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ARTICLE |

The Problem of Chest "Pain": Title and subTitle BreakEmphasis on the Workup of Myocardial Ischemia FREE

J. Willis Hurst, MD; Spencer B. King, III, MD
[+] Author Affiliations

Reprint requests to Department of Medicine, Emory University School of Medicine, Thomas K. Glenn Memorial Bldg, 69 Butler St SE, Atlanta, GA 30303 (Dr Hurst).


JAMA. 1976;236(18):2100-2103. doi:10.1001/jama.1976.03270190056038
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THE ALGORITHM presented here emphasizes the workup of a patient who has chest "pain" whose clinical features might be associated with myocardial ischemia caused by coronary atherosclerosis. Note that the arrows in the algorithm are numbered and correspond to related numbered paragraphs in the discussion. The discussion highlights some of the variables one needs to consider in order to move from one place in the algorithm to another.

The physician whose goal is to give comprehensive care should define in advance the items in the history, physical examination, and laboratory workup (which includes a chest roentgenogram and ECG) that should be done on every patient. Items done occasionally are not included in the initial data-gathering process. With this approach, the physician should be able to identify the cause of the chest discomfort in the majority of instances without resorting to additional diagnostic studies. More often than not, the chest pain

REFERENCES

Blackburn H, Taylor HL, Keys A:  The electrocardiogram in prediction of five-year coronary heart disease incidence among men aged 40 through 59 . Circulation 41( (suppl 1) ):154-161, 1970;.
Cohen MV, Cohn PF, Herman MV, et al:  Diagnosis and prognosis of main left coronary artery obstruction . Circulation 45( (suppl 1) ):57-67, 1972;.
Profant GR, Early RG, Nilson KL, et al:  Responses to maximal exercise in healthy middleaged women . J Appl Physiol 33:595-599, 1972;.
Redwood DR, Epstein SE:  Uses and limitations of stress testing in the evaluation of ischemic heart disease . Circulation 46:1115-1131, 1972;.
Barnard RJ, MacAlpin R, Kattus AA, et al:  Ischemic response to sudden strenuous exercise in healthy men . Circulation 48:936-942, 1973;.
Cumming GR, Dufresne C, Samm J:  False positive ECGs in women . Can Med Assoc J 109:108-111, 1973;.
Cheitlin MD, Davia JE, deCastro CM, et al:  Correlation of 'critical' left coronary artery lesions with positive submaximal exercise tests in patients with chest pain . Am Heart J 89:305-310, 1975;.
Siegel W, Lim JS, Proudfit WL, et al:  The spectrum of exercise test and angiographic correlations in myocardial revascularization surgery . Circulation 51( (suppl 1) ):156-162, 1975;.
Froelicher VF, Thompson AJ, Longo MR, et al:  Value of exercise testing for screening asymptomatic men for latent coronary artery disease . Prog Cardiovasc Dis 18:265-276, 1976;.
Krauss KR, Hutter AM, DeSanctis RW:  Acute coronary insufficiency . Circulation 45( (suppl 1) ):66-71, 1972;.
Bruschke AVG, Proudfit WL, Sones FM:  Progress study of 590 consecutive nonsurgical cases of coronary disease followed five to nine years: I. Arteriographic correlations . Circulation 47:1147-1153, 1973;.
Bruschke AVG, Proudfit WL, Sones FM:  Progress study of 590 consecutive nonsurgical cases of coronary disease followed five to nine years: II. Ventriculographic and other correlations . Circulation 47:1154-1163, 1973;.
Cheanvechai C, Effler DB, Loop FD, et al:  Aortocoronary artery graft during early and late phases of acute myocardial infarction . Ann Thorac Surg 16:249-260, 1973;.
Spencer FC, Isom OW, Glassman E, et al:  The long-term influence of coronary bypass grafts on MI and survival . Ann Surg 180:439-451, 1974;.
Reul GJ Jr, Cooley DA, Wukasch DC, et al:  Long-term survival following coronary artery bypass . Arch Surg 110:1419-1424, 1975;.
Sheldon WC, Rincon G, Pichard AD, et al:  Surgical treatment of coronary artery disease: Pure graft operations, with a study of 741 patients followed three to seven years . Prog Cardiovasc Dis 28:237-252, 1975;.

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Blackburn H, Taylor HL, Keys A:  The electrocardiogram in prediction of five-year coronary heart disease incidence among men aged 40 through 59 . Circulation 41( (suppl 1) ):154-161, 1970;.
Cohen MV, Cohn PF, Herman MV, et al:  Diagnosis and prognosis of main left coronary artery obstruction . Circulation 45( (suppl 1) ):57-67, 1972;.
Profant GR, Early RG, Nilson KL, et al:  Responses to maximal exercise in healthy middleaged women . J Appl Physiol 33:595-599, 1972;.
Redwood DR, Epstein SE:  Uses and limitations of stress testing in the evaluation of ischemic heart disease . Circulation 46:1115-1131, 1972;.
Barnard RJ, MacAlpin R, Kattus AA, et al:  Ischemic response to sudden strenuous exercise in healthy men . Circulation 48:936-942, 1973;.
Cumming GR, Dufresne C, Samm J:  False positive ECGs in women . Can Med Assoc J 109:108-111, 1973;.
Cheitlin MD, Davia JE, deCastro CM, et al:  Correlation of 'critical' left coronary artery lesions with positive submaximal exercise tests in patients with chest pain . Am Heart J 89:305-310, 1975;.
Siegel W, Lim JS, Proudfit WL, et al:  The spectrum of exercise test and angiographic correlations in myocardial revascularization surgery . Circulation 51( (suppl 1) ):156-162, 1975;.
Froelicher VF, Thompson AJ, Longo MR, et al:  Value of exercise testing for screening asymptomatic men for latent coronary artery disease . Prog Cardiovasc Dis 18:265-276, 1976;.
Krauss KR, Hutter AM, DeSanctis RW:  Acute coronary insufficiency . Circulation 45( (suppl 1) ):66-71, 1972;.
Bruschke AVG, Proudfit WL, Sones FM:  Progress study of 590 consecutive nonsurgical cases of coronary disease followed five to nine years: I. Arteriographic correlations . Circulation 47:1147-1153, 1973;.
Bruschke AVG, Proudfit WL, Sones FM:  Progress study of 590 consecutive nonsurgical cases of coronary disease followed five to nine years: II. Ventriculographic and other correlations . Circulation 47:1154-1163, 1973;.
Cheanvechai C, Effler DB, Loop FD, et al:  Aortocoronary artery graft during early and late phases of acute myocardial infarction . Ann Thorac Surg 16:249-260, 1973;.
Spencer FC, Isom OW, Glassman E, et al:  The long-term influence of coronary bypass grafts on MI and survival . Ann Surg 180:439-451, 1974;.
Reul GJ Jr, Cooley DA, Wukasch DC, et al:  Long-term survival following coronary artery bypass . Arch Surg 110:1419-1424, 1975;.
Sheldon WC, Rincon G, Pichard AD, et al:  Surgical treatment of coronary artery disease: Pure graft operations, with a study of 741 patients followed three to seven years . Prog Cardiovasc Dis 28:237-252, 1975;.
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