Charles A. Henrikson, MD, MPH; Eric E. Howell, MD; David E. Bush, MD; J. Shawn Miles, MD; Glenn R. Meininger, MD; Tracy Friedlander; Andrew C. Bushnell, MD; Nisha Chandra-Strobos, MD
Acknowledgments: The authors thank Edward Bessman, MD, for administrative support; Johann Brandes, MD, for assistance with patient follow-up; and Angel Sampedro for assistance with data analysis.
Grant Support: By a National Heart, Lung and Blood Institute Training grant #T32-HLO7227-26 (Dr. Henrikson).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Nisha Chandra-Strobos, MD, Division of Cardiology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Henrikson, Miles, and Meininger: Division of Cardiology, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21205.
Dr. Howell: Divison of General Internal Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.
Drs. Bush, Chandra-Strobos, and Ms. Friedlander: Division of Cardiology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.
Dr. Bushnell: Division of Emergency Medicine, University of Vermont, 111 Colchester Ave., Burlington, VT 05401.
Author Contributions: Conception and design: C.A. Henrikson, E.E. Howell, D.E. Bush, N. Chandra-Strobos.
Analysis and interpretation of the data: C.A. Henrikson, E.E. Howell, D.E. Bush, N. Chandra-Strobos.
Drafting of the article: C.A. Henrikson.
Critical revision of the article for important intellectual content: C.A. Henrikson, E.E. Howell, D.E. Bush, J.S. Miles, G.R. Meininger, T. Friedlander, A.C. Bushnell, N. Chandra-Strobos.
Final approval of the article: C.A. Henrikson, E.E. Howell, D.E. Bush, J.S. Miles, G.R. Meininger, T. Friedlander, A.C. Bushnell, N. Chandra-Strobos.
Provision of study materials or patients: E.E. Howell, A.C. Bushnell, N. Chandra-Strobos.
Statistical expertise: C.A. Henrikson, D.E. Bush.
Administrative, technical, or logistic support: N. Chandra-Strobos.
Collection and assembly of data: C.A. Henrikson, E.E. Howell, J.S. Miles, G.R. Meininger, T. Friedlander, A.C. Bushnell.
Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, et al. Chest Pain Relief by Nitroglycerin Does Not Predict Active Coronary Artery Disease. Ann Intern Med. 2003;139:979-986. doi: 10.7326/0003-4819-139-12-200312160-00007
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Published: Ann Intern Med. 2003;139(12):979-986.
In the United States, “chest pain” accounts for up to 20% of emergency department visits and hospitalizations and uses valuable hospital resources (1). The major concern in most patients presenting with chest pain is that it represents active coronary artery disease (CAD). However, the causes of chest pain in patients presenting to the emergency department vary, and only a small percentage of such patients are actually having angina or an acute coronary syndrome as the manifestation of their CAD (2).
Nitrates are an accepted mainstay in treating both acute and chronic coronary disease; however, the diagnostic and prognostic value of chest pain relief with nitroglycerin has been poorly studied. The Coronary Artery Surgery Study (CASS) (3) used prompt relief of chest pain by rest or nitroglycerin as 1 of the criteria for “definite angina,” and Diamond and colleagues (4, 5) listed prompt relief of chest pain by rest or nitroglycerin as 1 of 3 diagnostic criteria for angina. In addition, Sox and colleagues (6) gave chest pain relief by nitroglycerin the greatest weight in their chest pain decision rule. In contrast, in developing their chest pain protocol, Goldman and colleagues (7) gathered information on chest pain response to nitroglycerin but did not use it in their decision-making algorithm. Its absence implies that it may not have substantial prognostic information. Recent research reports (8), handbooks (9), and current publications by the American Heart Association and American College of Cardiology (10-12) list chest pain relief by nitroglycerin as a poor prognostic sign in materials meant for physicians and describe it as a defining characteristic of angina in materials meant for physicians and patients. In addition, current emergency department literature refers to chest pain relief with rest or nitroglycerin as conferring an intermediate risk (13), although other emergency department literature implies that chest pain relief by nitroglycerin does not predict acute myocardial infarction (14).
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