Unexplained Chest Pain in Patients with Normal Coronary Arteriograms: A Follow-up Study of Functional Status

Approximately 10 per cent of patients referred for coronary arteriography because of chest pain have angiographically normal coronary arteries and no other heart disease. We examined the functional status of 57 patients who had undergone catheterization (23 men and 34 women), all of whom were told that their hearts were normal, that their pain was noncardiac, and that no limitation on activity was necessary. At a mean follow-up time of 16±7.7 months, 27 of the 57 patients (47 per cent) still described their activity as limited by chest pain (before catheterization, 42 of 57 or 74 per cent); 29 of 57 (51 per cent) were unable to work (before catheterization, 36 of 57 or 63 per cent); and 25 of 57 (44 per cent) still believed that they had heart disease (before catheterization, 45 of 57 or 79 per cent). Use of medical facilities was significantly reduced after catheterization (P<0.001). At follow-up the physician was more likely than the patient to believe that the symptoms had improved. We conclude that many of these patients remain limited in activity and may benefit from further efforts at communication and rehabilitation. (N Engl J Med. 1980; 303:1249–52). FOR many years physicians have recognized that certain patients with chest pain are incorrectly diagnosed as having coronary-artery disease. In 1892, Osler noted that differentiating patients with “pseudo-angina” from those with atherosclerotic involvement was difficult.¹ He pointed out that anginal pain without coronary-artery disease was more common in women, carried a good prognosis, and was characterized by discomfort that was often long-lasting, not related to exertion, and inconstant. Our diagnostic skills appear to be only slightly better today. Among patients referred for cardiac catheterization because of chest pain, 10 to 30 per cent are found to have either normal coronary.