0
March 15, 1995, Vol 273, No. 11 >
ARTICLE | March 15, 1995

The Sensitive Heart: Title and subTitle BreakA Syndrome of Abnormal Cardiac Pain Perception FREE

Richard O. Cannon, III, MD
[+] Author Affiliations

Reprint requests to the Cardiology Branch, Bldg 10, Room 7B-15, National Institutes of Health, Bethesda, MD 20892 (Dr Cannon).

Grand Rounds at the Clinical Center of the National Institutes of Health section editors: John I. Gallin, MD, the Clinical Center of the National Institutes of Health, Bethesda, Md; David S. Cooper, MD, Contributing Editor, JAMA.


JAMA. 1995;273(11):883-887. doi:10.1001/jama.1995.03520350065031
Text Size: A A A
Published online
Article
References

SELECTED CASE  A 50-year-old woman was referred to the National Institutes of Health because of a 12-year history of anginalike chest pain despite normal coronary angiograms. She described her symptom as a substernal pressure sensation radiating to the left shoulder and arm, provoked by effort and relieved by rest. Two years prior to admission, she underwent cardiovascular evaluation that included treadmill exercise testing associated with ischemic-appearing electrocardiogram (ECG) changes. Beta-blocker therapy (120 mg of nadolol daily) diminished symptoms somewhat, but because of continued effort-provoked chest pain, she underwent cardiac catheterization, which demonstrated normal-appearing coronary arteries and left ventricle. Nadolol was discontinued, and she was started on 90 mg of diltiazem hydrochloride twice daily, which did not relieve her symptoms. She did find sublingual nitroglycerin to be of help in relieving pain. Her past medical history is significant for a cholecystectomy 3 years prior to admission and cigarette smoking discontinued 10

REFERENCES

1 +
Proudfit WL, Shirley EK, Sones FM.  Selective cine coronary arteriography: correlation with clinical findings in 1000 patients. Circulation . 1966;;33: 901-910.
2 +
Kemp HG, Vokonas PS, Cohn PF, Gorlin R.  The anginal syndrome associated with normal coronary angiograms: report of a six year experience. Am J Med . 1973;;54:735-742.
3 +
Pasternak RC, Thibault GE, DeSanctis RW, Hutter AM.  Chest pain with angiographically insignificant coronary arterial obstruction: clinical presentation and long-term follow-up. Am J Med . 1980;; 68:813-817.
4 +
Dart AM, Davies HA, Dalal J, Ruttley M, Henderson AH.  'Angina' and normal coronary arteriograms: a follow-up study. Eur Heart J . 1980;;1:97-100.
5 +
Papaniculaou MN, Califf RM, Hlatky MA, et al.  Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol . 1986;;58:1181-1187.
6 +
Kemp HG, Kronmal RA, Vliestra RE, Frye RL.  Seven year survival of patients with normal or near normal coronary arteriograms: a CASS registry study. J Am Coll Cardiol . 1986;;7:479-483.
7 +
Day LJ, Sowton E.  Clinical features and follow-up of patients with angina and normal coronary arteries. Lancet . 1976;;2:334-337.
8 +
Ockene IS, Shay MJ, Alpert JS, Weiner BH, Dalen JE.  Unexplained chest pain in patients with normal coronary arteriograms: a follow-up study of functional status. N Engl J Med . 1980;;303:1249-1252.
9 +
Isner JM, Salem DN, Banas JS, Levine HJ.  Long-term clinical course of patients with normal coronary arteriography: follow-up study of 121 patients with normal or nearly normal coronary arteriograms. Am Heart J . 1981;;102:645-653.
10 +
Cannon RO, Camici PG, Epstein SE.  Pathophysiological dilemma of syndrome X. Circulation . 1992;;85:883-892.
11 +
Motz W, Vogt M, Rabenau O, Scheler S, Luckhoff A, Strauer BE.  Evidence of endothelial dysfunction in coronary resistance vessels in patients with angina pectoris and normal coronary angiograms. Am J Cardiol . 1991;;68:996-1003.
12 +
Quyyumi AA, Cannon RO, Panza JA, Diodati JG, Epstein SE.  Endothelial dysfunction in patients with chest pain and normal coronary arteries. Circulation . 1992;;86:1864-1871.
13 +
Egashira K, Inou T, Hirooka Y, Yamada A, Urabe Y, Takeshita A.  Evidence of impaired endothelium-dependent coronary vasodilation in patients with angina pectoris and normal coronary angiograms. N Engl J Med . 1993;;328:1659-1664.
14 +
Bortone AS, Hess OM, Eberli FR.  Abnormal coronary vasomotion during exercise in patients with normal coronary arteries and reduced coronary flow reserve. Circulation . 1989;;79:516-527.
15 +
Montorsi P, Manfredi M, Laoldi A.  Comparison of coronary vasomotor responses to nifedipine in syndrome X and in Prinzmetal's angina pectoris. J Cardiol . 1989;;63:1198-1202.
16 +
Galassi AR, Kaski JC, Crea F.  Heart rate response during exercise testing and ambulatory ECG monitoring in patients with syndrome X. Am Heart J . 1991;;122:458-463.
17 +
Chauhan A, Mullins PA, Taylor G, Petch MC, Schofield PM.  Effect of hyperventilation and mental stress on coronary blood flow in syndrome X. Br Heart J . 1993;;69:516-524.
18 +
Rosano GMC, Ponikowski P, Adamopoulos S, et al.  Abnormal autonomic control of the cardiovascular system in syndrome X. Am J Cardiol . 1994;;73:1174-1179.
19 +
Zeiher AM, Drexler H, Wollschlager H, Just H.  Modulation of coronary vasomotor tone in humans: progressive endothelial dysfunction with different early stages of coronary atherosclerosis. Circulation . 1991;;82:391-401.
20 +
Egashira K, Inou T, Hirooka Y, et al.  Impaired coronary flow response to acetylcholine in patients with coronary risk factors and proximal atherosclerotic lesions. J Clin Invest . 1993;;91:29-37.
21 +
Brush JE, Cannon RO, Schenke WH, et al.  Angina due to coronary microvascular disease in hypertensive patients without left ventricular hypertrophy. N Engl J Med . 1988;;319:1302-1307.
22 +
Treasure CB, Klein JL, Vita JA, et al.  Hypertension and left ventricular hypertrophy are associated with impaired endothelium-dependent relaxation in human coronary resistance vessels. Circulation . 1993;;87:86-93.
23 +
Reis SE, Gloth ST, Blumenthal RS, et al.  Ethinyl estradiol acutely attenuates abnormal coronary vasomotor responses to acetylcholine in postmenopausal women. Circulation . 1994;;89:52-60.
24 +
Gilligan DM, Quyyumi AA, Cannon RO.  Effects of physiological levels of estrogen on coronary vasomotor function in postmenopausal women. Circulation . 1994;;89:2545-2551.
25 +
Opherk D, Zebe H, Schuler G, Weihe E, Mall G, Kubler W.  Reduced coronary reserve and abnormal exercise left ventricular reserve in patients with syndrome X. Arch Mal Coeur Vaiss . 1983;;76: 231-235.
26 +
Legrand V, Hodgson JM, Bates ER, et al.  Abnormal coronary flow reserve and abnormal radionuclide exercise test results in patients with normal coronary angiograms. J Am Coll Cardiol . 1985;; 6:1245-1253.
27 +
Cannon RO, Bonow RO, Bacharach SL, et al.  Left ventricular dysfunction in patients with angina pectoris, normal epicardial coronary arteries, and abnormal vasodilator reserve. Circulation . 1985;; 71:218-226.
28 +
Arbogast R, Bourassa MG.  Myocardial function during atrial pacing in patients with angina pectoris and normal coronary arteriograms: comparison with patients having significant coronary artery disease. Am J Cardiol . 1973;;32:257-263.
29 +
Kemp HG.  Left ventricular function in patients with the anginal syndrome and normal coronary arteriograms. Am J Cardiol . 1973;;32:375-376.
30 +
Likoff W, Segal BL, Kasparian H.  Paradox of normal selective coronary arteriograms in patients considered to have unmistakable coronary heart disease. N Engl J Med . 1967;;276:1063-1066.
31 +
Kemp HG, Elliott WC, Gorlin R.  The anginal syndrome with normal coronary arteriography. Trans Assoc Am Physicians . 1967;;80:59-70.
32 +
Levy RD, Shapiro LM, Wright C, Mockus L, Fox KM.  Syndrome X: the hemodynamic significance of ST segment depression. Br Heart J . 1986;; 56:353-357.
33 +
Crake T, Canepa-Anson R, Shapiro L, Poole-Wilson PA.  Continuous recording of coronary sinus oxygen saturation during atrial pacing in patients with coronary artery disease or with syndrome X. Br Heart J . 1988;;59:31-38.
34 +
Camici PG, Marraccini P, Lorenzoni R, et al.  Coronary hemodynamics and myocardial metabolism in patients with syndrome X: response to pacing stress. J Am Coll Cardiol . 1991;;17:1461-1470.
35 +
Nihoyannopoulos P, Kaski JC, Crake T, Maseri A.  Absence of myocardial dysfunction during stress in patients with syndrome X. J Am Coll Cardiol . 1991;;18:1463-1470.
36 +
Miller TD, Taliercio CP, Zinsmeister AR, Gibbons RJ.  Prognosis in patients with an abnormal exercise radionuclide angiogram in the absence of significant coronary artery disease. J Am Coll Cardiol . 1988;;12:637-641.
37 +
Pamelia FX, Gibson RS, Watson DD, Craddock GB, Sirowatka J, Beller GA.  Prognosis with chest pain and normal thallium-201 exercise scintigrams. Am J Cardiol . 1985;;55:920-926.
38 +
Opherk D, Schuler G, Wetterauer K, Manthey J, Schwarz F, Kubler W.  Four-year follow-up study in patients with angina pectoris and normal coronary arteriograms ('syndrome X'). Circulation . 1989;; 80:1610-1616.
39 +
Bass C, Cawley R, Wade C, et al.  Unexplained breathlessness and psychiatric morbidity in patients with normal coronary arteries. Lancet . 1983;;1:605-609.
40 +
Wielgosz AT, Fletcher RH, McCants CB, McKinnis RA, Haney TL, Williams RB.  Unimproved chest pain in patients with minimal or no coronary disease: a behavioral phenomenon. Am Heart J . 1984;;108:67-72.
41 +
Katon W, Hall ML, Russo J, et al.  Chest pain: relationship of psychiatric illness to coronary arteriographic results. Am J Med . 1988;;84:1-9.
42 +
Lantinga LJ, Sprafkin RP, McCroskery JH, Baker MT, Warner RA, Hill NE.  One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries. Am J Cardiol . 1988;;62:201-213.
43 +
Beitman BD, Mukerji V, Lamberti JW, et al.  Panic disorder in patients with chest pain and angiographically normal coronary arteries. Am J Cardiol . 1989;;63:1399-1403.
44 +
Carter C, Maddock R, Amsterdam E, McCormick S, Waters C, Billett J.  Panic disorder and chest pain in the coronary care unit. Psychosomatics . 1992;;33:302-309.
45 +
Brand DL, Martin D, Pope CE II.  Esophageal manometrics in patients with angina-like chest pain. Am J Dig Dis . 1977;;22:300-304.
46 +
Traube M, Albibi R, McCallum RW.  High-amplitude peristaltic esophageal contractions associated with chest pain. JAMA . 1983;;250:2655-2659.
47 +
Janssens J, Vantrappen G, Ghilebert G.  24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain. Gastroenterology . 1986;;90:1978-1984.
48 +
Richter JE, Bradley LA, Castell DO.  Esophageal chest pain: current controversies in pathogenesis, diagnosis, and therapy. Ann Intern Med . 1989;; 110:66-78.
49 +
Shapiro LM, Crake T, Poole-Wilson PA.  Is altered cardiac sensation responsible for chest pain in patients with normal coronary arteries? clinical observation during cardiac catheterization. BMJ . 1988;; 296:170-171.
50 +
Cannon RO, Quyyumi AA, Schenke WH, et al.  Abnormal cardiac sensitivity in patients with chest pain and normal coronary arteries. J Am Coll Cardiol . 1990;;16:1359-1366.
51 +
Lagerqvist B, Sylven C, Waldenstrom A.  Lower threshold for adenosine-induced chest pain in patients with angina and normal coronary angiograms. Br Heart J . 1992;;68:282-285.
52 +
Sylven C, Beermann B, Jonzon B, Brandt R.  Angina pectoris-like pain provoked by intravenous adenosine in healthy volunteers. BMJ . 1986;;293: 227-230.
53 +
Chauhan A, Mullins PA, Thuraisingham SI, Taylor G, Petch MC, Schofield PM.  Abnormal cardiac pain perception in syndrome X. J Am Coll Cardiol . 1994;;24:329-335.
54 +
Rosen SD, Uren NG, Kaski JC, Tousoulis D, Davies GJ, Camici PG.  Coronary vasodilator reserve, pain perception, and sex in patients with syndrome X. Circulation . 1994;;90:50-60.
55 +
Richter JE, Barish CF, Castell DO.  Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology . 1986;;91:845-852.
56 +
Cannon RO, Cattau EL, Yakshe PN, et al.  Coronary flow reserve, esophageal motility and chest pain in patients with angiographically normal coronary arteries. Am J Med . 1990;;88:217-222.
57 +
Lynn RB, Friedman LS.  Irritable bowel syndrome. N Engl J Med . 1993;;329:1940-1945.
58 +
Turiel M, Galassi AR, Glazier JJ, Kaski JC, Maseri A.  Pain threshold and tolerance in women with syndrome X and women with stable angina pectoris. Am J Cardiol . 1987;;60:503-507.
59 +
Maseri A, Crea F, Kaski JC, Crake T.  Mechanisms of angina pectoris in syndrome X. J Am Coll Cardiol . 1991;;17:499-506.
60 +
Crea F, Pupita G, Galassi AR, et al.  Role of adenosine in pathogenesis of anginal pain. Circulation . 1990;;81:165-172.
61 +
Cannon RO, Quyyumi AA, Mincemoyer R, et al.  Imipramine in patients with chest pain despite normal coronary angiograms. N Engl J Med . 1994;; 330:1411-1417.
62 +
Durate IDG, Lorenzetti BB, Ferreira SH.  Acetylcholine induces peripheral analgesia by the release of nitric oxide.  In: Moncada S, Higgs EA, eds. Nitric Oxide From L-Arginine: A Bioregulatory System . Amsterdam, the Netherlands: Elsevier Science Publishers; 1990;:165-170.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Proudfit WL, Shirley EK, Sones FM.  Selective cine coronary arteriography: correlation with clinical findings in 1000 patients. Circulation . 1966;;33: 901-910.
2 +
Kemp HG, Vokonas PS, Cohn PF, Gorlin R.  The anginal syndrome associated with normal coronary angiograms: report of a six year experience. Am J Med . 1973;;54:735-742.
3 +
Pasternak RC, Thibault GE, DeSanctis RW, Hutter AM.  Chest pain with angiographically insignificant coronary arterial obstruction: clinical presentation and long-term follow-up. Am J Med . 1980;; 68:813-817.
4 +
Dart AM, Davies HA, Dalal J, Ruttley M, Henderson AH.  'Angina' and normal coronary arteriograms: a follow-up study. Eur Heart J . 1980;;1:97-100.
5 +
Papaniculaou MN, Califf RM, Hlatky MA, et al.  Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol . 1986;;58:1181-1187.
6 +
Kemp HG, Kronmal RA, Vliestra RE, Frye RL.  Seven year survival of patients with normal or near normal coronary arteriograms: a CASS registry study. J Am Coll Cardiol . 1986;;7:479-483.
7 +
Day LJ, Sowton E.  Clinical features and follow-up of patients with angina and normal coronary arteries. Lancet . 1976;;2:334-337.
8 +
Ockene IS, Shay MJ, Alpert JS, Weiner BH, Dalen JE.  Unexplained chest pain in patients with normal coronary arteriograms: a follow-up study of functional status. N Engl J Med . 1980;;303:1249-1252.
9 +
Isner JM, Salem DN, Banas JS, Levine HJ.  Long-term clinical course of patients with normal coronary arteriography: follow-up study of 121 patients with normal or nearly normal coronary arteriograms. Am Heart J . 1981;;102:645-653.
10 +
Cannon RO, Camici PG, Epstein SE.  Pathophysiological dilemma of syndrome X. Circulation . 1992;;85:883-892.
11 +
Motz W, Vogt M, Rabenau O, Scheler S, Luckhoff A, Strauer BE.  Evidence of endothelial dysfunction in coronary resistance vessels in patients with angina pectoris and normal coronary angiograms. Am J Cardiol . 1991;;68:996-1003.
12 +
Quyyumi AA, Cannon RO, Panza JA, Diodati JG, Epstein SE.  Endothelial dysfunction in patients with chest pain and normal coronary arteries. Circulation . 1992;;86:1864-1871.
13 +
Egashira K, Inou T, Hirooka Y, Yamada A, Urabe Y, Takeshita A.  Evidence of impaired endothelium-dependent coronary vasodilation in patients with angina pectoris and normal coronary angiograms. N Engl J Med . 1993;;328:1659-1664.
14 +
Bortone AS, Hess OM, Eberli FR.  Abnormal coronary vasomotion during exercise in patients with normal coronary arteries and reduced coronary flow reserve. Circulation . 1989;;79:516-527.
15 +
Montorsi P, Manfredi M, Laoldi A.  Comparison of coronary vasomotor responses to nifedipine in syndrome X and in Prinzmetal's angina pectoris. J Cardiol . 1989;;63:1198-1202.
16 +
Galassi AR, Kaski JC, Crea F.  Heart rate response during exercise testing and ambulatory ECG monitoring in patients with syndrome X. Am Heart J . 1991;;122:458-463.
17 +
Chauhan A, Mullins PA, Taylor G, Petch MC, Schofield PM.  Effect of hyperventilation and mental stress on coronary blood flow in syndrome X. Br Heart J . 1993;;69:516-524.
18 +
Rosano GMC, Ponikowski P, Adamopoulos S, et al.  Abnormal autonomic control of the cardiovascular system in syndrome X. Am J Cardiol . 1994;;73:1174-1179.
19 +
Zeiher AM, Drexler H, Wollschlager H, Just H.  Modulation of coronary vasomotor tone in humans: progressive endothelial dysfunction with different early stages of coronary atherosclerosis. Circulation . 1991;;82:391-401.
20 +
Egashira K, Inou T, Hirooka Y, et al.  Impaired coronary flow response to acetylcholine in patients with coronary risk factors and proximal atherosclerotic lesions. J Clin Invest . 1993;;91:29-37.
21 +
Brush JE, Cannon RO, Schenke WH, et al.  Angina due to coronary microvascular disease in hypertensive patients without left ventricular hypertrophy. N Engl J Med . 1988;;319:1302-1307.
22 +
Treasure CB, Klein JL, Vita JA, et al.  Hypertension and left ventricular hypertrophy are associated with impaired endothelium-dependent relaxation in human coronary resistance vessels. Circulation . 1993;;87:86-93.
23 +
Reis SE, Gloth ST, Blumenthal RS, et al.  Ethinyl estradiol acutely attenuates abnormal coronary vasomotor responses to acetylcholine in postmenopausal women. Circulation . 1994;;89:52-60.
24 +
Gilligan DM, Quyyumi AA, Cannon RO.  Effects of physiological levels of estrogen on coronary vasomotor function in postmenopausal women. Circulation . 1994;;89:2545-2551.
25 +
Opherk D, Zebe H, Schuler G, Weihe E, Mall G, Kubler W.  Reduced coronary reserve and abnormal exercise left ventricular reserve in patients with syndrome X. Arch Mal Coeur Vaiss . 1983;;76: 231-235.
26 +
Legrand V, Hodgson JM, Bates ER, et al.  Abnormal coronary flow reserve and abnormal radionuclide exercise test results in patients with normal coronary angiograms. J Am Coll Cardiol . 1985;; 6:1245-1253.
27 +
Cannon RO, Bonow RO, Bacharach SL, et al.  Left ventricular dysfunction in patients with angina pectoris, normal epicardial coronary arteries, and abnormal vasodilator reserve. Circulation . 1985;; 71:218-226.
28 +
Arbogast R, Bourassa MG.  Myocardial function during atrial pacing in patients with angina pectoris and normal coronary arteriograms: comparison with patients having significant coronary artery disease. Am J Cardiol . 1973;;32:257-263.
29 +
Kemp HG.  Left ventricular function in patients with the anginal syndrome and normal coronary arteriograms. Am J Cardiol . 1973;;32:375-376.
30 +
Likoff W, Segal BL, Kasparian H.  Paradox of normal selective coronary arteriograms in patients considered to have unmistakable coronary heart disease. N Engl J Med . 1967;;276:1063-1066.
31 +
Kemp HG, Elliott WC, Gorlin R.  The anginal syndrome with normal coronary arteriography. Trans Assoc Am Physicians . 1967;;80:59-70.
32 +
Levy RD, Shapiro LM, Wright C, Mockus L, Fox KM.  Syndrome X: the hemodynamic significance of ST segment depression. Br Heart J . 1986;; 56:353-357.
33 +
Crake T, Canepa-Anson R, Shapiro L, Poole-Wilson PA.  Continuous recording of coronary sinus oxygen saturation during atrial pacing in patients with coronary artery disease or with syndrome X. Br Heart J . 1988;;59:31-38.
34 +
Camici PG, Marraccini P, Lorenzoni R, et al.  Coronary hemodynamics and myocardial metabolism in patients with syndrome X: response to pacing stress. J Am Coll Cardiol . 1991;;17:1461-1470.
35 +
Nihoyannopoulos P, Kaski JC, Crake T, Maseri A.  Absence of myocardial dysfunction during stress in patients with syndrome X. J Am Coll Cardiol . 1991;;18:1463-1470.
36 +
Miller TD, Taliercio CP, Zinsmeister AR, Gibbons RJ.  Prognosis in patients with an abnormal exercise radionuclide angiogram in the absence of significant coronary artery disease. J Am Coll Cardiol . 1988;;12:637-641.
37 +
Pamelia FX, Gibson RS, Watson DD, Craddock GB, Sirowatka J, Beller GA.  Prognosis with chest pain and normal thallium-201 exercise scintigrams. Am J Cardiol . 1985;;55:920-926.
38 +
Opherk D, Schuler G, Wetterauer K, Manthey J, Schwarz F, Kubler W.  Four-year follow-up study in patients with angina pectoris and normal coronary arteriograms ('syndrome X'). Circulation . 1989;; 80:1610-1616.
39 +
Bass C, Cawley R, Wade C, et al.  Unexplained breathlessness and psychiatric morbidity in patients with normal coronary arteries. Lancet . 1983;;1:605-609.
40 +
Wielgosz AT, Fletcher RH, McCants CB, McKinnis RA, Haney TL, Williams RB.  Unimproved chest pain in patients with minimal or no coronary disease: a behavioral phenomenon. Am Heart J . 1984;;108:67-72.
41 +
Katon W, Hall ML, Russo J, et al.  Chest pain: relationship of psychiatric illness to coronary arteriographic results. Am J Med . 1988;;84:1-9.
42 +
Lantinga LJ, Sprafkin RP, McCroskery JH, Baker MT, Warner RA, Hill NE.  One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries. Am J Cardiol . 1988;;62:201-213.
43 +
Beitman BD, Mukerji V, Lamberti JW, et al.  Panic disorder in patients with chest pain and angiographically normal coronary arteries. Am J Cardiol . 1989;;63:1399-1403.
44 +
Carter C, Maddock R, Amsterdam E, McCormick S, Waters C, Billett J.  Panic disorder and chest pain in the coronary care unit. Psychosomatics . 1992;;33:302-309.
45 +
Brand DL, Martin D, Pope CE II.  Esophageal manometrics in patients with angina-like chest pain. Am J Dig Dis . 1977;;22:300-304.
46 +
Traube M, Albibi R, McCallum RW.  High-amplitude peristaltic esophageal contractions associated with chest pain. JAMA . 1983;;250:2655-2659.
47 +
Janssens J, Vantrappen G, Ghilebert G.  24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain. Gastroenterology . 1986;;90:1978-1984.
48 +
Richter JE, Bradley LA, Castell DO.  Esophageal chest pain: current controversies in pathogenesis, diagnosis, and therapy. Ann Intern Med . 1989;; 110:66-78.
49 +
Shapiro LM, Crake T, Poole-Wilson PA.  Is altered cardiac sensation responsible for chest pain in patients with normal coronary arteries? clinical observation during cardiac catheterization. BMJ . 1988;; 296:170-171.
50 +
Cannon RO, Quyyumi AA, Schenke WH, et al.  Abnormal cardiac sensitivity in patients with chest pain and normal coronary arteries. J Am Coll Cardiol . 1990;;16:1359-1366.
51 +
Lagerqvist B, Sylven C, Waldenstrom A.  Lower threshold for adenosine-induced chest pain in patients with angina and normal coronary angiograms. Br Heart J . 1992;;68:282-285.
52 +
Sylven C, Beermann B, Jonzon B, Brandt R.  Angina pectoris-like pain provoked by intravenous adenosine in healthy volunteers. BMJ . 1986;;293: 227-230.
53 +
Chauhan A, Mullins PA, Thuraisingham SI, Taylor G, Petch MC, Schofield PM.  Abnormal cardiac pain perception in syndrome X. J Am Coll Cardiol . 1994;;24:329-335.
54 +
Rosen SD, Uren NG, Kaski JC, Tousoulis D, Davies GJ, Camici PG.  Coronary vasodilator reserve, pain perception, and sex in patients with syndrome X. Circulation . 1994;;90:50-60.
55 +
Richter JE, Barish CF, Castell DO.  Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology . 1986;;91:845-852.
56 +
Cannon RO, Cattau EL, Yakshe PN, et al.  Coronary flow reserve, esophageal motility and chest pain in patients with angiographically normal coronary arteries. Am J Med . 1990;;88:217-222.
57 +
Lynn RB, Friedman LS.  Irritable bowel syndrome. N Engl J Med . 1993;;329:1940-1945.
58 +
Turiel M, Galassi AR, Glazier JJ, Kaski JC, Maseri A.  Pain threshold and tolerance in women with syndrome X and women with stable angina pectoris. Am J Cardiol . 1987;;60:503-507.
59 +
Maseri A, Crea F, Kaski JC, Crake T.  Mechanisms of angina pectoris in syndrome X. J Am Coll Cardiol . 1991;;17:499-506.
60 +
Crea F, Pupita G, Galassi AR, et al.  Role of adenosine in pathogenesis of anginal pain. Circulation . 1990;;81:165-172.
61 +
Cannon RO, Quyyumi AA, Mincemoyer R, et al.  Imipramine in patients with chest pain despite normal coronary angiograms. N Engl J Med . 1994;; 330:1411-1417.
62 +
Durate IDG, Lorenzetti BB, Ferreira SH.  Acetylcholine induces peripheral analgesia by the release of nitric oxide.  In: Moncada S, Higgs EA, eds. Nitric Oxide From L-Arginine: A Bioregulatory System . Amsterdam, the Netherlands: Elsevier Science Publishers; 1990;:165-170.

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