Abstract 12863: Non-Cardiac Chest Pain: Is It Really?

Abstract

Background: Of patients with acute chest pain(CP), only 10% have acute coronary syndrome. About 20% of these CP patients have an obvious non-cardiac etiology, while the remaining 70% undergo diagnostic testing to exclude coronary atherosclerosis(CAD). Myocardial perfusion imaging(MPI) is commonly used to assess these patients. A normal MPI effectively excludes CAD and the patient is labeled as having “non-cardiac” CP. Late gadolinium enhancement(LGE) by Cardiac MRI(CMR) offers detection of pericardial disease. This study was undertaken to assess the role of CMR in CP patients with a normal MPI. Methods: An institutional cardiac imaging database was queried for all patients with new onset CP. The study was composed of those CP patients who did not have ACS or an obvious non-cardiac etiology. The cohort was divided into 2 groups. Group A patients underwent MPI as their initial test and were negative for ischemia, but had continued CP. Group B had CMR as their initial test and were negative for ischemia. The detection of pericarditis in these 2 patient groups was assessed using LGE of the pericardium. Results: 3,525 patients who presented with chest pain and no evidence of ACS underwent nuclear MPI. 347(9.8%) of these 3,525 patients had a normal nuclear MPI, but subsequently underwent a CMR for persistent chest pain and constituted Group A. 63 of 347(18.1%) Group A patients with a normal MPI had evidence of pericarditis on LGE. Group B had 505 patients with chest pain who underwent a CMR stress study, noting 461(82.4%) were normal, while 89(17.6%) had evidence of CAD. Of the 461 patients with a normal CMR stress, 80(19.2%) had evidence of pericarditis on LGE. Conclusions: About 10% of patients with CP and normal MPI may continue to complain of discomfort. These patients are usually labeled as “non-cardiac”, and often undergo gastrointestinal and musculoskeletal evaluation. Evaluation of this group of patients with CMR shows that 18-19% have pericarditis by LGE and are incorrectly labeled as “non-cardiac”. Newer treatments for pericarditis with colchicine/non-steroid anti-inflammatory drugs have high success rates, while undiagnosed/untreated pericarditis is likely a precursor to constrictive disease, making the need for a correct initial diagnosis imperative.