): 407–12. doi:10.1067/mge.2003.123. PMID 12612531.
  121. Straumann A, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A (May 2008). "Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients". Clin. Gastroenterol. Hepatol. 6 (5): 598–600. doi:10.1016/j.cgh.2008.02.003. PMID 18407800.
  122. Prasad GA, Alexander JA, Schleck CD, Zinsmeister AR, Smyrk TC, Elias RM, Locke GR, Talley NJ (October 2009). "Epidemiology of eosinophilic esophagitis over three decades in Olmsted County, Minnesota". Clin. Gastroenterol. Hepatol. 7 (10): 1055–61. doi:10.1016/j.cgh.2009.06.023. PMC 3026355. PMID 19577011.
  123. Prasad GA, Talley NJ, Romero Y, Arora AS, Kryzer LA, Smyrk TC, Alexander JA (December 2007). "Prevalence and predictive factors of eosinophilic esophagitis in patients presenting with dysphagia: a prospective study". Am. J. Gastroenterol. 102 (12): 2627–32. doi:10.1111/j.1572-0241.2007.01512.x. PMID 17764492.
  124. Desai TK, Stecevic V, Chang CH, Goldstein NS, Badizadegan K, Furuta GT (June 2005). "Association of eosinophilic inflammation with esophageal food impaction in adults". Gastrointest. Endosc. 61 (7): 795–801. PMID 15933677.
  125. Loyd JE, Tillman BF, Atkinson JB, Des Prez RM (September 1988). "Mediastinal fibrosis complicating histoplasmosis". Medicine (Baltimore). 67 (5): 295–310. PMID 3045478.
  126. 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.
  127. Garrett HE, Roper CL (December 1986). "Surgical intervention in histoplasmosis". Ann. Thorac. Surg. 42 (6): 711–22. PMID 3539049.
  128. Sherrick AD, Brown LR, Harms GF, Myers JL (August 1994). "The radiographic findings of fibrosing mediastinitis". Chest. 106 (2): 484–9. PMID 7774324.
  129. Fitzgerald JE, White MJ, Lobo DN (April 2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
  130. Yang MH, Chen TH, Wang SE, Tsai YF, Su CH, Wu CW, Lui WY, Shyr YM (July 2008). "Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy". Surg Endosc. 22 (7): 1620–4. doi:10.1007/s00464-007-9665-2. PMID 18000708.
  131. Prat F, Meduri B, Ducot B, Chiche R, Salimbeni-Bartolini R, Pelletier G (March 1999). "Prediction of common bile duct stones by noninvasive tests". Ann. Surg. 229 (3): 362–8. PMC 1191701. PMID 10077048.
  132. Tse F, Barkun JS, Barkun AN (September 2004). "The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy". Gastrointest. Endosc. 60 (3): 437–48. PMID 15332044.
  133. Dickson AP, Imrie CW (October 1984). "The incidence and prognosis of body wall ecchymosis in acute pancreatitis". Surg Gynecol Obstet. 159 (4): 343–7. PMID 6237447.
  134. Yadav D, Agarwal N, Pitchumoni CS (June 2002). "A critical evaluation of laboratory tests in acute pancreatitis". Am. J. Gastroenterol. 97 (6): 1309–18. doi:10.1111/j.1572-0241.2002.05766.x. PMID 12094843.
  135. Fortson MR, Freedman SN, Webster PD (December 1995). "Clinical assessment of hyperlipidemic pancreatitis". Am. J. Gastroenterol. 90 (12): 2134–9. PMID 8540502.
  136. Lecesne R, Taourel P, Bret PM, Atri M, Reinhold C (June 1999). "Acute pancreatitis: interobserver agreement and correlation of CT and MR cholangiopancreatography with outcome". Radiology. 211 (3): 727–35. doi:10.1148/radiology.211.3.r99jn08727. PMID 10352598.
  137. Stimac D, Miletić D, Radić M, Krznarić I, Mazur-Grbac M, Perković D, Milić S, Golubović V (May 2007). "The role of nonenhanced magnetic resonance imaging in the early assessment of acute pancreatitis". Am. J. Gastroenterol. 102 (5): 997–1004. doi:10.1111/j.1572-0241.2007.01164.x. PMID 17378903.
  138. Weston AP (October 1996). "Hiatal hernia with cameron ulcers and erosions". Gastrointest. Endosc. Clin. N. Am. 6 (4): 671–9. PMID 8899401.
  139. 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.
  140. 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.
  141. Wolf E, Stern S (February 1976). "Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease". Arch. Intern. Med. 136 (2): 189–91. PMID 1247350.
  142. Fam AG, Smythe HA (September 1985). "Musculoskeletal chest wall pain". CMAJ. 133 (5): 379–89. PMC 1346531. PMID 4027804.
  143. Bösner S, Becker A, Hani MA, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Haasenritter J, Baum E, Donner-Banzhoff N (August 2010). "Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis". Fam Pract. 27 (4): 363–9. doi:10.1093/fampra/cmq024. PMID 20406787.
  144. Zaruba RA, Wilson E (June 2017). "IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES". Int J Sports Phys Ther. 12 (3): 458–467. PMC 5455195. PMID 28593100.
  145. Scott EM, Scott BB (July 1993). "Painful rib syndrome--a review of 76 cases". Gut. 34 (7): 1006–8. PMC 1374244. PMID 8344569.
  146. Aeschlimann A, Kahn MF (1990). "Tietze's syndrome: a critical review". Clin. Exp. Rheumatol. 8 (4): 407–12. PMID 1697801.
  147. LIPKIN M, FULTON LA, WOLFSON EA (October 1955). "The syndrome of the hypersensitive xiphoid". N. Engl. J. Med. 253 (14): 591–7. doi:10.1056/NEJM195510062531403. PMID 13266001.
  148. van Holsbeeck M, van Melkebeke J, Dequeker J, Pennes DR (September 1992). "Radiographic findings of spontaneous subluxation of the sternoclavicular joint". Clin. Rheumatol. 11 (3): 376–81. PMID 1458785.
  149. Almansa C, Wang B, Achem SR (March 2010). "Noncardiac chest pain and fibromyalgia". Med. Clin. North Am. 94 (2): 275–89. doi:10.1016/j.mcna.2010.01.002. PMID 20380956.
  150. Disla E, Rhim HR, Reddy A, Karten I, Taranta A (November 1994). "Costochondritis. A prospective analysis in an emergency department setting". Arch. Intern. Med. 154 (21): 2466–9. PMID 7979843.
  151. Wise CM, Semble EL, Dalton CB (February 1992). "Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients". Arch Phys Med Rehabil. 73 (2): 147–9. PMID 1543409.
  152. Rodríguez-Henríquez P, Solano C, Peña A, León-Hernández S, Hernández-Díaz C, Gutiérrez M, Pineda C (July 2013). "Sternoclavicular joint involvement in rheumatoid arthritis: clinical and ultrasound findings of a neglected joint". Arthritis Care Res (Hoboken). 65 (7): 1177–82. doi:10.1002/acr.21958. PMID 23335586.
  153. Ramonda R, Lorenzin M, Lo Nigro A, Vio S, Zucchetta P, Frallonardo P, Campana C, Oliviero F, Modesti V, Punzi L (September 2012). "Anterior chest wall involvement in early stages of spondyloarthritis: advanced diagnostic tools". J. Rheumatol. 39 (9): 1844–9. doi:10.3899/jrheum.120107. PMID 22798267.
  154. Wendling D, Prati C, Demattei C, Loeuille D, Richette P, Dougados M (July 2013). "Anterior chest wall pain in recent inflammatory back pain suggestive of spondyloarthritis. data from the DESIR cohort". J. Rheumatol. 40 (7): 1148–52. doi:10.3899/jrheum.121460. PMID 23678156.
  155. 155.0 155.1 155.2 Jurik AG (1992). "Seronegative anterior chest wall syndromes. A study of the findings and course at radiography". Acta Radiol Suppl. 381: 1–42. PMID 1488919.
  156. Guglielmi G, Cascavilla A, Scalzo G, Salaffi F, Grassi W (2009). "Imaging of sternocostoclavicular joint in spondyloarthropaties and other rheumatic conditions". Clin. Exp. Rheumatol. 27 (3): 402–8. PMID 19604431.
  157. Saghafi M, Henderson MJ, Buchanan WW (February 1993). "Sternocostoclavicular hyperostosis". Semin. Arthritis Rheum. 22 (4): 215–23. PMID 8484129.
  158. Magrey M, Khan MA (October 2009). "New insights into synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome". Curr Rheumatol Rep. 11 (5): 329–33. PMID 19772827.
  159. Colina M, Govoni M, Orzincolo C, Trotta F (June 2009). "Clinical and radiologic evolution of synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: a single center study of a cohort of 71 subjects". Arthritis Rheum. 61 (6): 813–21. doi:10.1002/art.24540. PMID 19479702.
  160. Carneiro S, Sampaio-Barros PD (May 2013). "SAPHO syndrome". Rheum. Dis. Clin. North Am. 39 (2): 401–18. doi:10.1016/j.rdc.2013.02.009. PMID 23597971.
  161. Turner-Stokes L, Turner-Warwick M (April 1982). "Intrathoracic manifestations of SLE". Clin Rheum Dis. 8 (1): 229–42. PMID 6749397.
  162. Hunder GG, McDuffie FC, Hepper NG (March 1972). "Pleural fluid complement in systemic lupus erythematosus and rheumatoid arthritis". Ann. Intern. Med. 76 (3): 357–63. PMID 5015911.
  163. Porcel JM, Ordi-Ros J, Esquerda A, Vives M, Madroñero AB, Bielsa S, Vilardell-Tarrés M, Light RW (2007). "Antinuclear antibody testing in pleural fluid for the diagnosis of lupus pleuritis". Lupus. 16 (1): 25–7. doi:10.1177/0961203306074470. PMID 17283581.
  164. 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.
  165. 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.
  166. 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.
  167. 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.
  168. 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.
  169. 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.
  170. Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, Betts RF, Gershon AA, Haanpaa ML, McKendrick MW, Nurmikko TJ, Oaklander AL, Oxman MN, Pavan-Langston D, Petersen KL, Rowbotham MC, Schmader KE, Stacey BR, Tyring SK, van Wijck AJ, Wallace MS, Wassilew SW, Whitley RJ (January 2007). "Recommendations for the management of herpes zoster". Clin. Infect. Dis. 44 Suppl 1: S1–26. doi:10.1086/510206. PMID 17143845.
  171. Oxman MN (December 1995). "Immunization to reduce the frequency and severity of herpes zoster and its complications". Neurology. 45 (12 Suppl 8): S41–6. PMID 8545018.
  172. Jumaan AO, Yu O, Jackson LA, Bohlke K, Galil K, Seward JF (June 2005). "Incidence of herpes zoster, before and after varicella-vaccination-associated decreases in the incidence of varicella, 1992-2002". J. Infect. Dis. 191 (12): 2002–7. doi:10.1086/430325. PMID 15897984.
  173. Kishida H, Tada Y, Tetsuoh Y, Yamazaki Y, Saito T, Fukuma N; et al. (1991). "A new strategy for the reduction of acute myocardial infarction in variant angina". Am Heart J. 122 (6): 1554–61. doi:10.1016/0002-8703(91)90271-i. PMID 1835559.
  174. Myerburg RJ, Kessler KM, Mallon SM, Cox MM, deMarchena E, Interian A; et al. (1992). "Life-threatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary-artery spasm". N Engl J Med. 326 (22): 1451–5. doi:10.1056/NEJM199205283262202. PMID 1574091.
  175. Kishida H, Tada Y, Tetsuoh Y, Yamazaki Y, Saito T, Fukuma N; et al. (1991). "A new strategy for the reduction of acute myocardial infarction in variant angina". Am Heart J. 122 (6): 1554–61. doi:10.1016/0002-8703(91)90271-i. PMID 1835559.
  176. Bory M, Pierron F, Panagides D, Bonnet JL, Yvorra S, Desfossez L (1996). "Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients". Eur Heart J. 17 (7): 1015–21. doi:10.1093/oxfordjournals.eurheartj.a014996. PMID 8809518.
  177. de Luna AB, Cygankiewicz I, Baranchuk A, Fiol M, Birnbaum Y, Nikus K; et al. (2014). "Prinzmetal angina: ECG changes and clinical considerations: a consensus paper". Ann Noninvasive Electrocardiol. 19 (5): 442–53. doi:10.1111/anec.12194. PMID 25262663.
  178. Yasue H, Takizawa A, Nagao M, Nishida S, Horie M, Kubota J; et al. (1988). "Long-term prognosis for patients with variant angina and influential factors". Circulation. 78 (1): 1–9. doi:10.1161/01.cir.78.1.1. PMID 3260150.
  179. Yasue H, Takizawa A, Nagao M, Nishida S, Horie M, Kubota J; et al. (1988). "Long-term prognosis for patients with variant angina and influential factors". Circulation. 78 (1): 1–9. doi:10.1161/01.cir.78.1.1. PMID 3260150.
  180. Yasue H, Mizuno Y, Harada E, Itoh T, Nakagawa H, Nakayama M; et al. (2008). "Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers". J Am Coll Cardiol. 51 (18): 1742–8. doi:10.1016/j.jacc.2007.12.049. PMID 18452779.
  181. Miwa K, Fujita M, Miyagi Y (1994). "Beneficial effects of smoking cessation on the short-term prognosis for variant angina--validation of the smoking status by urinary cotinine measurements". Int J Cardiol. 44 (2): 151–6. doi:10.1016/0167-5273(94)90019-1. PMID 8045660.
  182. Corcos T, David PR, Bourassa MG, Val PG, Robert J, Mata LA; et al. (1985). "Percutaneous transluminal coronary angioplasty for the treatment of variant angina". J Am Coll Cardiol. 5 (5): 1046–54. doi:10.1016/s0735-1097(85)80004-8. PMID 3157733.
  183. Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
  184. 184.0 184.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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