非心因性胸痛患者並不常接受腸胃道檢查
作者：Emma Hitt, PhD
出處：WebMD醫學新聞
April 21, 2010 — 根據一項發表於4月號梅約臨床進展期刊的報告，有非心因性胸痛（NCCP）的患者比較不常接受腸胃道（GI）諮詢以及檢查。研究者們建議NCCP族群應該接受心臟危險因子篩檢。
紐約羅徹斯特梅約診所胃腸肝膽科的Michael D. Leise醫師表示，在診斷NCCP後，我們對於醫療照護的使用並不清楚。
作者們解釋，因此，這項研究的目的，以未發生顯著心臟表面冠狀動脈狹窄的情況下，發生胸骨下胸痛的非心因性胸痛來定義。胃食道逆流是NCCP最常見的病因，大約占了60%的病例。
Leise醫師與同事們想要確認照會腸胃科專家的百分比，以及所進行的GI、心臟檢查種類與頻率，還有被診斷罹患NCCP患者發生心臟相關死亡的比率。
受試者們來自明尼蘇達奧姆斯特德郡，在1985年1月1日到1992年12月31日之間，因為胸痛到急診（ED）就診的居民（透過羅徹斯特流行病學計畫）。總共有320位診斷不明原因NCCP或是肇因於GI相關診斷的病患被納入。
這些病患中，49%在ED接受評估，42%重複接受心臟評估，只有15%在他們的初步診斷後接受腸胃科專家評估。總共有38%接受食道、胃、十二指腸內視鏡，但是只有4%接受壓力測量；2%接受pH探針檢查。
研究者們表示，雖然因為胸痛再次至ED就診是可以預期的，重複進行心臟學檢查，但是沒有腸胃科諮詢令人意外。
研究團隊也想要確認這個族群的心臟相關死亡事件數目。10年時，未知原因的NCCP患者免於心臟死亡機率為93.7%，20年時則是88.1%，而罹患NCCP且有腸胃道疾病的患者，10年時為90.2%，20年時為84.8%。
作者們寫到，雖然整個樣本並未顯示出死亡機率顯著增加，但相較於我們於社區所期待看到的，相當心血管死亡事件數目發生在NCCP族群。
研究者們表示，罹患NCCP患者的心臟血管死亡事件可能與胃食道逆流及冠狀動脈血管疾病的危險因子重疊。直到這個族群的心臟血管死亡更進一步地了解，篩檢心臟危險因子，例如高血壓、高膽固醇、以及糖尿病且積極地處理這些共病症是合理的。
在隨後的主編評論中，來自佛州Jacksonville梅約診所心臟血管疾病部門的Thomas C. Gerber博士及其同事們表示，該族群過去有心肌梗塞的盛行率為22%，因此顯然非低風險族群的這些病患，之後轉介給心臟科評估的頻率並非意料之外。主編們也指出，在收集資料的那段時間，心臟生化標記並不普及，部分有非心因性胸痛臨床診斷的患者，事實上是罹患了急性冠心症。
這項研究由TAP藥廠（現在是武田藥廠北美分公司的分公司）。
Gastrointestinal Workup Occurs Infrequently in Patients With Noncardiac Chest Pain
By Emma Hitt, PhD
Medscape Medical News
April 21, 2010 — Relatively few gastrointestinal (GI) consultations and tests are performed in patients with noncardiac chest pain (NCCP), but a sizeable percentage receive cardiology consultation and workup, and not a small number suffer cardiac death at a later time, according to a report in the April issue of the Mayo Clinic Proceedings. Screening the NCCP population for cardiac risk factors is recommended by the researchers.
"Little is known about health care utilization after a diagnosis of NCCP," note Michael D. Leise, MD, from the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, New York, and colleagues.
For the purposes of the study, NCCP was defined as noncardiac chest pain presenting as substernal chest pain in the absence of significant epicardial coronary artery stenoses. "[Gastroesophageal reflux disease] is the most prevalent cause of NCCP, accounting for up to 60% of cases," the authors explain.
Dr. Leise and colleagues sought to determine the percentage of GI consultations obtained, as well as the type and frequency of both GI and cardiac testing performed and the incidence of cardiac related deaths in patients with a diagnosis of NCCP.
Participants were derived from a cohort of Olmsted County, Minnesota, residents (via the Rochester Epidemiology Project) presenting to the emergency department (ED) with chest pain between January 1, 1985, and December 31, 1992. A total of 320 patients with NCCP of unknown origin or secondary to GI diagnoses were included.
Of the patients, 49% were evaluated in the ED, 42% had repeated cardiology evaluations, and only 15% were assessed by a gastroenterologist after their initial diagnosis. A total of 38% underwent esophagogastroduodenoscopy, but only 4% underwent manometry; 2% underwent pH probes.
"Although repeated ED visits for chest pain are to be expected, the number of repeated cardiology evaluations and the paucity of GI consultations are surprising," the authors note.
The researchers also sought to determine the number of cardiac deaths in this group. Survival free of cardiac death was 93.7% at 10 years and 88.1% at 20 years for the subset of patients with NCCP of unknown origin compared with 90.2% at 10 years and 84.8% at 20 years in the subset of patients with NCCP in addition to a GI disorder.
"Although the total sample did not display a significantly increased frequency of death compared with what would be expected in this community, a substantial number of cardiac deaths occurred in an NCCP population," the authors write.
The researchers suggest that cardiac death in patients with NCCP may relate to overlapping risk factors for gastroesophageal reflux disease and coronary artery disease. "Until cardiac death in this population is better understood, it is prudent to screen for cardiac risk factors such as hypertension, hypercholesterolemia, and diabetes mellitus and aggressively manage these comorbid conditions when present."
In a related editorial, Thomas C. Gerber, MD, PhD, from the Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, Florida, and colleagues note that the cohort of patients had a 22% prevalence of prior myocardial infarction, and therefore was "clearly not a low-risk group, and the frequency of subsequent referral for cardiology evaluation is not unexpected." The editorialists also point out that cardiac biomarkers were not widely available at the time of the data collection, and that "it is conceivable that some of the patients with a clinical diagnosis of noncardiac chest pain in fact had an [acute coronary syndrome]."
Support was provided by TAP Pharmaceutical Products (now part of Takeda Pharmaceuticals North America).
Mayo Clin Proc. 2010;85:309-313, 323-330.
